Every finding on record at Taconic Rehabilitation And Nursing At Ulster

Based on record review and interviews conducted during an Abbreviated Survey, the facility did not ensure that one (Resident #3) of three residents reviewed for medication administration was free of significant medication errors. Specifically, Licensed Practical Nurse #10 entered the wrong order for morphine for Resident #3 on 06/26/2026. The physician order entered by Licensed Practical Nurse #10 and transmitted to the pharmacy documented Morphine Sulfate Concentrate Solution 20 milligrams per milliliter to give 0.25 milligram by mouth every four hours as needed for pain, 0.25 milliliter (one prefilled syringe). The pharmacy dispensed and delivered Morphine 10 milligrams/0.5 milliliter oral syringes with directions to give 0.25 milligram (one syringe) every four hours as needed for pain. The physician's order was electronically signed by Nurse Practitioner #1 on 06/26/2026. Resident #3 received the morphine 10 milligrams/0.5 milliliter(prefilled syringe) doses on 06/27/2026 at 02:36 AM, 07:51 AM, and 01:06 PM. There was no documented evidence that the facility staff clarified the morphine order with the physician or the pharmacy before administering the morphine. Based on record review and interviews conducted during an Abbreviated Survey, the facility did not ensure that one (Resident #3) of three residents reviewed for medication administration was free of significant medication errors. Specifically, Licensed Practical Nurse #10 entered the wrong order for morphine for Resident #3 on 06/26/2026. The physician order entered by Licensed Practical Nurse #10 and transmitted to the pharmacy documented Morphine Sulfate Concentrate Solution 20 milligrams per milliliter to give 0.25 milligram by mouth every four hours as needed for pain, 0.25 milliliter (one prefilled syringe). The pharmacy dispensed and delivered Morphine 10 milligrams/0.5 milliliter oral syringes with directions to give 0.25 milligram (one syringe) every four hours as needed for pain. The physician's order was electronically signed by Nurse Practitioner #1 on 06/26/2026. Resident #3 received the morphine 10 milligrams/0.5 milliliter(prefilled syringe) doses on 06/27/2026 at 02:36 AM, 07:51 AM, and 01:06 PM. There was no documented evidence that the facility staff clarified the morphine order with the physician or the pharmacy before administering the morphine. Resident #3 received The findings include: Review of the facility policy titled Medication/Treatment Administration: Documentation, revised 06/2024, documented that medications and treatments were to be checked against the prescription order before administration and administered according to physician's orders. The policy further documented that electronic Medication/Treatment Administration Records were to be checked by nursing staff against current physician's orders and necessary revisions were to be made. Resident #3 was admitted with diagnoses including, but not limited to, unspecified sequela of cerebral infarction with left sided hemiplegia/hemiparesis, chronic diastolic congestive heart failure, and Stage 1 through Stage 4 chronic kidney disease. The 06/25/2026 Significant Change Minimum Data Set (MDS) documented that Resident #3 had severely impaired cognition. Review of the 06/26/2026 Medication Order Audit Report documented that on 06/26/2026 at 12:24 PM, Licensed Practical Nurse #10 entered a physician's order into the electronic medical record for Morphine Sulfate Concentrate Solution 20 milligrams per milliliter, give 0.25 milligram by mouth every four hours as needed for pain, 0.25 milliliter (one prefilled syringe). The Medication Order Audit Report further documented that Nurse Practitioner #1 electronically signed the physician's order on 06/26/2026 at 12:36 PM. Review of the ProCare Controlled Medication Packing Slip documented that Morphine 10 milligrams/0.5 milliliter oral syringes, quantity 14, were delivered to the facility for Resident #3. The packing slip documented that facility staff signed for receipt of the medication on 06/27/2026.Review of the Facility Controlled Drug Receipt Record/Disposition Form documented that on 06/26/2026, the facility received 14 Morphine 10 milligrams/0.5 milliliter oral prefilled syringes from the pharmacy. The directions documented, Give 0.25 milligram (1 syringe) by mouth every 4 hours as needed for pain. The record documented that one syringe was removed on 06/27/2026 at 02:30 AM, one syringe was removed at 07:50 AM, and one syringe was removed at 01:05 PM.Review of the Facility Controlled Drug Receipt Record/Disposition Form documented Morphine 10 milligrams/0.5 milliliter oral syringes, quantity 14, for Resident #3. The record documented that on 06/27/2026, Registered Nurse #4 signed for one syringe at 02:30 AM. Licensed Practical Nurse #11 signed for one syringe at 07:50 AM and one syringe at 01:05 PM. Review of the June 2026 Medication Administration Record documented an order for Morphine Sulfate Concentrate Solution 20 milligrams/milliliter, give 0.25 milligram by mouth every four hours as needed for pain, 0.25 milliliter (one prefilled syringe). The Medication Administration Record documented that Morphine Sulfate Concentrate Solution was signed as administered to Resident #3 on 06/27/2026 at 02:36 AM, 07:51 AM, and 01:06 PM. The order was discontinued on 06/28/2026 at 06:06 PM.Review of the Order Listing Report for Morphine documented multiple Morphine orders entered and discontinued between 06/26/2026 and 07/07/2026, with changes to the prescribed dose, concentration, route, frequency, and administration instructions.The physician's order dated 06/28/2026 at 05:54 PM documented Morphine Sulfate Concentrate Solution 20 milligrams/milliliter, give 2.5 milligrams sublingually every four hours as needed for pain/shortness of breath, with directions to give one-half of a prefilled syringe for a dose of 2.5 milligrams, equal to 0.125 milliliter. Review of the 06/29/2026 Facility Order Audit Report documented that on 06/29/2026 at 04:36 PM, a physician's order was entered for Morphine Sulfate Concentrate Oral Solution 10 milligrams/0.5 milliliter, place and dissolve 0.5 milliliter buccally every one hour as needed for shortness of breath or pain.During a telephone interview on 07/15/2026 at 01:40 PM, Registered Nurse Supervisor #1 stated that they were the supervisor on duty on 06/27/2026. Licensed Practical Nurse #9, while administering medications to Resident #3, identified an issue with the Morphine order and reported it to them. Registered Nurse Supervisor #1 stated that they and Licensed Practical Nurse #9 contacted the Director of Nursing and reported the issue. Registered Nurse Supervisor #1 stated that the Director of Nursing instructed them to discontinue the order, secure the medication, and not administer any additional doses. The Director of Nursing stated they would take care of it. A new physician's order was entered on 06/28/2026 at 05:54 PM for Morphine Sulfate Concentrate Solution 20 milligrams/milliliter, give 2.5 milligrams sublingually every four hours as needed for pain/shortness of breath, with directions to give one-half of a prefilled syringe, equal to 0.125 milliliter. Registered Nurse Supervisor #1 stated that they did not notify the physician or Resident #3's family and did not complete a Registered Nurse assessment of Resident #3 because the Director of Nursing informed them that they the Director of Nursing would take care of it.During an interview on 07/15/2026 at 03:01 PM, Licensed Practical Nurse #5 stated that they administered one entire prefilled syringe of Morphine 10 milligrams/0.5 milliliter to Resident #3 on two occasions on 06/27/2026 and documented the administrations on the Medication Administration Record and Controlled Drug Receipt Record/Disposition Form. Licensed Practical Nurse #5 stated that they did not identify an issue with the Morphine prior to administering the medication and did not verify that the amount contained in the prefilled syringe corresponded with the physician's order prior to administration. Licensed Practical Nurse #5 stated that they later became aware that there was an issue involving the physician's order and the Morphine dispensed by the pharmacy. Licensed Practical Nurse #5 stated that upon reviewing the physician's order and the medication after the issue was identified, the physician's order documented 0.25 milligram and the prefilled syringe provided by the pharmacy contained Morphine 10 milligrams/0.5 milliliter. Licensed Practical Nurse #5 stated that the issue was not identified until after the Morphine had already been administered to Resident #3. Licensed Practical Nurse #5 stated that the physician and pharmacy were subsequently contacted regarding the Morphine, and clarification was obtained regarding the amount that should have been administered from the prefilled syringe. Licensed Practical Nurse #5 stated that the Registered Nurse Supervisor was made aware of the issue and that they were informed that the Director of Nursing had been notified. Licensed Practical Nurse #5 stated that no medication error report was completed regarding the Morphine administered to Resident #3. During a telephone interview conducted on 07/20/2026 at 02:31 PM and 03:41 PM, Nurse Practitioner #1 stated that the intended Morphine order for Resident #3 was 2.5 milligrams every four hours as needed for pain and stated that the intended Morphine regimen was documented in a 06/26/2026 progress note. Nurse Practitioner #1 stated that they did not enter the Morphine order into the resident's electronic medical record and that the Morphine order entered by nursing was not what they intended. Nurse Practitioner #1 stated that their progress notes clearly documented the intended Morphine dose. Nurse Practitioner #1 stated that they were not working when the Morphine order was entered into the electronic medical record and that Physician #1 was the physician on call. Nurse Practitioner #1 stated that although they electronically signed the Morphine order, nursing staff sometimes select the first physician or nurse practitioner listed when entering orders. Nurse Practitioner #1 stated that they sometimes signed orders without reviewing them and stated that they had to be honest about that practice. Nurse Practitioner #1 stated that they were not made aware of the medication error at the time. Nurse Practitioner #1 stated that the pharmacy should have clarified the order and completed a second check prior to providing the medication. Nurse Practitioner #1 stated that the Morphine provided by the pharmacy would have required nursing staff to waste a portion of the syringe to administer the intended dose. Nurse Practitioner #1 stated that the medication provided and administered to Resident #3 was less than the Morphine dose intended for Resident #3.Review of the medical record did not identify a 06/26/2026 physician/provider progress note documenting the intended Morphine regimen.During an interview on 07/21/2026 at 02:21 PM, Registered Nurse #4 stated that they administered one entire prefilled syringe of Morphine 10 milligrams/0.5 milliliter to Resident #3 and signed for the medication on the Facility Controlled Drug Receipt Record/Disposition Form and the Medication Administration Record. Registered Nurse #4 stated that they did not verify the medication against the physician's order prior to administration. Registered Nurse #4 stated that they later learned there was an error involving the Morphine and that the Director of Nursing addressed the medication error with them several days later, after another nurse identified the issue. Registered Nurse #4 stated that the Director of Nursing provided education regarding verification of physician's orders. Registered Nurse #4 stated that they should have verified the medication against the physician's order prior to administering the Morphine to Resident #3. During an interview on 07/21/2026 at 03:53 PM, Licensed Practical Nurse #9 stated that at the beginning of the shift, they reviewed Resident #3's Morphine and observed that the amount in the prefilled syringe did not appear correct. Licensed Practical Nurse #9 stated that they did not administer the Morphine, reviewed the physician's order, and requested that a Registered Nurse also review the medication and physician's order. Licensed Practical Nurse #9 stated that they contacted the pharmacy to clarify the physician's order and medication provided. Licensed Practical Nurse #9 stated that the pharmacy informed them that the Morphine 10 milligrams/0.5 milliliter prefilled syringes provided to the facility were incorrect, instructed that the medication is not to be administered to Resident #3, and requested for the medication to be returned to the pharmacy. The Pharmacy requested that a new physician's order be entered for processing. Licensed Practical Nurse #9 stated that the pharmacy informed them that no one from the facility had contacted them to clarify the physician's order. They notified Registered Nurse Supervisor #1 of the medication error and Registered Nurse Supervisor #1 notified the Director of Nursing. They were instructed by the Director of Nursing not to administer the Morphine. Licensed Practical Nurse #9 stated that they informed the Director of Nursing that the medication had previously been administered to Resident #3 by staff and that the administrations were documented in the Medication Administration Record. Licensed Practical Nurse #9 stated that they did not complete a written statement regarding the medication error. During a telephone interview on 07/21/2026 at 04:43 PM, Physician #1 stated that they were made aware of an issue involving Resident #3's Morphine. Physician #1 was unable to state when they were made aware of the issue, including whether they were notified immediately following the incident. Physician #1 stated that they did not have access to a computer at the time of the interview and would need to review Resident #3's medical record to determine when they were notified and what instructions, if any, were provided regarding the Morphine. Physician #1 stated that they could not speak to the actions taken by nursing staff regarding Resident #3's Morphine. During an interview on 07/15/2026 at 03:42 PM, the Director of Nursing stated that a medication error report was not completed after Resident #3 received Morphine from the medication provided by the pharmacy that did not correspond with the physician's order. The Director of Nursing stated that they were not made aware that Resident #3 had received the Morphine and stated that they first became aware during the surveyor's investigation beginning on 07/13/2026. 10(NYCRR) New York Codes, Rules and Regulations 415.12(m)(2)m)(2)

