Every finding on record at Terrace View Long Term Care Facility

Based on observation, interview, and record review conducted during a Standard survey completed 07/08/2026 the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one main Kitchen and seven (Kensington Unit, Naval Unit, Lighthouse Unit, [NAME] Basin [NAME] Unit, Canalside Unit, [NAME] King Unit, and Front Park Unit) of 17 unit dining room refrigerators. Specifically, the main Kitchen and dining room refrigerators had issues with opened, undated, outdated, and/or unlabeled food and drink items. In addition, a servery cooler had suboptimal food/drink temperatures. The findings include:The facility policy and procedure titled Food and Nutrition (Dietary) Infection Control Guidelines, dated 03/2025, documented all food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. All goods should be stored in clean wrappers/ containers and properly marked with the date received and contents. Stock should be checked routinely for expiration dates. Perishable foods should be discarded if not consumed within 72 hours of preparation.The facility policy and procedure titled Food Brought to Residents from Outside Facility, dated 07/2025, documented it was their policy to inform and assist residents who bring food from outside of the facility on procedures to ensure food is handled properly and the purpose was to assure proper handling to prevent foodborne illness. The food is to be stored in a container with a tight-fitting lid, clearly labeled with the resident's name, room number and date the food was brought in by/for the resident. Food will be thrown away 72 hours after the date on the container during the dining service routine refrigerator checks.The sign posted on the refrigerators in multiple resident units documented, Attention all staff and residents - please label & date all food items, remember to throw out any food items after 3 days. The sign posted on the refrigerators in multiple resident units documented, Any items put into this refrigerator must have: bulk juice date when opened, any items for a specific resident must contain their name, the date it was put in the refrigerator, not be past the manufacturer expiration date, any item without a manufacturer expiration date will be discarded after 3 days, at no time can staff lunches or staff related items be stored in this refrigerator, any item found not to be compliant with the above specific criteria will be discarded.Review of the log sheets revealed they were titled Daily Freezer Temperature Log - Twice Daily Reading - Must be 0 F and Daily Cooler Temperature Log - Twice Daily Reading - Must be 41 F. The log sheets had times, temperatures, and team member's initials twice daily.1a. Observation in the Kensington Unit Servery on 06/30/2026 at 10:30 AM revealed a single roll in cooler containing a tall, rolling tiered metal cart with seven trays consisting of six half gallons of milk, fifteen 46 fluid ounce containers of juice, a tray full of eight fluid ounce dietary supplements (Glucerna), multiple premade sandwiches, 3.5-ounce sealed containers of Jello and pudding, four (4) ounce containers of yogurt, and a half loaf of bread. The digital thermometer on the outside of cooler read 58 degrees Fahrenheit. Inside cooler walls did not feel cool, refrigerator thermometer hanging from a shelf of tiered metal cart inside cooler read 58 degrees Fahrenheit. Condensation was observed on the drink items inside the cooler. On 06/30/2026 at 10:42 AM, during an observation and interview, the General Manager/Food Service Director stated they were not aware of any issues with the Ground Floor Area C servery roll in cooler. The General Manager/Food Service Director, utilizing a facility digital thermometer, took a temperature of a four (4) ounce yogurt and stated the temperature was 46.6 degrees Fahrenheit and was too warm. The temperature of a half gallon of whole milk taken was 47 degrees Fahrenheit. They stated the temperature should be between 37-42 degrees Fahrenheit. The General Manager/Food Service Director stated the server takes inventory every morning and restocks the cooler around 8:00 AM. They stated the refrigerated items would have to be removed and disposed of as the drink items were not within temp. Additionally, they stated a work order would have to be placed to have the cooler serviced. 1b. Observation in the [NAME] King unit on 06/30/2026 at 1:40 PM revealed the Dining Room refrigerator contained a grocery store bag with about eight zip top bags of guacamole, each bag approximately six ounces. The grocery store bag and the individual zip top bags were not labeled with a name or date.At the time of the observation, Registered Nurse Team Leader #1 stated there was one resident whose family brought in foods often, and they would speak to that resident now. A moment later, Registered Nurse Team Leader #1 returned and stated they confirmed which resident the food belonged to and that resident told them that the food was brought in yesterday. At this time, Registered Nurse Team Leader #1 labeled the grocery bag with the resident's name and yesterday's date.1c. Observation in the Front Park unit on 06/30/2026 at 2:10 PM revealed the Dining Room refrigerator contained one slice of pizza labeled with a resident's name, but no date. This refrigerator also contained two black and white checkered insulated bags. The bags were each locked with a keyed padlock.At the time of the