Based on observations, record reviews and interviews conducted during the Abbreviated Survey, the facility did not ensure necessary care and services were provided to timely identify and monitor changes in skin integrity for one (Resident #2) of three residents reviewed for quality of care. Specifically, Resident #2 who was care planned as at risk for impaired skin integrity and needed daily skin monitoring and checks as well as weekly skin checks on shower days was identified with a small skin opening to the right buttock during a shower on 10/16/2025. The area was later evaluated by the facility's wound care doctor, a physician assistant, and identified as a Stage three pressure injury on 10/16/2025. Prior to the identification of the wound on 10/16/2025, Resident #2's electronic clinical record contained no documented evidence of Resident #2 refusing skin assessment or skin monitoring or receiving education related to refusal of skin assessment or skin monitoring.The findings include: The facility policy titled Documentation of Pressure Ulcer and Chronic Wounds, effective 1/1/2000 and revised 6/23, documented that Risk factors will be identified, monitored and documented on the Skin Risk Data Collection Tool; upon admission, then quarterly and whenever there is a change in condition. The policy further documented that A skin Inspection is completed weekly on shower day. The policy also documented that All skin surfaces are inspected upon admission and results documented on the Nursing admission Evaluation, and that Weekly skin inspections are documented on the TAR/designated location. The policy's Skin Inspection Requirements included, Inspect all skin surfaces (including heels & elbows) and In order to do a thorough skin inspection, resident must be turned side to side in bed or if able/necessary stand for inspection.Resident #2 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus type 2, major depressive disorder, ischemic cardiomyopathy, and protein calorie malnutrition. The 09/12/2025 admission Minimum Data Set(MDS) documented that Resident #2 had intact cognition and did not have venous or arterial ulcers. The 09/06/2025 Skin Integrity Care Plan documented that Resident #2 was at risk for impaired skin integrity related to surgical sites. Interventions included monitoring the skin for changes daily during care, checking the skin and feet with daily care and documenting weekly on shower day, and applying moisture barrier following incontinence care and as needed. The Certified Nurse Aide Kardex documented the same skin integrity interventions and documented shower and skin inspection on the 7:00 AM to 3:00 PM shift every Monday and Thursday for a skin audit and complete skin inspection. Review of the Quality Improvement Shower & Skin Inspection records documented the following: 09/11/2025, no redness and refusal of the shower due to a new incision; 09/15/2025, skin clear; 09/18/2025, No issues and no redness; 09/25/2025, no issue and no redness; 09/29/2025, No issues and no redness; 10/02/2025, no issues; 10/06/2025, no skin concern and no redness; 10/08/2025, no redness and no skin concern; and 10/13/2025, no issues and no redness. Except for the 09/11/2025 shower refusal related to a new incision; the records reviewed prior to 10/16/2025 did not document refusal of skin assessment or skin monitoring. Although the Quality Improvement Shower & Skin Inspection records through 10/13/2025 documented no identified skin concerns and did not document refusal of skin assessment or skin monitoring, a small skin opening to Resident #2's right buttock was identified during a shower on 10/16/2025 and was subsequently identified as a Stage III pressure injury. The 10/16/2025 nursing progress note by Licensed Practical Nurse #10 documented that during a shower; a Certified Nurse Aide identified a small skin opening to Resident #2's right buttock. The 10/16/2025 nursing progress note by the Assistant Director of Nursing/Wound Care Nurse documented an open area to Resident #2's right inner buttock measuring approximately 1.3 centimeters by 1.2 centimeters by 0.1 centimeter. The 10/17/2025 Nursing Weekly Skin Status identified the area as a suspected deep tissue injury. The 10/21/2025 Nursing Weekly Skin Status documented a Stage III pressure injury to the right inner buttock measuring 2.9 centimeters by 2.6 centimeters by 0.1 centimeter. The 10/21/2025 Nursing Skin Risk Data Collection Tool identified noncompliance with care despite counseling and education as a risk factor but did not identify the specific care Resident #2 was noncompliant with or the counseling or education provided. The 10/21/2025 Pressure Ulcer Rationale Documentation similarly identified Non-compliance of care issues despite counseling/education and included the handwritten statement, Resident non-compliant to care. However, review of the clinical record prior to 10/16/2025 did not identify documentation that Resident #2 refused skin assessment or skin monitoring, prevented staff from completing skin inspection, or received counseling or education related to refusal or noncompliance During an interview on 07/15/2026 at 11:23 AM, the facility's wound care doctor, a physician assistant, stated that Resident #2's wound could have been related to the resident's reported noncompliance with care because nursing staff had reported that the resident was not following care and education. When asked where the resident's refusals or noncompliance were documented in the clinical record, the wound care doctor stated that this was an issue because nursing staff would report that residents were not following education or encouragement but did not document the refusals. The wound care doctor further stated that, at times, they are not made aware that a resident has a wound until sometimes one week after. During an interview on 07/21/2026 at 02:02 PM, the Assistant Director of Nursing/Wound Care Nurse stated that residents received showers, and that nursing staff and Certified Nurse Aides were expected to document skin checks. The Assistant Director of Nursing/Wound Care Nurse stated that if a resident had a wound, staff would ask them to evaluate the area, and that weekly wound documentation is completed after a wound is identified. The Assistant Director of Nursing/Wound Care Nurse stated that they were not made aware that Resident #2 refused care, refused skin checks, or otherwise refused skin assessment or monitoring prior to identification of the right buttock wound. The Assistant Director of Nursing/Wound Care Nurse further stated that Resident #2 did not have a known wound before the right buttock wound was identified and that they had not been asked to evaluate Resident #2's skin before the discovery. During a follow-up telephone interview on 07/21/2026 at 03:50 PM, the Assistant Director of Nursing/Wound Care Nurse stated that they reviewed the clinical record after the previous interview and did not identify documentation that Resident #2 refused skin assessment or skin monitoring prior to identification of the wound. The Assistant Director of Nursing/Wound Care Nurse stated that nursing staff and Certified Nurse Aides were expected to document skin concerns and refusals of care and that the documentation should have been completed. During an interview on 07/29/2026 at 11:30 AM, the Director of Nursing stated that after Resident #2 was identified with the Stage III pressure injury, they were made aware that the resident was not following education and recommendations related to wound healing. The Director of Nursing stated that they then discussed the reported noncompliance with the resident's family. When a resident refuses an intervention or treatment, nursing staff are expected to document the refusal in the progress note. Review of the clinical record prior to identification of the wound did not identify documentation that Resident #2 refused skin assessment, skin monitoring, or other skin-integrity interventions. During an interview on 07/29/2026 at 11:35 AM, the Administrator stated that the facility has recently identified issues with identifying wounds and that when residents are identified with a wound, the facility is now going to investigate how the wound occurred. 10 New York Codes, Rules and Regulations (NYCRR) 415.12

Based on observations, record review, and interviews conducted during an Abbreviated Survey, the facility did not ensure the resident environment remained as free from accident hazards as possible and did not ensure residents received adequate supervision to prevent accidents for two residents (Residents #4 and #6) of five residents reviewed for accidents. Specifically, 1. On 06/26/2026, Licensed Practical Nurse #7 reported to Registered Nurse Supervisor #2 that Licensed Practical Nurse #8 left their medication cart opened and Resident #4 with moderately impaired cognition with documented wandering behaviors, accessed the cart and was found by Certified Nurse Aides #5 and #6 in the day room with medications in their lap. Licensed Practical Nurse #7 was notified by Certified Nurse Aides #5 and #6. There was no documented evidence of a nursing assessment, ongoing monitoring, physician notification, family notification, or completion of an accident/incident report following the reported medication incident on 06/26/2026. Additionally, the investigation did not include the root cause of how Resident #4 had access to the medications or what medications were found in the resident's possession and which resident it belonged to. 2) Resident #4 with a history of wandering behaviors, and had a Wander Guard, exited the second floor on the elevator and was found by facility staff on the first-floor ventilator unit attempting to take food from a meal cart on 07/11/2026. Resident #4 resided on the second-floor unit. The findings include: Review of the facility policy titled Accident/Incident Investigation and Prevention, revised 06/2023, documented that all accidents and incidents were to be recorded, investigated, and corrective measures initiated. The policy further documented that licensed nursing staff were responsible for documenting and completing the follow-up investigation of each incident. Resident #4 was admitted with diagnoses including, but not limited to, wandering, psychotic disorder with delusions due to known physiological condition, and persistent mood (affective) disorder. The 04/22/2026 admission Minimum Data Set documented that Resident #4 had moderately impaired cognition, exhibited wandering behaviors daily, and the wandering placed the resident at significant risk of getting to a potentially dangerous place and significantly intruded on the privacy or activities of others. The 06/09/2026 Alteration in Behavior Pattern Care Plan documented that Resident #4 exhibited socially inappropriate behaviors including chewing and eating items, grabbing random items, and wandering. Interventions included, but were not limited to, communicating the resident's behavioral care needs to caregivers, providing diversion for inappropriate behaviors, keeping food and drinks off the nurses' station and hallways, and securing items to prevent the resident from removing them. Review of Resident #4's physician progress notes from 06/26/2026 through 07/13/2026 revealed no documented evidence of a physician assessment related to the 06/26/2026 incident involving the unidentified medications. Review of Resident #4's nursing progress notes revealed no nursing progress notes documented from 06/26/2026 through 06/30/2026 regarding the medication incident. The 07/01/2026 at 11:44 PM nursing progress note by Registered Nurse Supervisor #2 documented a late entry for 06/26/2026, which indicated that a Certified Nurse Aide reported observing Resident #4 with a spoon attempting to scoop unidentified pills from the resident's lap. The note documented that Resident #4 was assessed, and no pills or residue were found in the resident's mouth. Resident #4 did not respond when asked where the pills came from or whether any pills had been swallowed. The note further documented that the Director of Nursing was notified and instructed staff to monitor Resident #4 and obtain vital signs every two hours for 24 hours. The 07/02/2026 at 10:22 AM nursing progress note by the Director of Nursing documented a late entry for 06/26/2026, which indicated that the physician was notified regarding Resident #4 being found with pills and instructed staff to monitor the resident for safety. Review of Resident #4's vital sign records revealed no documented vital signs obtained every two hours for 24 hours as documented in the 07/01/2026 late-entry nursing progress note. There was no documented vital signs on the evening shift on 06/26/2026 following the medication incident. The first documented vital signs following the incident were obtained on 06/27/2026 at 09:06 AM and included blood pressure, temperature, pulse, respirations, and oxygen saturation. Review of the clinical record did not identify concurrent documentation that the physician was notified of the incident on 06/26/2026. On 07/15/2026 at 03:44 PM, the surveyor requested the facility's completed investigation file related to the 06/26/2026 medication incident involving Resident #4. At approximately 05:15 PM, while onsite at the facility, the Director of Nursing provided a hard copy of the investigation file and supporting staff statements and stated that the investigation was completed. The surveyor also requested that the same documentation provided in hard copy be submitted through the secure file-transfer process. After the onsite survey, the facility submitted additional documentation related to the investigation that was not provided during the onsite visit and was not included in the completed investigation file provided to the surveyor in hard copy on 07/15/2026. The findings below are based on the investigation file provided to the surveyor while onsite at the facility. Review of the facility's investigation summary, dated 06/26/2026, documented that Resident #4 was observed with medications in their lap following medication administration. The investigation summary documented that staff immediately removed the medications. The Facility Investigative Summary Immediate Response section documented that Resident #4 was immediately assessed by the nursing supervisor, no medication residue was observed in or around the resident's mouth, the resident exhibited no signs or symptoms of distress, vital signs were obtained and remained stable, and the resident was placed under observation for changes in condition or adverse reactions. The Immediate Response section further documented that the Director of Nursing informed Registered Nurse Supervisor #2 that the Director of Nursing would notify the attending physician and the Administrator. The Facility Investigative Summary Investigation section documented that the unit nurse continued to monitor Resident #4 and reported that the resident remained at baseline with no behavioral changes, signs of distress, or adverse reactions. The Investigation section further documented that the attending physician contacted the Director of Nursing the following morning regarding the resident's condition and that the responsible party/family was notified of the incident and updated regarding the resident's condition. The investigation summary was signed and dated 06/26/2026. Review of the clinical record did not identify corresponding nursing documentation of the 06/26/2026 incident, nursing assessment, ongoing monitoring, physician notification, or responsible-party notification. The Facility Investigative Summary Findings section documented that there was no evidence Resident #4 consumed the medications, experienced harm, or had a change in condition during continued observation. The Facility Investigative Summary Corrective Actions section documented that nursing staff received re-education regarding the facility's medication administration policy; staff were instructed to visually verify that each resident completely consumed prescribed medications before leaving the bedside; staff were reminded to immediately report medication variances or concerns to the charge nurse and nursing supervisor; and medication administration practices would continue to be monitored. The Facility Investigation documents provided to the surveyor did not include documentation of the identified staff re-education, staff instruction, or monitoring. The Facility Investigative Summary Conclusion section documented that, based on the evidence, it was believed the pills in Resident #4's possession were from another resident who did not consume them. The investigation documents did not identify the medications involved, identify the resident from whom the medications were believed to have originated, or document how the source of the medications was determined. Review of the 06/26/2026 handwritten statement by Licensed Practical Nurse #7 documented that two Certified Nurse Aides notified the nurse that Resident #4 had pills in their lap. Licensed Practical Nurse #7 removed the pills, immediately notified the nursing supervisor, and documented that Resident #4 was unable to state where the pills had been obtained. Review of an undated handwritten statement by Licensed Practical Nurse #8 documented that upon returning from lunch, they were informed that Resident #4 had been found with pills in their lap. The Licensed Practical Nurse #8 obtained vital signs, reported the findings to the nursing supervisor, and continued monitoring as directed. Review of the handwritten statement by Certified Nurse Aide #5, dated 07/10/2026, documented that Resident #4 was observed with a spoon in their hand and approximately eight pills in their lap. Certified Nurse Aide #5 documented that staff notified the resident's nurse and reported the incident to the nursing supervisor. The statement further documented that staff approached a medication cart and observed that the cart was unlocked and that two empty medication cups with room numbers written on them were identified in the dayroom. The completed investigation file provided to the surveyor did not document review of the unlocked medication cart as a potential source of the medications, did not document how Resident #4 obtained the medications, and did not reconcile the staff statement regarding the unlocked medication cart with the investigation conclusion that documented the medications were believed to have originated from another resident who did not consume them.During a telephone interview on 07/15/2026 at 01:40 PM, Registered Nurse Supervisor #1 stated that they were not present in the facility when the 06/26/2026 incident occurred and later learned of the incident from Licensed Practical Nurse #9. Registered Nurse Supervisor #1 stated that Licensed Practical Nurse #9 reported that Resident #4 had been found with unidentified pills and that Licensed Practical Nurse #8 was not on the unit at the time. Registered Nurse Supervisor #1 stated that they were informed that Licensed Practical Nurse #7 and Registered Nurse Supervisor #2 checked Licensed Practical Nurse #8's medication cart and observed that the cart was open. Registered Nurse Supervisor #1 further stated that Licensed Practical Nurse #9 reported that the Director of Nursing had been notified and would notify the physician and Resident #4's family. Registered Nurse Supervisor #1 stated that Registered Nurse Supervisor #2 later documented a late-entry progress note after being informed that State surveyors were in the facility. Registered Nurse Supervisor #1 also stated that staff had been instructed not to leave items accessible to Resident #4 because the resident had a history of taking items that did not belong to the resident. During an interview on 07/21/2026 at 04:43 PM, Physician #1 stated that they were made aware of the 06/26/2026 incident involving Resident #4 and unidentified medications. Physician #1 stated that they instructed staff to monitor Resident #4 and obtain vital signs; however, they could not recall the frequency or duration of the vital sign monitoring. Physician #1 stated that an order for the vital signs should have been entered into the resident's medical record as a verbal or telephone order. Physician #1 stated that they were not at a computer during the interview and could not verify whether the order was entered or whether the vital signs were obtained. When asked why there were no nursing progress notes documented following the incident and notification to Physician #1, they stated that they could not explain the absence of nursing documentation. Physician #1 stated that they assessed Resident #4 following the incident; however, when asked about the absence of a physician progress note regarding the assessment, Physician #1 stated that they were not at a computer and were unable to review the resident's medical record or provide further information regarding the assessment. During an interview on 07/15/2026 at 03:44 PM, the Director of Nursing stated that an Accident/Incident Investigation was not completed for the 06/26/2026 incident involving Resident #4 who had been found with medications in their lap because there was no evidence that Resident #4 ingested the medications. During the interview, the Director of Nursing reviewed their cellular phone and stated that Registered Nurse Supervisor #2 contacted them at 07:58 PM on 06/26/2026 regarding the incident. The Director of Nursing stated that they contacted the physician regarding Resident #4 and were instructed to obtain vital signs and monitor Resident #4 every two hours for 24 hours. When asked why the physician's instructions were not entered into the resident's medical record as an order, the Director of Nursing stated that they did not have access to a computer at the time. The Director of Nursing stated that an internal investigation was initiated on 06/29/2026 and that Resident #4's family was notified on 06/29/2026. The Director of Nursing stated that Registered Nurse Supervisor #2 completed an assessment of Resident #4 on the night of the incident; however, the assessment was documented later. The Director of Nursing further stated that Registered Nurse Supervisor #2 discarded the medications on 06/26/2026. The Director of Nursing stated that Licensed Practical Nurse #8 was unable to identify the medications or determine the number of medications involved because the medications had already been discarded.During an interview on 07/23/2026 at 01:32 PM, Licensed Practical Nurse #7 stated that on 06/26/2026 during the evening shift, Certified Nurse Aide #5 reported that Resident #4 had multiple pills in their lap. Licensed Practical Nurse #7 stated that they told Certified Nurse Aide #5 that the pills could not belong to Resident #4 because the resident receives their medications crushed in applesauce. Licensed Practical Nurse #7 stated that approximately eight pills were observed in Resident #4's lap and staff attempted to retrieve the pills; however, Resident #4 would not give the pills to staff. Licensed Practical Nurse #7 stated that when Registered Nurse Supervisor #2 arrived on the unit, Licensed Practical Nurse #7 and Registered Nurse Supervisor #2 checked Licensed Practical Nurse #8's medication cart. Licensed Practical Nurse #8 was not on the unit and could not be located. Licensed Practical Nurse #7 stated that Licensed Practical Nurse #8's medication cart was located near the nurses' station and was found unlocked with medications prepoured in cups in the cart. Licensed Practical Nurse #7 stated that a written statement was not requested at the time of the incident and that approximately one to two weeks later, the Director of Nursing requested that Licensed Practical Nurse #7 complete a written statement. Licensed Practical Nurse #7 stated they were asked to write their statement on a piece of notepad paper and did not date it for 06/26/2026 at the top of the statement. Licensed Practical Nurse #7 further stated that Resident #4 had a history of taking items and attempting to eat items. During an interview on 07/23/2026 at 01:32 PM, Certified Nurse Aide #5 stated that on 06/26/2026, they and another Certified Nurse Aide observed Resident #4 with a spoon in their hand and approximately eight pills in their lap. Certified Nurse Aide #5 stated that Licensed Practical Nurse #7 was notified and advised that the pills were not Resident #4's medications because the resident received medications crushed in applesauce. Certified Nurse Aide #5 stated that staff initially attempted to retrieve the medications; however, Resident #4 would not give the medications to staff. Certified Nurse Aide #5 stated that Resident #4 later complied and gave the medications to Licensed Practical Nurse #7. Certified Nurse Aide #5 stated that approximately one to two weeks after the incident, they were contacted and asked to complete a written statement. Certified Nurse Aide #5 further stated that on 07/17/2026, the Director of Nursing called them into the office and also requested that a written statement regarding the 06/26/2026 incident be completed. Certified Nurse Aide #5 stated that they were provided with a page from a notepad to write the statement and did not write the date of the incident, 06/26/2026, at the top of the statement. Certified Nurse Aide #5 further stated that Resident #4 had a history of taking items, going through items, and attempting to eat items. 2) Resident #4 primarily utilized a wheelchair for mobility, resided on the second-floor unit, and had a history of wandering behaviors. Resident #4 exhibited socially inappropriate behaviors including chewing and eating items, grabbing random items, and wandering. The resident had a Wander Guard in place. The 05/04/2026 Elopement Care Plan documented that Resident #4 was at risk for elopement related to exit-seeking behaviors, including attempting to go through doors on the unit, and had a Wander Guard on the right ankle. Interventions included a wander detection/monitoring system, identifying Resident #4 as an elopement risk, observing for elopement triggers, completing an Elopement Risk Tool per facility policy, and maintaining Resident #4 in common areas with increased supervision, as practicable. The 07/11/2026 at 6:53 PM nursing progress note documented that Resident #4 exhibited multiple episodes of behaviors, including attempting to leave the unit and attempting to take items that did not belong to the resident. Resident #4 was redirected multiple times without success. On 07/11/2026, following lunch, the alarm sounded and Resident #4 left the second-floor unit and was found on the first-floor ventilator unit. The Registered Nurse Supervisor was notified. During a telephone interview on 07/15/2026 at 01:40 PM, Registered Nurse Supervisor #1 stated that on 07/11/2026, Resident #4 left the second-floor unit and was found downstairs on the first-floor ventilator unit. Registered Nurse Supervisor #1 stated that Resident #4 had a history of taking food, drinks, clothing items such as gowns and socks, and other items that were left accessible, regardless of whether the items belonged to residents or staff, and attempting to eat items that appeared edible. Registered Nurse Supervisor #1 stated that Resident #4 was very quick and difficult to monitor because there was one nurse assigned to each side of the unit. Registered Nurse Supervisor #1 further stated that Resident #4 had a Wander Guard that activated two alarms; however, when triggered, the alarms sounded but did not lock the doors or elevators. During an interview on 07/15/2026 at 3:31 PM, the Administrator stated that an Accident/Incident Investigation was not completed after Resident #4 left the second-floor unit and was found on the first-floor ventilator unit because the facility did not consider the incident an elopement since Resident #4 did not exit the building. 10 New York Codes, Rules and Regulations (NYCRR) 415.12(h)

Based on record review and interviews conducted during the abbreviated survey, the facility failed to ensure that the Facility Assessment thoroughly assessed the needs of the resident population and determined the resources necessary to care for residents competently during day-to-day operations, including nights and weekends. Specifically, the Facility Assessment did not address what was considered sufficient staffing, particularly on weekends, and how the care required on a weekend shift differed from the care required on weekdays. The Facility Assessment identified staffing levels for day, evening, and night shifts, but did not identify or account for the 12-hour and modified nursing shifts utilized on weekends or identify how the staffing levels established for the day, evening, and night shifts applied to the weekend staffing pattern. The Facility Assessment identified specific staffing levels for registered nurse Nursing Supervisors, licensed practical nurses, and certified nurse aides, however, review of Daily Staffing Sheets revealed multiple dates when staffing did not reflect the levels identified in the Facility Assessment. Additionally, although the Facility Assessment identified residents with psychiatric and mood disorders and behavioral health needs, the Facility Assessment did not identify the behavioral health services, number and types of staff, and staff competencies and skill sets necessary to meet the behavioral health needs of the resident population.The findings include: Review of the Facility Assessment, updated 02/10/2026, revealed the facility identified one full-time Registered Nurse Nursing Supervisor for the day shift, one full-time Registered Nurse Nursing Supervisor for the evening shift, and one full-time Registered Nurse Nursing Supervisor for the night shift. The Facility Assessment identified six Licensed Practical Nurses for the day shift, six Licensed Practical Nurses for the evening shift, and four Licensed Practical Nurses for the night shift. The Facility Assessment further identified nine Certified Nursing Assistants for the day shift, nine Certified Nursing Assistants for the evening shift, and six Certified Nursing Assistants for the night shift. Further review of the Facility Assessment revealed staffing needs were identified for the day, evening, and night shifts. However, the Facility Assessment did not identify or account for the 12-hour and modified nursing shifts utilized by the facility on weekends and did not identify how the staffing levels established for the day, evening, and night shifts applied to the 12-hour and modified weekend shifts. Review of the Facility Assessment revealed the facility identified residents with psychiatric and mood disorders and behavioral health needs. However, the Facility Assessment did not identify the behavioral health services, number and types of staff, and staff competencies and skill sets necessary to meet the behavioral health needs of the resident population. Review of the Daily Staffing Sheets dated 06/06/2026, 06/07/2026, 06/20/2026, 06/21/2026, 06/27/2026, 06/28/2026, 07/04/2026, and 07/05/2026 revealed the facility utilized 12-hour and modified nursing shifts during weekends. The 12-hour and modified weekend nursing shifts were not identified or accounted for in the Facility Assessment. Review of the Daily Staffing Sheet dated 06/26/2026 revealed five Licensed Practical Nurses were documented as the staff on the day shift. The Facility Assessment identified six Licensed Practical Nurses for the day shift. Review of the Daily Staffing Sheet dated 06/28/2026 revealed the Registered Nurse documented as the Nursing Supervisor for the 7:00 AM to 7:30 PM shift was crossed out and a licensed practical nurse was documented in place of the Registered Nurse Nursing Supervisor. Further review revealed a Registered Nurse was not documented among the nursing staff assigned during the daytime staffing period. The Facility Assessment identified one full-time Registered Nurse Nursing Supervisor for the day shift. Review of the Daily Staffing Sheet dated 07/15/2026 revealed a Nursing Supervisor was not documented for the 11:00 PM to 7:00 AM shift. The Facility Assessment identified one full-time Registered Nurse Nursing Supervisor for the night shift. During an interview on 07/14/2026 at 02:42 PM, Licensed Practical Nurse #4 stated that the usual staffing on the rehabilitation unit was two certified nurse aides. Licensed Practical Nurse #4 stated that several residents on the unit preferred not to receive care from male certified nurse aides and that on the previous Sunday, only one male certified nurse aide was available until 7:00 PM. Licensed Practical Nurse #4 stated that because of this, the licensed practical nurse had to stop nursing duties to assist with resident care. Licensed Practical Nurse #4 further stated that during the previous weekend, staff utilized a three-way assignment and crossed over to assist on the ventilator unit. During an interview on 07/14/2026 at 02:51 PM, Certified Nurse Aide #2 stated that Certified Nurse Aide #2 worked the day shift and at times was the only certified nurse aide assigned to the unit for the entire day. Certified Nurse Aide #2 stated that this occurred frequently, especially on weekends, and that the facility was always short staffed, which was aggravating. Certified Nurse Aide #2 stated that at times certified nurse aides had to be split between the ventilator unit and the assigned unit. During an interview on 07/15/2026 at 03:31 PM, the Administrator stated that there was no difference between weekday and weekend staffing. The Administrator stated that the staffing numbers identified in the Facility Assessment were the numbers the facility was striving to maintain and were applicable seven days a week throughout the facility. The Administrator stated that when staffing fell below the identified numbers, the facility utilized bonuses and agency staff to obtain coverage, and the Director of Nursing and Nursing Supervisors would pick up shifts when necessary. The Administrator stated that nurses also assisted with resident care when needed. The Administrator stated that separate staffing requirements for weekdays and weekends did not need to be identified because there was no difference between weekday and weekend staffing. During an interview on 08/07/2026 at 10:28 AM, the Staffing Coordinator stated that the minimum staffing level for certified nurse aides was four on each long-term care floor. The Staffing Coordinator stated that the facility frequently operated below the minimum staffing level and that there were times when leaving for the weekend that sufficient staff could not be obtained to cover the shifts because staff could not be asked to work additional shifts. The Staffing Coordinator stated that when there were call-outs or staffing shortages, facility staff were contacted, agency staff were utilized, bonuses were offered, and the Nursing Supervisor may have to provide coverage. The Staffing Coordinator stated that when the Staffing Coordinator was unavailable, the Director of Nursing and Assistant Director of Nursing were responsible for obtaining staff or the Nursing Supervisor on duty addressed staffing needs. The Staffing Coordinator stated that staffing requirements were the same Sunday through Saturday. The Staffing Coordinator stated being unaware of the staffing requirements identified in the Facility Assessment and was not familiar with the staffing levels established in the Facility Assessment. The Staffing Coordinator identified four certified nurse aides as the minimum staffing level, while the Facility Assessment revised 02/10/2026 identified six certified nurse aides. 10 New York Codes, Rules and Regulations (NYCRR) 415.19

REVISED 6/10/2025 IIDR Based on observation, record review, and interview conducted during the recertification survey from 3/5/2025 through 3/12/2025, the facility did not ensure residents received quality of care in accordance with professional standards of practice for one (1) of four (4) residents reviewed for accidents. Specifically, on 12/12/24, Resident #69 was observed ambulating to the bathroom in their room unassisted, as Certified Nurse Aide # 8 assisted the resident their legs became weak, and the resident was lowered to the floor. Certified Nurse Aide #8 left Resident #69 to seek help, upon return Resident #69 was found in a different position, complained of pain to the right side of lower back, and sustained a hematoma (bruise) to the face. Resident #69 was transferred from the floor to the wheelchair and then to the bed by Licensed Practical Nurse #10 and two Certified Nurse Aides (#8 and one unidentified) without being physically assessed by Registered Nurse or Medical Provider. There was no documented evidence of an assessment by a qualified professional (Physician or Registered Nurse) from the time of the fall on 12/12/2024 at 4:00 AM until the resident was transferred to the hospital on 12/13/2024 at 8:32 AM. An X-ray was completed on 12/12/2024 at 6:30 PM which revealed an acute fracture of the trochanteric femur (area in the upper thigh). The hospital discharge summary dated 12/19/2024 documented the resident underwent an open reduction with internal fixation (surgical repair of broken bone) of the right hip on 12/14/2024. This resulted in actual harm to Resident #69 that was not immediate jeopardy. Findings include: The facility's policy titled Accident/Incident Investigation and Prevention revised 6/2023, documented the facility will provide an environment that is free from accident hazards over which the facility provides supervision and assistive devices to each resident to prevent avoidable accidents. All residents who have an accident/injury will be assessed by a Registered Nurse. Resident #69 was admitted to the facility with diagnoses including seizure disorder, heart failure (the heart does not pump blood as well as it should), and traumatic brain injury. The 11/05/2024 Quarterly Minimum Data Set (resident assessment) documented the resident had moderately impaired cognition and required maximal assistance with lying to sitting in bed, was dependent with transfers, and was non-ambulatory. The Care Plan for Falls dated 11/18/2024, documented interventions included to monitor for orthostatic hypotension (low blood pressure with positional changes), supervised area when out of bed, remind resident to call for assistance, and to prevent self-ambulation remove wheelchair from bedside while in bed. The Certified Nurse Aide Care Instructions for Resident #69 on 12/12/2024, documented Resident #69 required maximum assist of two (2) people with transfers and toilet transfers, and dependent assist of two (2) people with toileting task, non-ambulatory in corridor and in room. The facility's Witnessed Fall Incident Report dated 12/12/2024, completed by Licensed Practical Nurse Unit Manager #12 (who was not present at the time of fall) documented a fall at 4:00 AM. Certified Nurse Aide #8 called Licensed Practical Nurse #10 into the room. The resident was observed sitting on the bathroom floor in front of the sink, feet were straight out in front of the resident with their back against the wall. The resident had shoes on and was able to move all extremities. The resident had a hematoma to the face. The resident was oriented to person only, not situation, time or place. Neurological checks were not initiated. The resident complained of pain to the right side of lower back. Certified Nurse Aide #8 stated that they found the resident ambulating to the bathroom when they were doing rounds and went to assist the resident to the bathroom. The Certified Nurse Aide stated the resident became unsteady on their feet and the Certified Nurse Aide lowered the resident to the floor. The Primary Care Physician was made aware at 4:30 AM, and orders were received for acetaminophen (for pain) as needed, and x-ray of the lumbar spine and right hip. Certified Nurse Aide #8's written statement dated 12/12/2024 documented the resident was last toileted at 3:30 AM, they observed the resident ambulating to the bathroom and assisted the resident to slide to the floor in the bathroom. The resident had complaints of pain, and they went to get help. The resident was safely seated on the floor, leaning against the wall when they left the room to get the nurse. When they returned, the resident was lying under the sink. They documented that the nurse and another unidentified Certified Nurse Aide assisted in lifting the resident from the floor to the bed. Licensed Practical Nurse #10's written statement dated 12/12/2024 documented that Certified Nurse Aide #8 called them to Resident's #69 room, where they observed the resident in the bathroom with their back against the wall near the sink and their feet straight out in front of them. Licensed Practical Nurse #10 documented they asked the resident if they would like to go to the hospital and resident refused. The resident was transferred to the wheelchair with a two (2) person assist and then to the bed. Licensed Practical Nurse #10's progress note dated 12/12/2024 at 6:45 AM documented at approximately 4:00 AM Certified Nurse Aide #8 called them to the resident's room. Resident #69 was observed sitting on the bathroom floor in front of the sink. Their feet were straight out in front of them with their back against the wall. They had shoes on and were able to move all extremities. They complained of pain to the right side of their lower back. Certified Nurse Aide #8 reported that they found the resident ambulating to the bathroom while doing rounds and assisted the resident the rest of the way to the bathroom. The resident became unsteady on their feet and the aide lowered them to the floor. The primary physician was called and ordered to give acetaminophen and get an X-ray. Order for x-ray of the lumbar spine and right hip placed. The resident representative was called, and message left. The 12/12/2024 at 10:59 AM Physical Therapy note documented the resident presented with hip and facial bruising and was going to have an x-ray to check for fractures. Licensed Practical Nurse Manager #12's note dated 12/12/2024 at 1:56 PM documented the resident had a hematoma on the lower left eyebrow, purpura/bruise like area on their right mid-back and complained of a lot of discomfort in their right groin and upper thigh area which was swollen. They encouraged the resident to go to the hospital to make sure the hip or pelvis was not broken but the resident declined and would wait for the portable x-ray. Licensed Practical Nurse Unit Manager #12's progress note dated 12/12/2024 at 2:21 PM documented Primary Physician #1 examined Resident #69, and the resident refused to go to the hospital. The resident was informed by the physician if the x-ray results showed a hip fracture, the resident would have to go to the hospital; the resident agreed to this. There was no documented evidence Primary Physician #1 completed a medical evaluation of Resident #69 on 12/12/2024. Licensed Practical Nurse #21's progress note dated 12/13/2024 at 12:21 AM documented an X-ray was done at 6:30 PM (12/12/2024) and the results were pending. The x-ray report signed on 12/13/2024 at 7:44 AM, documented the resident had a fracture of the right femur (thigh bone). Licensed Practical Nurse Manager #12's progress note dated 12/13/2024 at 8:32 AM documented the Primary Physician was made aware of the x-ray results and ordered to send the resident to the hospital. Licensed Practical Nurse Unit Manager #12's progress note dated 12/13/2024 at 8:52 AM, documented the resident left the facility by ambulance. The hospital discharge summary dated 12/19/2024 documented the resident underwent surgery for an open reduction with internal fixation of the right hip on 12/14/2024. During a telephone interview on 3/11/2025 at 6:02 AM, Registered Nurse Supervisor #19 stated Resident #69 had frequent falls. They stated the process when a resident had a fall was that the staff would notify the Registered Nurse Unit Manager or the Registered Nurse Supervisor before transferring the resident from the floor. The Registered Nurse would assess the resident for injuries and document a risk assessment in the resident's electronic medical record. During a telephone interview on 3/11/2025 at 8:10 AM, Licensed Practical Nurse #10 stated they transferred Resident #69 from the floor to the wheelchair with the assistance of two (2) Certified Nurse Aides (#8 and an unidentified) on 12/12/2024. They stated they called the resident's physician who gave an order to transfer the resident to the hospital, but the resident refused to go to the hospital. They stated they called Licensed Practical Nurse Supervisor #13's phone, and no one answered. Licensed Practical Nurse #10 did not answer when asked if a Registered Nurse needed to assess a resident prior to transferring the resident off the floor or after a fall. During an interview on 3/11/2025 at 9:05 AM, the Director of Nursing stated that Licensed Practical Nurse #10 did not notify the Director of Nursing that Resident #69 had a fall. The Director of Nursing stated they were not made aware of the fall until 12/12/2024 when they came in to work. The Director of Nursing stated that Licensed Practical Nurse #10 did not report that they transferred the resident from the floor without a Registered Nurse assessment. The Director of Nursing stated Licensed Practical Nurse #10 should not have moved the resident from the floor without a Registered Nurse assessment. The Director of Nursing stated they reviewed the fall incident report and completed an investigation and stated that Licensed Practical Nurse Supervisor #13 re-educated Licensed Practical Nurse #10 on 12/12/2024. During a telephone interview on 3/11/2025 at 12:21 PM, Primary Physician #1 stated they were familiar with Resident #69, but only vaguely remember the incident where they got a call from a nurse related to the resident's fall. They did not know whether the nurse that called was a Registered Nurse or a Licensed Practical Nurse. The Primary Physician stated they did not remember details of their assessment of Resident #69 after the fall incident on 12/12/2024. They stated when a resident had a fall it was their practice to send the resident to the emergency room for evaluation. During a telephone interview on 3/11/2025 at 10:05 PM, Licensed Practical Nurse Supervisor #13 stated they were the assigned Supervisor for the night shift on 12/12/2024 and they were not made aware by Licensed Practical Nurse #10 that Resident #69 had a fall. Licensed Practical Nurse Supervisor #13 stated they were made aware of the fall at the end of the night shift by Licensed Practical Nurse Unit Manager #12. Licensed Practical Nurse Supervisor #13 stated they were trained to call the Director of Nursing when there were any falls or any emergency situations. During a telephone interview on 3/12/2025 at 6:25 AM Certified Nurse Aide #8 stated they came to work at 11:00 PM on 12/11/2024 and were told by the nurse that Resident #69 had sustained a fall in the afternoon of 12/11/2024. They stated that on 12/12/2024, the resident had another fall at around 4:00 AM. They stated they called the nurse (Licensed Practical Nurse #10) but could not remember the name of the nurse. They stated the resident was on the floor in the bathroom and the nurse asked the resident if they were in pain, and resident stated they were in pain. Certified Nurse Aide # 8 stated they went to the other unit to get another Certified Nurse Aide, and then three staff (Certified Nurse Aide #8 and Licensed Practical Nurse #10 and another Certified Nurse Aide) manually transferred the resident from the floor to the wheelchair, and then from the wheelchair to bed. During an interview on 3/12/2025 at 9:01 AM, the Director of Rehabilitation stated Resident #69 required two (2) staff assistance with toileting, transfers, and was non-ambulatory. They stated Resident #69 received Occupational Therapy and Physical Therapy from 8/14/2024 to 10/14/2024 when it was discontinued due to not making further progress. NYCRR 415.12

Based on observations, interviews, and record review conducted during the recertification survey from 3/5/2025 to 3/12/2025, the facility did not ensure a resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of their quality of life. This was evident for 1 of 1 residents (Resident #65) reviewed for Dignity. Specifically, Resident # 65 was observed ambulating wearing socks that were labeled with the resident's name on the top of the foot clearly visible to other residents, visitors and staff. The findings are: Resident #65 with diagnoses that included, but not limited to, Dementia, Anemia, and Hypertension. The Facility Policy titled Dignity, Respect, and Privacy in Treatment and Care revised 10/2023 documented that the Resident is treated with consideration, respect, and full recognition of his/her dignity and individuality, including privacy in treatment and in care for his personal needs. The Annual Minimum Data Set, dated dated dated [DATE] documented Resident #65 had severely impaired decision making, memory problem, and required maximal assistance for dressing and footwear. The Care Plan titled Dressing, revised 1/1/2025, documented Resident #65 required maximal assist of 1 staff for dressing. During observations on 03/05/25 at 10:04 AM, 03/06/25 at 11:13 AM, and 03/07/25 at 08:56 AM, Resident #65 was observed ambulating independently in the hallway, wearing socks labeled with their name clearly visible to other residents, staff, and visitors on the top of their foot. During an interview on 03/10/25 at 2:42 PM, Licensed Practical Nurse Unit Manager #14 stated the labels on clothing were so items returned from the laundry went to the appropriate resident. They were not aware that labels on clothing with the resident's name should not be visible to others. During an interview on 03/10/25 at 2:53 PM, the Social Worker stated they did not feel it was a problem having the name label visible to others on items of clothing. During an interview on 03/10/25 at 3:25 PM, the Director of Nursing stated clothing labels should not be in a location visible to others, and it was a dignity issue. They contacted the unit and requested that Resident #65's socks be collected and relabeled so that the name label was not visible to others. 10 NYCRR 415.5(a)

Based on observations, record review and interviews conducted during the recertification survey from 3/5/25-3/12/25, the facility did not ensure that they were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for Resident #30 reviewed for Call Systems/Environment. Specifically, the call system unit at the bedside for Resident #30 was not accessible. Findings include: The facility's policy titled Call Light revised 10/24/22 documented all residents will be provided with a method to communicate requests and needs directly to a staff or a centralized work area from the bedside, bathroom, and bathing areas, and to always place the call light within the resident's reach. The facility policy titled Fall Prevention revised July 2023 documented that all reasonable steps will be taken to keep the residents safe from falls and related injuries. Resident #30 was admitted with diagnoses which included fracture of the right femur, cerebral infarct, and hemiplegia and hemiparesis affecting the left side. The 12/9/24 Minimum Data Set admission assessment documented the resident had intact cognition and required supervision with toileting hygiene, sit to stand and chair to bed and toilet transfers. Resident #30 had a fall in the past month, prior to admission, and a fracture related to a fall in the past 6 months prior to admission. The 3/4/25 Quarterly Minimum Data Set (resident assessment) documented Resident #30 had moderately impaired cognition and required supervision with toileting hygiene and sit to stand and chair to bed transfers and toilet transfers. The Nursing Falls Risk Data Collection Tools dated 12/3/24, 12/31/24, 1/26/25, 1/27/25, 1/30/25, 2/19/25 and the Falls Risk Tool dated 2/22/25 documented the resident was at risk for falls. The 3/5/25 Care Plan for Activities of Daily Living documented Resident #30 required supervision with toileting and transfers and ambulation with rolling walker. The 3/5/25 Care Plan for Falls documented Resident #30 was at risk for falls related to prior fall in the last 90 days prior to admission. Interventions included to remind to call for assistance. The Kardex documented ambulation in room with supervision, fall injury alert-anticoagulant therapy use, remind to call for assistance. On 03/05/25 at 01:02 PM, Resident #30 was observed in their wheelchair in their room. The call bell was observed out of the resident's reach and out of the resident's sight, lying on the stationary chair behind the resident in the corner of the room. When asked, how do you call for help, Resident #30 stated lately it has been difficult because I don't have a call bell. Resident #30 stated they have to yell for the nurse if they need something. Resident #30 additionally stated they take themself to the toilet by wheeling themself into the bathroom, hold onto the grab bar, and transfer themself. On 03/05/25 at 01:25 PM, Resident #30 was observed sitting in their wheelchair, the call bell was still located out of the resident's reach and out of the resident's sight, on the stationary chair in the corner of the room. On 03/05/25 at 01:54 PM Resident #30 was observed lying in bed awake. The call bell was observed on the stationary chair in the corner of the room. When asked, Resident #30 stated they did not know where their call bell was. Resident #30 looked around their room and stated they did not see the call bell. The surveyor gave the resident their call bell. On 03/06/25 at 08:55 AM Resident #30 was not observed in their room. The call bell was observed on the stationary chair in the corner of the room. On 03/06/25 at 10:55 AM and at 11:55 AM, Resident #30 was observed sleeping in bed, the call bell was observed on a stationary chair in the corner of the room, out of the resident's reach and out of the resident's sight. On 03/06/25 at 12:22 PM, Resident #30 was observed sitting in their wheelchair in their room eating lunch. The call bell was observed out of sight and out of reach of the resident, lying on the stationary chair in the corner of the room. On 03/07/25 at 12:30 PM during an interview, Licensed Practical Nurse Unit Manager #4 stated that all residents should have their call bell in reach at all times. They stated they are aware that Resident #30 had a fall prior to admission and is confused. On 03/07/25 at 01:24 PM during an interview with the Director of Nursing, they stated the Certified Nurse Aides and any other staff should place all resident's call bells within resident's reach. 10NYCRR 415.29

Based on record review and interview conducted during the recertification and abbreviated surveys (NY00346725) from 3/5/25 to 3/12/25, the facility did not ensure residents and/or representatives were provided written notification in a manner they understood for 5 of 5 residents reviewed for discharge (Resident #50, #202, #203, #68, and #69) who were transferred/discharged to the hospital. Specifically, Residents #50, #202, #203, #68 and #69 were transferred to the hospital and the facility was unable to provide evidence that written notice of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand was provided to the resident and the resident's representative(s). The findings are: The facility policy titled Discharge Notice and dated 3/25 documented; Nursing homes must provide residents with a detailed, written discharge/transfer notice which must include specific information regarding the resident's rights in this process. 1.Resident #50 was admitted with diagnoses including anxiety, acute respiratory failure and dependence on mechanical ventilation. The Minimum Data Set, an assessment tool dated 1/4/25 documented the resident had intact cognition and was dependent on staff for all activities of daily living. The Respiratory therapy note dated 12/20/24 at 01:43 AM documented the resident was on assist control ventilator settings, was given a nebulizer for increased work of breathing using accessory muscles and respiratory rate of 36. The physician was notified and ordered the resident to be sent to the hospital for evaluation. The 12/20/24 Minimum Data Set Discharge/Return Anticipated assessment documented Resident #50 was discharged to the hospital. There was no documented evidence the resident and/or resident's representative was notified in writing of the transfer to the hospital. During an interview with the Director of Social Work on 03/11/25 at 12:04 PM they stated they were responsible for sending transfer/discharge notices in writing but could not provide documented evidence that it was provided to the resident or representative. They stated there was a service gap with the change of Administration staff and it had not been done for a few months. During an interview with the Administrator on 3/10/25 at 03:27 PM they stated they started at the facility about six weeks ago and during an audit they realized the facility had not been giving discharge notices in writing and began implementing it right away. Thery stated there was a lot of new staff recently and provided education about the process and added it to their Quality Assurance and Performance Improvement program. 2.Resident #202 was admitted with diagnoses which included atrial fibrillation, hypertension, and peripheral vascular disease. The 6/17/24 Minimum Data Set, an assessment tool, documented the resident had moderately impaired cognition and required staff assistance with activities of daily living. The facility Accident Report/Investigation Report dated 6/28/24 documented Resident #202 was transferred to the hospital for evaluation. The 6/28/24 Minimum Data Set Discharge/Return Anticipated assessment documented Resident #202 was discharged to the hospital. There was no documented evidence the resident and/or resident's representative was notified in writing of the transfer to the hospital. On 03/11/25 at 12:04 PM during an interview, the Director of Social Work stated they could not provide documented evidence that written notice of reason for transfer to the hospital was provided to the resident or representative. 3.Resident #203 was admitted with diagnoses including dementia, psychosis, and depression. The 6/21/24 Modification of admission Minimum Data Set, an assessment tool, documented moderately impaired cognition and required staff assistance with activities of daily living. The facility Accident Report/Investigation Report dated 6/28/24 documented Resident #203 was transferred to the hospital for evaluation. The 6/28/24 Minimum Data Set Discharge/Return Anticipated assessment documented Resident #202 was discharged to the hospital. There was no documented evidence the resident and/or resident's representative was notified in writing of the transfer to the hospital. On 03/11/25 at 12:04 PM during an interview, the Director of Social Work stated they could not provide documented evidence that written notice of reason for transfer to the hospital was provided to the resident or representative. 10NYCRR 415.3 (i)(1)(ii)(a)(b)

Based on record review and interview conducted during the recertification and abbreviated surveys (NY00346725) from 3/5/25 to 3/12/25, the facility did not ensure residents or resident representatives were notified in writing of the facility bed hold policy for 5 of 5 residents (Resident #50, #202, #203, #68,#69) reviewed for discharge. Specifically, Residents #50, #202, #203, #68 and #69 were transferred to the hospital and the facility was unable to provide evidence that written notice of facility bed hold policy was given to the resident or their representatives. The findings are: The facility policy titled Bed Hold and Notice dated 8/24 documented the facility will notify the designated representative and/or the resident of the facility's bed reservation policies, verbally and in writing at the time of admission and at the time of transfer. 1.Resident #50 was admitted with diagnoses including anxiety, acute respiratory failure and dependence on mechanical ventilation. The Minimum Data Set, an assessment tool dated 1/4/24 documented the resident had intact cognition and was dependent on staff for all activities of daily living. The Respiratory therapy note dated 12/20/24 at 01:43 AM documented the resident was on assist control ventilator settings, was given a nebulizer for increased work of breathing using accessory muscles and respiratory rate of 36. The physician was notified and ordered the resident to be sent to the hospital for evaluation. The 12/20/24 Minimum Data Set Discharge/Return Anticipated assessment documented Resident #50 was discharged to the hospital. There was no documented evidence a written notice of the facility Bed Hold Policy was given to the resident or their representative. During an interview on 03/11/25 at 12:04 PM with the Director of Social Work, they stated they could not provide documented evidence that a written notice of the facility bed hold policy was provided to the to the resident or representative. They stated there had been a service gap due to recent changes in administration. During an interview with the Administrator on 03/10/25 at 03:38 PM they stated when they started working at the facility, there was noticeable inconsistency with notices of bed hold policy. Since then, notices have been going out to families and the issue has been added to the facility's Quality Assurance and Performance Improvement plan. 2.Resident #202 was admitted with diagnoses which included atrial fibrillation, hypertension, and peripheral vascular disease. The 6/17/24 Minimum Data Set, an assessment tool, documented the resident had moderately impaired cognition and required staff assistance with activities of daily living. The facility Accident Report/Investigation Report dated 6/28/24 documented Resident #202 was transferred to the hospital for evaluation. The 6/28/24 Minimum Data Set Discharge/Return Anticipated assessment documented Resident #202 was discharged to the hospital. There was no documented evidence the resident and/or resident's representative was notified in writing of facility bed hold policy. On 03/11/25 at 12:04 PM during an interview, the Director of Social Work stated they could not provide documented evidence that a written notice of the facility bed hold policy was provided to the to the resident or representative. 3.Resident #203 was admitted with diagnoses including dementia, psychosis, and depression. The 6/21/24 Modification of admission Minimum Data Set, an assessment tool, documented moderately impaired cognition and required staff assistance with activities of daily living. The facility Accident Report/Investigation Report dated 6/28/24 documented Resident #203 was transferred to the hospital for evaluation. The 6/28/24 Minimum Data Set Discharge/Return Anticipated assessment documented Resident #202 was discharged to the hospital. There was no documented evidence the resident and/or resident's representative was notified in writing of the facility bed hold policy. On 03/11/25 at 12:04 PM during an interview, the Director of Social Work stated they could not provide documented evidence that a written notice of the facility bed hold policy was provided to the to the resident or representative for their transfer to the hospital. 10NYCRR 415.3 (i)(3)(i)(a)

Based on observation, record review, and interview during the recertification survey from 3/5/25-3/12/25, the facility did not ensure that the Comprehensive Care Plans were reviewed and revised in a timely manner for 1 (Resident #68) of 4 residents reviewed for pressure ulcers. Specifically, Resident #68's Skin Integrity at Risk Care Plan dated 11/15/24 and updated 2/12/25 documented to float Resident #68's heels, however it was not updated to include a new intervention when staff observed the resident moving their legs frequently when in bed. The findings are: The facility policy titled Interdisciplinary Care Planning revised 4/15/2024 documented a comprehensive resident centered care plan is developed by the interdisciplinary team upon admission and reviewed/ updated on a regular basis throughout the residence length of stay. The comprehensive care plan is reviewed and updated with changes and minimally on a quarterly basis. Resident #68 had diagnoses including protein calorie malnutrition, failure to thrive, and dementia. The 11/20/24 Quarterly Minimum Data Set Medicare 5-day assessment documented intact cognition. Resident #68 required maximum assistance with rolling in bed and had two unstageable pressure ulcers present on admission. The 11/15/24 Skin Integrity at Risk Care Plan documented an intervention to float Resident #68's heels in bed. The 2/4/25 Skin Integrity at Risk Care Plan documented intervention to float heels in bed. The 2/15/25 Quarterly Minimum Data Set assessment documented intact cognition. Resident #68 required maximum assistance with rolling in bed, and one stage two pressure ulcer present on admission. The Kardex (Certified Nurse Aide instructions) documented to float Resident #68's heels in bed. On 03/05/25 at 10:37 AM, Resident #68 was observed sitting in their wheelchair wearing sneakers, with their right foot on the floor, although their wheelchair footrest was in place. Resident #68 stated their right heel is bruised and it feels better when they are wearing sneaker because the sneaker has padding. They stated their heel hurts at night when they move their foot. Resident #68 stated that nobody offered padded booties in bed. On 03/06/25 at 09:06 AM, Resident #68 was observed in bed with their heels directly on the mattress, and no heel booties or pillow was observed to float their heels, and there was no air mattress in place. On 03/07/25 at 10:45 AM, Resident #68 was observed lying in bed with their heels directly on the mattress, no air mattress was in place, no heel booties or pillow were observed to float their heels. On 03/07/25 at 11:00 AM during an interview, Licensed Practical Nurse #1 stated that Resident #68 moves in bed, and therefore pillows are not effective to float Resident #68's heels, but they never requested another intervention such as heel booties or another device for the resident. They stated they should have told the Nurse Manager. On 03/07/25 at 04:10 PM during an interview, Licensed Practical Nurse Unit Manager stated that nursing staff who was aware that the pillow was not effective for floating the resident's heels should have reported the concern to them or therapy or any nursing management, so that a new intervention could have been implemented. 10 NYCRR415.11(c)(2)(i-iii)

Based on observations, record reviews and interviews during the recertification survey from 3/5/25 through 3/12/25, the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 1 of 1 resident (Resident #29) reviewed for activities of daily living. Specifically, Resident #29 required staff assistance with personal hygiene was observed on three (3) occasions with long, stained fingernails. Findings include: The facility policy titled nail care revised October 2011 documented that routine nail care is to be done following baths and showers whenever possible. The facility policy titled activities of daily living revised October 2023 documented that a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living including hygiene bathing dressing grooming and oral care. Resident #29 was admitted with diagnoses including heart failure, need for assistance with personal care, and dementia. The 1/5/25 Significant Change Minimum Data Set assessment documented Resident #29 had severely impaired cognition, required dependent assistance with showers. The 1/2/25 Care Plan documented Resident #29 required maximal assistance with upper body bathing. The Kardex documented showers on day shift Wednesdays & Saturdays, dependent with lower body, maximal assistance with upper body. There was no documented evidence regarding trimming or cleaning fingernails. On 03/05/25 at 12:55 PM and on 03/06/25 08:55 AM, Resident #29 was observed with long fingernails with yellow-brown stains on them. On 03/07/25 at 12:13 PM during an observation and interview, Certified Nurse Aide #7 observed Resident #29's fingernails. Certified Nurse Aide #7 stated they did not pay attention to resident's fingernails when they provided care. They stated they provided care to Resident #29 two days ago and did not notice Resident #29's long fingernails. They stated that fingernails should be clipped when they are long. On 03/07/25 at 12:22 PM during an interview, Licensed Practical Nurse Unit Manager #4 stated the Certified Nurse Aides were responsible for cutting residents' fingernails unless the resident was diabetic. They stated the Certified Nurse Aide should have told the nurse if a resident's nails were long. When Licensed Practical Nurse Unit Manager #4 observed Resident #29's fingernails, they stated the resident's fingernails were long. 10 NYCRR 415.12 (a)(3)

Based on observation, record review, and interview during the recertification survey and abbreviated surveys (NY00347643) from 3/5/25-3/12/25, the facility did not ensure residents at risk for pressure ulcers and residents who had pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, and prevent new ulcers from developing for 2 of 4 residents (Residents #68 and #352) reviewed for Pressure Ulcers. Specifically, 1) Resident #68's feet were not floated in bed as ordered and there was no documented evidence that wound care treatments were administered 10 of 48 times in February and 4 of 18 times in March, and 2) for Resident #352, there was no documented evidence that wound care treatments were administered five (5) times in May and June 2024 for their Stage 3 pressure ulcers to their coccyx, and left lateral ankle, and Stage 4 pressure ulcer to their left dorsal foot. The findings are: The 6/23 facility policy titled Documentation of Pressure Ulcer and Chronic Wounds documented pressure ulcers and chronic wounds are monitored closely to monitor effectiveness of treatment and change in risk factors, all pressure ulcers and chronic wound dressings will be inspected daily, pressure, stasis, and or chronic wounds will be monitored daily with documentation. 1) Resident #68 had diagnoses including protein calorie malnutrition, failure to thrive, and dementia. The 11/20/24 Quarterly Minimum Data Set Medicare 5-day assessment documented intact cognition. Resident #68 required maximum assistance with rolling in bed and had two unstageable pressure ulcers present on admission. The 11/13/24 Hospital Nursing Wound Summary documented follow-up evaluation for two left lateral heel deep tissue injuries approximately 0.5-centimeter X 1.5 centimeter deep, maroon in color, diffuse wound edges, bilateral heels red and slow to blanch. Area cleaned, skin prep applied, and area offloaded with pillow. Dayshift nurse informed. General Care Instructions to continue implementation of the pressure injury prevention bundle. Mattress type recommended-pressure redistribution bed/mattress, schedule regular repositioning and turning. The 11/15/24 Skin Integrity at Risk Care Plan documented intervention to float Resident #68's heels in bed. The 1/15/25 Skin Risk Data Collection Tool documented an unstageable pressure injury to the bottom of right foot. It was not open and there was no drainage. Care Planning interventions included to float heels when in bed. The 2/4/25 Skin Integrity at Risk Care Plan documented intervention to float heels in bed. The 2/12/25 Physician's Orders documented to apply Skin Prep to heels as prophylaxis every shift. The 2/15/25 Quarterly Minimum Data Set assessment documented intact cognition. Resident #68 required maximum assistance with rolling in bed, and one Stage 2 pressure ulcer present on admission. The Kardex (Certified Nurse Aide instructions) documented to float Resident #68's heels in bed. The February 2025 Treatment Administration Record documented no evidence that skin prep was administered as ordered 10 of 48 times (2/14, 2/18, 2/24, and 2/25 on the evening shift, 2/15 and 2/23 on the day shift, and 2/16, 2/21, 2/22, and 2/24 on the night shift). The March 2025 Treatment Administration Record documented no evidence that skin prep was administered 4 of 18 times between 3/1/25 and 3/6/25 (3/2 on the evening shift, 3/3 on the day shift, and 3/2 and 3/6 on the night shift). On 3/05/25 at 10:37 AM, Resident #68 was observed sitting in their wheelchair wearing sneakers, with their right foot on the floor, although their wheelchair footrest was in place. Resident #68 stated their right heel was bruised and it felt better when they were wearing sneaker because the sneaker had padding. They stated their heel hurts at night when they move their foot. Resident #68 stated that nobody offered padded booties in bed. On 3/06/25 at 9:06 AM, Resident #68 was observed in bed with their heels directly on the mattress, and no heel booties or pillow was observed to float their heels, and there was no air mattress in place. On 3/07/25 at 10:45 AM, Resident #68 was observed lying in bed with their heels directly on the mattress, no air mattress was in place, no heel booties or pillow were observed to float their heels. On 3/07/25 at 10:47 AM during an interview, Certified Nurse Aide #3 stated they were responsible for Resident #68 and did not know much about Resident #68's left foot. They stated they did not get report about any specifics on Resident #68's positioning or floating their heels. Certified Nurse Aide #3 stated they looked at the Kardex before providing cares to Resident #68, and did not notice anything about positioning or floating their heels. When they reviewed the Kardex during the interview, they stated they should have put a pillow under Resident #68's calves. On 3/07/25 at 10:54 AM during an interview, Licensed Practical Nurse #2 stated they were responsible for Resident #68. They stated they were aware of the order to apply skin prep to Resident #68's bilateral heels and Resident #68's heels should be floated in bed. On 3/07/25 at 11:15 AM during an interview, the Assistant Director of Nursing stated they did weekly wound care rounds with the wound care physician. The Assistant Director of Nursing reviewed the resident's care plan and stated the Certified Nurse Aide should have checked the Kardex and floated Resident #68's heels. On 3/07/25 at 11:08 AM during an interview, Licensed Practical Nurse #1 stated they were responsible to apply the Skin Prep to Resident #68's heels on 2/15/25. They stated they believed they applied the treatment but forgot to sign and should have signed. On 03/07/25 at 1:27 PM during an interview with the Director of Nursing regarding administration omissions, they stated the nurses were responsible for administering treatments as ordered by the provider and for signing the administration records after completion. 51214 2. Resident #352 had diagnoses including Chronic Vascular Disorders of the Intestine, Peripheral Vascular Disease, and Peripheral Neuropathy. The Care Plan titled At Risk for Impaired Skin Integrity dated 2/14/24 documented the resident was at risk for impaired skin related to neuropathy and anemia. Interventions included to apply moisture barrier following incontinence care and as needed, turn and reposition every 2 hours and as needed, and skin and feet check with daily care, document weekly on shower day. The Admission 5 Day Minimum Data Set, dated dated dated [DATE] documented intact cognition, maximum assistance with most activities of daily living, at risk for pressure ulcers, and no ulcers present. The Medical Provider Note dated 4/14/24 documented a new Stage 1 to the coccyx. The Physician's Order dated 4/14/24 documented to cleanse coccyx with normal saline, pat dry, apply hydrogel to wound bed, and cover with border gauze. The Physician's Order dated 4/18/24 documented an air mattress. The Wound Care Note dated 4/23/24 documented: - a coccyx Stage 3 pressure injury measuring 4.5-centimeter x 3.5 centimeter x 0.1 centimeter, - a deep tissue injury to the right heel measuring 0.5-centimeter x 2.0 centimeter x unable to measure depth, - a deep tissue injury left lateral foot measuring 0.5 centimeter x 1.0 centimeter x unable to measure depth, - a deep tissue injury left lateral ankle measuring 5.6 centimeter x 1.4 centimeter x unable to measure depth. The Physician's Order dated 4/24/24 documented to apply Santyl Ointment topically every day shift for wound care. To cleanse the wound at coccyx with wound cleanser and pat dry, apply a thin layer of Santyl and cover with dry protective dressing. The Care Plan titled Impaired Skin Integrity revised 4/26/24 documented resident with impaired skin integrity related to dehydration, impaired mobility, poor nutrition, pressure ulcer. Interventions included administer treatment per physician's order, provide adequate calories and protein for healing, measure and evaluate wound at least weekly, offload heels. The Significant Change in Status Minimum Data Set, dated dated dated [DATE] documented intact cognition, maximum assistance to dependent on assistance for Activities of Daily Living, at risk for pressure ulcers, two Stage 3 pressure ulcers and one deep tissue injury/unstageable. The Physician's Order dated 5/7/24 documented Santyl Ointment for wound care; to cleanse left ankle with wound cleanser spray and apply Santyl to open area only, cover with Xeroform to open area and dry protective dressing. The Physician's Order dated 5/7/24 documented Xeroform Oil Emulsion 2x 2 External Pad apply to Coccyx topically in the evening for wound care. To cleanse coccyx with wound cleanser, apply Xeroform and cover with dry protective dressing. The Physician's Order dated 5/7/24 documented Xeroform Oil Emulsion 2x 2 External Pad apply to left ankle topically in the evening for wound care. The Treatment and Medication Administration Records for May 2024 had no documented evidence that the treatment to the coccyx was completed on 5/2, 5/6, 5/7, and 5/9/24; and no evidence it was completed for the left ankle on 5/9/24. The Physician Order dated 6/19/24 documented Santyl Ointment to apply topically every evening shift for wound care cleanse left dorsal foot with NS or wound cleanser. The Medication and Treatment Administration Records for June 2025 had no documented evidence that the treatments to the left ankle and left dorsal foot were completed on 6/21/24. During an Interview on 3/12/25 at 10:10 AM, Licensed Practical Nurse Unit Manager #14 stated the treatments for Resident #352's wound care were not signed on 5/2, 5/6, 5/7, 5/9, and 6/21 and the nurse failed to document a reason why. They stated that if the nurse did not complete the treatment, there should be documentation why the treatment was not done. During an interview on 03/12/25 at 10:40 AM, the Director of Nursing stated if the nurse did not sign for a treatment or medication on the administration records, that would mean the treatment or medication was not administered. They stated the nurse should have documented the reason the treatment was not done on the Medication or Treatment Administration records and/or in a progress note. 10 NYCRR 415.12

Based on observation, interview, and record review conducted during the recertification survey from [DATE]-[DATE], the facility did not ensure drugs and biologicals were maintained in accordance with currently accepted professional standards for expiration dates and storage. Specifically, 1) one (1) of two (2) medication rooms examined for medication storage, had a box of expired Jevity 1.5 feeding that was stored and being used; and expired nicotine patches were stored in 1 of 3 medication carts examined for medication storage. 2) Resident #60 was found with physician ordered Isosorbide, Amlodipine, Carvedilol (blood pressure pills), Sertraline (anti-depressant), Aspirin, Apixaban (blood thinner), Folic Acid (supplement), Levetiracetam (seizure medicine), Docusate (stool softener), and Omeprazole (anti-acid) in their room on their bedside table. The findings are: The facility policy titled Medication/Treatment Labeling and Storage revised ,d+[DATE], documented medications/treatments are stored under proper conditions of sanitation, temperature, light, moisture and ventilation. There is no documentation specific to expiration dates in the policy. 1. During an observation of the Medication Room on the First Floor Unit on [DATE] at 11:00 AM, an open box containing six bottles of Jevity 1.5 Cal with an expiration date of February 1, 2025 was found. During an observation on [DATE] at 11:25 AM with Licensed Practical Nurse #2, a nearly empty bottle of Jevity 1.5 Cal was observed in Resident #90's room hanging, but not running or being administered to resident at that time. A handwritten date of [DATE] was written on the bottle. The bottle had an expiration of February 1, 2025. During an interview on [DATE] at 11:33 AM, Licensed Practical Nurse #2 stated that the Jevity 1.5 Cal hanging in Resident #90's room was stopped by them that morning as their feeding was hung in the evening and taken down in the morning at 10 AM. They stated the Jevity 1.5 Cal used did have an expiration date of [DATE] and should not have been hung since it was expired. During an observation on the First Floor Unit on [DATE] at 11:40 AM with Licensed Practical Nurse #1, seven Nicotine Patches with an expiration date of ,d+[DATE] were loose in the top drawer of the medication cart with no resident label. Licensed Practical Nurse #1 was interviewed during the observation and stated the patches were house stock so that was why there was no label. They stated the patches should not have been in the cart since they were expired. During an interview on [DATE] at 3:57 PM, Licensed Practical Nurse Unit Manager #4 stated that the medication nurse hanging a tube feeding should check the expiration date prior to hanging it. They stated all nurses should check the contents of the medication room for any expired items. Medication nurses should be checking, and are responsible for, the contents of their medication carts. They should dispose of any expired items and let the Unit Manager know. 2. Resident #60 was admitted to the facility with diagnoses including Hypertension, Epilepsy, Atrial Fibrillation, and Folate Deficiency Anemia. The [DATE] admission Minimum Data Set assessment documented intact cognition, and required set-up and clean-up assistance with eating. The Physician Orders and February 2025 Medication Administration Record documented morning medications included Isosorbide 30 mg for Hypertension, Carvedilol 12.5 mg for Hypertension, Sertraline 50 mg for depression, Amlodipine 5 mg for Hypertension, Aspirin 81 mg tablet for prophylactic, Docusate 1 tablet for constipation, Apixaban 5 mg for Atrial Fibrillation, Folic Acid 1000 mcg for supplement, Levetiracetam 1000 mg for seizure, and Omeprazole 20 mg for Gastro-esophageal disease. The [DATE] Care Plan had no documented evidence Resident #60 could self-administer medications. On [DATE] at 10:15 AM during an observation, Registered Nurse Unit Manager #6 entered Resident #60's room and left a cup of medication at bed table and instructed Resident #60 to not take the medications until they returned with water. On [DATE] at 10:26 AM, during an observation Resident #60's medications were still sitting on bedside table. On [DATE] at 10:28 AM during an interview, Registered Nurse Unit Manager #6 stated the medications left at bedside were Isosorbide, Carvedilol, Sertraline, Amlodipine, Aspirin, Docusate, Apixaban, Folic acid, Keppra, and Omeprazole. Registered Nurse Unit Manager #6 stated Resident #60 was alert and would wait for them to bring water to take the medication. Registered Nurse Unit Manager #6 stated they should have left the medications locked in the medication cart while getting water for the resident. Registered Nurse Unit Manager #6 stated this was not normal practice or facility policy. 10 NYCRR 415.18(e) (,d+[DATE]) 51902

Based on observation and interview conducted during the recertification survey from 3/5/25 to 3/12/25, the facility did not ensure food was distributed and served in accordance with professional standards for food service safety. Specifically, nursing staff did not perform proper hand hygiene while serving beverages at lunch meal. The findings are: The facility policy last revised 11/2019, Dining Room Service documented dining room meal service is provided in a clean, comfortable and orderly atmosphere. On 3/5/25 at 12:28 PM in the main dining room, the Assistant Director of Nursing was observed serving beverages to multiple residents wearing disposable gloves and not changing gloves between service. The Assistant Director of Nursing touched the beverage cart handle, proceeded to pick up a resident's glass, touched the carafe/pitcher handle and replaced the glass for resident use. The Assistant Director of Nursing did not change their disposable gloves before moving to serve the next resident. This was observed multiple times until the Regional Director of Nursing was observed speaking to the Assistant Director of Nursing, upon which the Assistant Director of Nursing removed the disposable gloves. The Assistant Director of Nursing continued to serve residents without using hand sanitizer or washing their hands between serving residents. The Assistant Director of Nursing touched their own face with their bare hand while taking a beverage order at a table and proceeded to serve Resident #93 hot cocoa in a cup at a separate table. Resident #93 touched the cup to take a drink. The Assistant Director of Nursing touched a resident's walker with their bare hands to move it for a resident and continued to serve a beverage to that resident. After all beverages were served and beverage cart was put away, Assistant Director of Nursing used hand sanitizer. On 3/5/25 at 1:15 PM during an interview with the Assistant Director of Nursing, they stated they wore disposable gloves because they were worried the ice scoop would fall into the ice bin during service and bare hands would contaminate the ice. The Assistant Director of Nursing stated the Regional Director of Nursing asked why gloves were being used, and stated gloves were not needed. The Assistant Director of Nursing stated the disposable gloves were to protect the residents. The Assistant Director of Nursing stated they should have used the sink to wash hands, but the sink was out of soap. The surveyor confirmed no soap at sink. The Assistant Director of Nursing stated if they had no soap and no disposable gloves, they should have used hand sanitizer, which was used after beverage service. 10 NYCRR 415.14(h)

Based on observation, record review and interview conducted during a recertification survey from 3/5/25 to 3/12/25, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infection for all residents. Specifically, 1) the facility did not provide documentation of screening, administration, or declination and education provided for 2 of 10 staff (Certified Nurse Aide #15 and Laundry Aide #16) reviewed for pneumococcal vaccination; 2) there was no evidence that a Water Management Plan was reviewed and updated, if needed, annually to prevent and control Legionella; and 3) a Licensed Practical Nurse was observed putting an unsanitized blood pressure cuff into the medication cart before properly cleaning it. The findings are: The facility policy titled Pneumococcal Vaccination Program for employees dated 10/24 documented control of pneumococcal disease is increasingly important due to high morbidity rates. The pneumococcal vaccine will be offered to all employees. During the recertification survey the facility was asked to provide documentation that pneumococcal vaccination was offered, education was provided, and staff had the opportunity to consent or decline the vaccine for Certified Nurse Aid #15 and Laundry Aide #16, but none was provided. 1.During an interview on 3/12/25 at 10:59 AM, Licensed Practical Nurse #17 stated they were responsible for collecting data for employee immunization status which included eligibility, education and administration of vaccines. They stated they did not have completed forms for Certified Nurse Aide #15 and Laundry Aide #16 which verified they were eligible, educated and consented to or declined the pneumococcal vaccination. During an interview on 03/12/25 at 10:29 AM, the Director of Nursing stated the Infection Preventionist was new, and they had delegated the vaccines task to the Licensed Practical Nurse #17. Licensed Practical Nurse #17 was responsible for ensuring forms were signed by the employee as proof that education was provided. The Director of Nursing stated they would make sure vaccines were offered and declinations were on file for staff and was not sure why this happened. 2., The facility's Legionella binder was reviewed with the Director of Maintenance and the Regional Director of Maintenance. The Water Management Plan was undated, and there was no documented evidence as to when it was completed, reviewed, or updated. On 03/05/25 at 3:45 PM, the Director of Maintenance stated they did not realize the Water Management Plan was undated. 3. During an observation of the medication pass on the second-floor unit that started at 8:58 AM on 3/10/25, Licensed Practical Nurse #18 obtained a blood pressure reading for Resident #40 prior to administering their medications. They used a wrist cuff to obtain the reading. After obtaining the blood pressure, they returned the wrist cuff back into the medication cart without sanitizing the cuff. When asked about the sanitization of the cuff, Licensed Practical Nurse #18 stated it should have been wiped after use. During an interview on 3/10/25 at 11:03 AM, the Director of Nursing stated that all shared equipment should be sanitized between each use. They stated that staff may use either alcohol wipes or the sanitizing wipes with a purple top to sanitize the cuff. 10NYCRR 415.19 (a)(1-3) 43478 51214

Based on observation, record review and interview conducted during the recertification survey from 3/5/25 to 3/12/25, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infection for all residents. Specifically, the facility did not provide documentation of screening, administration or declination and education provided for 2 of 10 staff (Certified Nurse Aide #15 and Laundry Aide #16), reviewed for COVID-19 vaccinations. The findings are: The facility COVID-19 policy dated 10/30/24 documented the facility will ensure that all employees and contracted staff will be screened prior to offering the vaccination and prior to immunization, medical precautions and contraindications necessary for determining whether they are appropriate candidates for vaccination at any given time. Documentation will be maintained to reflect that the required education was provided and whether the resident and staff member received the vaccine. During the recertification survey, the facility was asked to provide documentation that COVID-19 vaccination was offered, education was provided, and staff had the opportunity to consent or decline the vaccine for Certified Nurse Aide #15 and Laundry Aide #16, but none was provided. During an interview on 3/12/25 at 10:59 AM with Licensed Practical Nurse #17, they stated they were responsible for collecting data for employee immunization status which included eligibility, education and administration of vaccines. They did not have a completed form for Certified Nurse Aide #15 and Laundry Aide #16 which verified they were eligible, educated and consented to or declined the vaccination. Licensed Practical Nurse # 17 stated they did not know the COVID-19 vaccine needed to be offered to staff. During an interview with the Director of Nursing on 03/12/25 at 10:29 AM they stated the Infection Preventionist was new and they delegated the vaccines to the Licensed Practical Nurse #17 to ensure forms were signed by the employee as proof education was provided. The Director of Nursing stated they were not sure why this happened. 10NYCRR 415.19 (a)(1-3)

F600 Based on record reviews and interviews conducted during an abbreviated survey (NY 548), the facility did not ensure that a resident is free from verbal and emotional abuse and mistreatment. This was evident for 1 of 6 residents sampled (Resident #1). Specifically, Certified Nursing Assistant (CNA#1) was witnessed by Licensed Practical Nurse (LPN#1) to be verbally abusive to Resident #1 on 05/23/2022. Despite witnessing the verbal abuse, LPN#1 left the resident with CNA#1 and did not report the incident. The incident was reported by Resident #1 on 05/24/2022 and that s/he felt scared and humiliated after the incident. Resident #1 further alleged that once LPN#1 left the room CNA#1 was rough while assistinghim/her in the wheelchair. The findings are: Review of the facility Policy and Procedure on Abuse dated 11/2016 and revised 4/2017 documented that the resident has the right to be free from abuse, neglect, mistreatment, and exploitation and instance of abuse of all residents, irrespective of any physical or mental condition that can cause physical harm, pain, or mental anguish. Willful as used in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, an assessment tool) dated 4/04/2022, documented that the resident had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 14/15, associated with intact cognition. The resident required total dependence two-person assistance for transfer via Hoyer lift, extensive two-person assistance for bed mobility and toilet use, and extensive one-person assistance for personal hygiene. The resident was incontinent of bowel and bladder function. Review of a facility Accident/Incident Report dated 5/24/2022 documented that Resident #1 informed LPN#1 that s/he would like the abuse that happened on 5/23/2022 reported. The resident made a complaint stating CNA#1 came into the room on 5/23/2022 to get the resident dressed and out of bed for a visit with his/her daughter and CNA#1 was very annoyed. The resident stated that CNA#1 stated, I gotta do all this work for you to be up for an hour? The resident stated that while CNA#1 was putting him/her into the chair, CNA#1 was rough with him/her, pushing him/her back into the chair. The resident also stated that LPN#1 was also in the room to assist CNA#1 and witnessed some of the interaction. During an interview conducted with Resident #1 on 6/14/2022 at 11:00 am, the resident stated that s/he reported to LPN#1 on 5/24/2022 that s/he wanted to report to the social worker that she was treated very badly by a CNA the day before. His/her daughter was coming to the facility for a visit, and s/he needed help to get out of bed and get dressed. Resident #1 stated that CNA #1 was very rough with him/her and was mad that s/he had to help the resident. CNA #1 complained the entire time that s/he didn't have time to get her work done because s/he had to spend so much time getting the resident out of bed for just one hour. Resident #1 stated that LPN #1 came into the room to help CNA #1 with the Hoyer Lift transfer. The nurse tried to calm the CNA down and told him/her not to talk about her complaints in front of the resident. This seemed to aggravate CNA #1 even more as his/her voice became louder. Resident #1 stated s/he was scared when the nurse left the room and s/he remained alone with CNA #1. Resident #1 also stated, I felt bad I couldn't do more for myself, but I need help because of my health. Resident #1 was unable to turn herself onto his/her side and CNA #1, shoved me very roughly into the side rail. Resident #1 described his/her feelings during this incident as being made to feel humiliated. During an interview conducted with CNA #1 on 6/14/2022 at 3:40pm, CNA #1 denied being physically, verbally and emotionally abusive and denied mistreating the resident. CNA #1 stated s/he was mad because the resident's chair would not support the resident. Also, because, the resident is obese s/he had to use force to turn the resident on his/her side towards the siderail on the bed. S/he stated that the resident would not help turn himself/herself, the CNA stated, s/he does not do anything to help himself/herself. During a telephone interview conducted with the Licensed Practical Nurse (LPN #1 / Witness) on 6/14/2022 at 2:24pm, the LPN stated that s/he was in the resident's room with CNA #1 to assist with the resident's Hoyer lift transfer into a wheelchair. LPN #1 stated that CNA #1 was very loud and verbally complaining that the resident needed a lot of work to get out of bed into a wheelchair for an hour's visit with his/her daughter. LPN #1 stated that CNA #1 continued to express loudly in front of the resident that s/he was tired of all this work and upset. LPN #1 stated that s/he told CNA #1 to talk about problems later outside of the resident's room and not in front of the resident. LPN #1 stated s/he left the room and felt that CNA#1 was addressing the situation because LPN#1 was present and that without an audience CNA #1 would have time to de-escalate. After the incident was reported by the resident, LPN #1 was asked to write a statement of what occurred. LPN #1 stated that CNA #1 approached him/her and started an argument as s/he was upset that the nurse wrote the statement. LPN #1 stated that s/he felt threatened as CNA #1 appeared mad. The nurse confirmed that she did not report the alleged abuse on 5/23/2022. S/he spoke to the social worker on 5/24 to inform her that the resident wanted to report the alleged abuse that occurred on 5/23/2022. During an interview conducted with the Administrator on 6/14/2022 at 10:30am, the Administrator stated that s/he visited the resident in his/her room on 5/24/2022. Upon receiving a report of alleged abuse, the facility immediately initiated an investigation, and reported the incident to the Department of Health (DOH). The accused CNA was suspended pending investigation, and the resident's family was informed. The resident was assessed, and no evidence of injury was found. The Administrator asked LPN#1 to write a statement about what s/he observed in the room. The written statement confirmed the resident's report of abuse. The Administrator confirmed LPN#1 witnessed verbal and emotional abuse but did not report the incident to a supervisor or any other facility staff. 415.4(b)(1)(i)

F 609 Based on record reviews and interviews conducted during an abbreviated survey (NY 548), the facility did not ensure that an alleged violation involving abuse was reported to the supervisor or the Administrator of the facility not later than 2 hours after the alleged event that involved verbal abuse. This was evident in 1 out of 6 residents (Resident #1) reviewed for abuse. Specifically, upon witnessing Certified Nursing Assistant (CNA)#1 of being verbally and emotionally abusive to Resident #1 on 05/23/2022, a Licensed Practical Nurse (LPN #1) did not report the incident to the Supervisor, Director of Nursing, and/or Administrator. Resident #1 reported the incident the following day and stated that s/he was scared when LPN #1 left him/her with CNA #1 and s/he felt humiliated by CNA #1's verbal comments. The findings are: Review of facility Policy and Procedure dated 11/2016 and revised 4/2017 addressing Resident Abuse included mental abuse. Staff responsibilities include any employee who has reasonable cause to believe a resident has been abused, mistreated, or neglected shall (after ensuring the safety of the resident) immediately report alleged incident to their Supervisor, Director of Nursing, and/or Administrator. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, an assessment tool) dated 4/04/2022, documented that the resident had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 14/15, associated with intact cognition. The resident required total dependence of two-person assistance for transfer via Hoyer lift, extensive two-person assistance for bed mobility and toilet use, and extensive one-person assistance for personal hygiene. The resident was incontinent of bowel and bladder function. Review of a facility Accident/Incident Report dated 5/24/2022 documented that Resident #1 informed LPN#1 that s/he would like the abuse that happened on 5/23/2022 reported. The resident made a complaint stating CNA#1 came into the room on 5/23/2022 to get the resident dressed and out of bed for a visit with his/her daughter and CNA#1 was very annoyed. The resident stated that CNA#1 stated, I gotta do all this work for you to be up for an hour? The resident stated that while CNA#1 was putting him/her into the chair, CNA#1 was rough with him/her, pushing him/her back into the chair. The resident also stated that LPN#1 was also in the room to assist CNA#1 and witnessed some of the interaction. During an interview conducted with Resident #1 on 6/14/2022 at 11:00 am, the resident stated s/he was treated very badly by a CNA on 05/23/2022 when his/her daughter was coming to the facility for a visit, and s/he needed help to get out of bed and get dressed. Resident #1 stated that CNA #1 was very rough with him/her and was mad that s/he had to help the resident. Resident #1 stated that LPN #1 came into the room to help CNA #1 with the Hoyer Lift transfer. LPN #1 tried to calm CNA #1 and told him/her not to talk about her complaints in front of the resident. However, this seemed to aggravate CNA #1 even more as his/her voice became louder. Resident #1 stated s/he was scared when LPN #1 left the room and s/he remained alone with CNA #1. Resident #1 also stated, s/he was unable to turn herself onto his/her side and CNA #1, shoved me very roughly into the side rail. Resident #1 described his/her feelings during this incident as being made to feel humiliated by CNA#1's verbal comments. During a telephone interview conducted with the Licensed Practical Nurse (LPN #1 / Witness) on 6/14/2022 at 2:24pm, the LPN stated s/he did not report the alleged abuse on 5/23/2022. LPN #1 stated that s/he told CNA #1 to talk about problems later outside of the resident's room and not in front of the resident. LPN #1 stated she left the room and didn't report the incident because s/he felt CNA #1 was addressing the complaints and aggressive attitude towards her and without an audience CNA #1 would de-escalate. The LPN#1 also stated that s/he only reported the alleged abuse on 5/24/2022 when the resident wanted to speak to the social worker to report the alleged abuse that occurred on 5/23/2022. During a follow up telephone interview conducted with the Licensed Practical Nurse on 7/1/2022 at 12:50pm. LPN #1 stated s/he didn't report the incident to her supervisor or anyone else stating I didn't think it was anything I should report because CNA #1 was mostly complaining about all the work and that she was tired. LPN #1 stated s/he didn't realize how that would affect the resident. S/he stated s/he has had abuse prevention training during orientation and at least annually and following any incidents. LPN#1 stated s/he understands the meaning of verbal abuse and it can be considered a form of mental abuse. LPN #1 stated she is familiar with the reporting chain of command, and she would first report to her floor supervisor, also to the Director of Nursing, the social worker, and she would confirm that the Administrator was made aware of the situation. During an interview conducted with the Administrator on 6/14/2022 at 10:30am, the Administrator stated that s/he visited the resident in his/her room on 5/24/2022. Upon receiving a report of alleged abuse, the facility immediately initiated an investigation, and timely reported to the Department of Health (DOH). The resident was assessed, and no evidence of injury was found. The Administrator asked LPN#1 to write a statement about what s/he observed in the room. The written statement confirmed the resident's report of abuse. The Administrator confirmed that LPN#1 witnessed verbal and emotional abuse but did not report the incident to a supervisor or any other facility staff. 415.4(b)

Based on interview and record reviews conducted during a complaint investigation (NY 548), the facility did not ensure that a Certified Nursing Aide (CNA#1) certification was current. Specifically, the New York State Nurse Aide Registry Verification Report for CNA #1 noted certification expired on [DATE] and was not renewed. CNA #1 continued to work in the facility from [DATE] to [DATE] without a valid certification from the NYS Nurse Aide Registry. FINDINGS: The Facility Policy and Procedures addressing Checklist for Hiring Certified/Licensed Staff was reviewed. Checklist for Hiring Certified/Licensed Staff revealed that the Certified Nursing Assistants must have a current New York State Certificate during the application for employment. Review of roster of 24 current CNAs in the facility and copies of all certificates revealed one certificate was expired. Certified Nursing Assistant (CNA #1) certification # 14E was reviewed and was found not current. Expiration date was noted as [DATE] indicating a lapsed status. Review of the facility schedule and time worked report for CNA #1 documented that from [DATE] to [DATE] CNA #1 continued to work in the facility providing direct care without a valid certification from the NYS Nurse Aide Registry. During an interview conducted with the Administrator on [DATE] at 2:00pm, the Administrator stated that the facility Human Resources (HR) department confirmed that CNA #1 did not have a current CNA certification. After discussing the issue with the surveyor, the administrator stated that CNA #1 will not be placed on the schedule until s/he has his/her certification reinstated. 415.26(c)(3)

Based on observations, record review and interviews conducted during a Recertification Survey and Abbreviated Survey (#NY 2), the facility failed to ensure that resident environment remains as free of accident hazards as possible, and each resident receives adequate supervision and assistance devices to prevent accidents. This has the likelihood to cause harm due to lack of supervision during meals for residents who are at risk for choking, and lack of provision to ensure the proper and accurate distribution of resident meal trays. Specifically, Resident #284 has diagnoses, which include Dysphagia, and Dementia. The physician's order indicated the resident was NPO (nothing by mouth) and received a gastrostomy tube (G-Tube) feeding. During investigation review of a nursing progress note dated 6/22/21 documented patient accidentally given lunch tray. A few bites of rice consumed. Nurse Practitioner and dietician made aware. A nursing progress note dated 6/28/2021 documented a chest x-ray was obtained on 6/28/2021 which showed slight right basilar infiltrate. The resident was placed on [MEDICATION(S)] 750mg via percutaneous endoscopic gastrostomy ( PEG) daily times seven days. This resulted in immediate jeopardy and substandard quality of care with the risk for more than minimal harm to Resident #284 and the likelihood of risk for more than minimal harm to 9 other resident's health and safety. The findings are: Review of the facility policy and procedures reveled there were no written policy and procedures in place for meal tray resident identification and distribution processes. Resident #284 has diagnoses, which include Dysphagia, and Dementia. The physician's order on 5/25/21, indicated the resident was NPO and received a G-Tube feeding. Review of the Quarterly Minimum Data Set (MDS; a resident assessment tool) dated 5/25/2021, documented that the resident had severe cognitive impairment and was totally dependent, requiring one person assist for eating via and received G-Tube Feedings. Review of the Dysphagia Care Plan related to [CONDITION(S)] dated 5/24/2021 documented the resident will tolerate the highest modified diet consistency without signs and symptoms of aspiration. Interventions include Nothing By Mouth (NPO). Review of the Nutritional Status Care Plan dated 5/25/2021 documented that tube feeding is the sole source of nutrition and hydration. Interventions include NPO status to be maintained. Speech language pathologist to follow and advise. Review of the Speech Language Pathologist (SLP) note dated 5/24/21 documented contacting Hospital to gather background about the history of resident's swallow function and skilled speech therapy service. Resident with complex history of oral pharyngeal dysphagia, nasogastric (NG) tube during recent hospitalization with eventual PEG tube placement. Resident to remain NPO until clarification regarding swallow function and Modified [MEDICATION(S)] Swallow result. Result findings of poor oral function, recommendation to continue tube feed. Review of the 6/22/21 discharge ST (Speech Therapy) note documented the resident to continue non-oral nutrition with continued skilled speech therapy services and Modified [MEDICATION(S)] Swallow to assess current swallow function and determine candidacy for intake by mouth. Review of the Nursing Progress Note dated 6/22/21 at 2:43 pm documented resident intermittently confused throughout the shift, family visited this morning and noted confusion. New order per Nurse Practitioner (NP) to dip urine and send for urinalysis if dip is positive, continue on oxygen at 2 liters, no respiratory distress, tube feed per orders, head of bed up. Resident was accidentally given a lunch tray, a few bites of rice consumed. NP and dietician made aware. Monitor for signs and symptoms of aspiration pneumonia. No coughing noted at this time. Review of the facility Incident/Accident Reports revealed that the facility did not conduct investigation or complete an Incident/Accident Report when resident #284 was provided a lunch meal tray on 6/22/21. Review of Nursing Progress Note dated 6/28/2021 at 4:27 pm documented resident's daughter made writer aware that resident was hallucinating during their visit this morning, intermittent confusion noted, resident self-transferred from bed to wheelchair this afternoon, writer kept resident in staff's vision for safety purposes. New order per NP, chest x-ray to rule out aspiration pneumonia. No signs or symptoms of respiratory distress. Review of Nursing Progress Note dated 6/28/2021 at 10:33 pm written by Director of Nursing documented chest x ray result slight right basilar infiltrate. NP made aware. Ordered [MEDICATION(S)] 750 mg via Tube daily x7 days. An interview was conducted with Licensed Practical Nurse LPN #1 on 2/01/22 at 10:24AM they stated on the day of the incident they and Certified Nursing Assistant (CNA) #1 went into Resident #284's room and saw the resident had somebody else's tray, they took the tray away, and checked the resident's mouth finding a bit of rice inside the mouth and on their lips. LPN #1 stated the tray was given to Resident #284 by CNA #1, who was not a regular employee on the floor. LPN #1 stated the staff are supposed to check the trays to make sure the diet is correct, and when trays are handed out, staff are supposed to check the resident's ID bracelets. LPN #1 stated they believed the family was made aware of the incident during a visit later in the day, however they indicated there was no documentation in Resident #284's electronic medical record (EMR) to confirm that. LPN #1 stated that at the time of the incident there weren't signs of aspiration but added aspiration pneumonia could take a few days to show up, LPN #1 stated they informed the Nurse Practitioner (NP) #1 and a chest x-ray was ordered. On 6/28/21, Resident #284's chest x-ray result revealed a slight right basilar infiltrate, and antibiotics were ordered. An interview was conducted on 2/01/22 at 10:53 am with the Director of Nursing (DON). The DON stated that staff including CNAs and per diem staff are made aware of orders by looking at the point of care and from reports they receive at the start of their shift from the nurse. DON stated they believed a conversation was had with CNA #1 after the incident, but nothing was documented. The DON stated that a record review revealed no documentation that family was notified at the time of the incident, or that an incident investigation report was completed. A telephone interview was conducted on 02/02/22 at 10:45 AM with Resident # 284's daughter. The daughter stated Licensed Practical Nurse (LPN #1) informed them the resident received a food tray and ate rice 2 days after the incident occurred. The daughter stated LPN #1 reported the Nurse observed the situation and stopped it after a few bites of rice. The daughter stated she was concerned and asked for a copy of the incident report but was told there was no incident report. An additional interview was conducted on 2/02/22 at 12:56 pm with the DON who stated, although there is no facility Policy and Procedure for meal tray distribution process and checking resident ID bands during meal pass, they believed in service would have been completed on orientation but did not believe yearly in-service training is completed on the process. The DON stated they were not the DON at the time CNA#1 was hired and cannot verify what education had been provided to them. They also indicated they could not verify what education was provided to CNA#1 before or after the incident on 6/22/21. An interview was conducted on 2/02/21 at 4:00 PM with the Nurse Practitioner (NP). They stated the nurse informed them that Resident #284 ate rice. They stated they had to wait a few days to see if the resident aspirated. During assessment on 6/23/21 the resident exhibited no respiratory concerns, and no cough. They indicated the plan was to monitor the resident. The NP stated they ordered a chest x-ray to be done on 6/28/21 solely to follow-up on the resident eating rice. The NP stated the resident has a history of pneumonitis and respiratory failure, and the result of the chest x-ray could have been due to the resident's history, but that could not be confirmed. An additional interview was conducted on 2/02/22 at 5:30 pm with LPN #1. They stated the meal tray that had been left with the resident was regular consistency, not pureed consistency. The nurse stated they reported the incident to the Director of Nursing and verbally educated CNA #1 but did not document that. The nurse stated that they did not write a statement and did not know if CNA#1 wrote a statement. LPN #1 further reported after the incident they were not directed to complete an Incident/Accident Report. An interview was conducted with Certified Nursing Assistant (CNA) #1 on 2/04/22 at 9:15 AM. CNA #1 stated that they do not always work on the Rehabilitation Unit. CNA #1 stated they were delivering meal trays on the unit and noticed one resident on the unit did not have a tray. CNA#1 indicated they went to the nurse and asked for another tray. At that time CNA #1 stated that both they and LPN #1 realized that resident #284 received a tray in error. CNA #1 stated LPN #1 then informed them that the tray was passed to a resident who was NPO, and they went to resident #284's room to remove the tray. CNA#1 stated they did not check the resident ID bracelet but should have. CNA#1 stated when oriented to their position at the facility, they did not receive training regarding the facility process for passing meal trays. CNA #1 stated they had not been in serviced regarding meal pass and checking resident ID with the meal tray after the incident. CNA #1 stated they had only been in-serviced 2 days ago about checking with the nurse prior to passing out trays and ensuring that they check the resident name/ID band to match the tray. 415.12(h)(1)(2) ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Immediate Jeopardy was removed on 2/4/22 at 5:37PM based on corrective measures taken by the facility prior to exit. The facility supplied evidence that 95.5% of staff was educated on the accurate distribution of meal trays including checking resident ID Facility staff were interviewed and had knowledge of accurate meal tray distribution including checking resident ID bands Follow up observations revealed staff were knowledgeable of the policy and procedue regarding meal tray distribution and checking resident ID. The facility created a Policy and Procedure for meal/snack distribution and included checking ID bands.