observation, Registered Nurse Team Leader #2 stated the pizza and the two locked bags belonged to the same resident. They stated they would speak to that resident now. A moment later, Registered Nurse Team Leader #2 returned and stated that resident told them to throw out the pizza, but that the bags and their contents were brought in on 06/28/2026.1d. Observation in the Lighthouse unit on 06/30/2026 at 3:03 PM revealed the Dining Room refrigerator contained a large, partially cut melon labeled with a resident's name, but no date. Also, an unlabeled and undated plastic container of about one cup of stew or chili was in the freezer.At the time of the observation, Registered Nurse #3 stated the melon belonged to one of the residents on this unit and this resident's family visited today and brought in the melon. Registered Nurse #3 also stated the melon needed to be labeled with today's date and the stew or chili needed to be discarded because it was not labeled with a resident's name or date.1e. Observation in the [NAME] Basin [NAME] unit on 06/30/2026 at 3:35 PM revealed the Dining Room refrigerator contained open bottles of honey thick water and honey thick orange juice. The bottles were labeled with the same resident's name. The honey thick water had a label that was hand-written, Exp N/A and the honey thick orange juice had a manufacturer's label that had Best if Used by 8/16/26 stamped on it, and the stamp was circled by hand. Also in this refrigerator was a 16-ounce glass jar that was labeled, Wild Crafted Sea Moss Gel. The glass jar was in a brown paper bag and neither the brown paper bag or the glass jar were labeled with a name or date. The label on the jar advised the product was edible and could be used as a face mask, and to Keep refrigerated, if not using immediately, freeze in airtight container for up to six months.At the time of the observation, Administrative Control Clerk #2 stated they were not aware of the jar of Wild Crafted Sea Moss Gel in the refrigerator and they would find out which resident it belonged to. A moment later, Administrative Control Clerk #2 returned and stated they found out which resident the jar belonged to and that it was brought in today. Administrative Control Clerk #2 stated it must be labeled with today's date and discarded in three days.1f. Observation in the Canalside unit on 06/30/2026 at 3:52 PM revealed the Dining Room refrigerator contained a plastic leftover container of approximately one cup of rice. The container had a label that was a series of numbers and did not indicate a date.At the time of the observation, Registered Nurse #4 stated they were not aware which resident the rice belonged to, but they would ask the most likely resident. A moment later, Registered Nurse #4 returned and stated they confirmed which resident the rice belonged to and they were told that the rice was brought in today. Registered Nurse #4 also stated the family must let staff know when they bring in food for the resident so it can be labeled. 1g. Observation in the Naval unit on 07/01/2026 at 11:14 AM revealed the Dining Room refrigerator contained four 46-ounce, juice cartons, one (1) half gallon of one percent milk opened, used and undated.At the time of the observation, Server #1 stated juice cartons and milk were provided from the main kitchen for the Dining Room refrigerators. They stated they go by the expiration date on the drink items to determine when to use them. They stated once milk or juice cartons are opened, they are good for just a few days, two to three days, or until the expiration date. They stated anything past the enjoy by date sticker must be thrown out. Server #1 stated just because something looks good doesn't mean it is good, could get food borne illness from outdated food and drink items.During an interview on 07/06/2026 at 11:40 AM, Dietary Aide #1 stated Dietary Supervisors checked the refrigerators on each unit two times per day. They stated Dietary Supervisors checked the refrigerators for temperatures and contents and logged their entries on the log sheet displayed on the servery glass.During an interview on 07/06/2026 at 1:00 PM, Dietary Supervisor #1 stated Dietary Supervisors checked the refrigerators and freezers on each unit servery two times daily. They stated the checks included temperatures, dates on foods, expired foods, stock levels, and cleanliness. Dietary Supervisor #1 stated if a food was not labeled with a name or date, they would discard it. If a food had a resident's name, but no date, they would ask nursing staff if they recognized it, and if nursing could not find an answer, the item would be discarded. They stated nursing staff was responsible for labeling foods brought in by residents or their families with a name and date. Most ready-to-eat foods could be kept in the refrigerator for three days. Dietary Supervisor #1 also stated when they initialed the log sheet, it meant that they checked all aspects of that refrigerator and freezer.2. During the initial kitchen walk through on 06/30/2026 at 8:44 AM with General Manager/Food Service Director the following were observed:-Walk in produce cooler contained a tray of sliced tomatoes labeled, dated 06/25/2026. General Manager/Food Service Director stated they should have been disposed of after three days.-Walk in freezer contained exposed turkey burger patties that were unsealed, and undated; case of exposed fish fillets unsealed and undated; large sealed clear plastic bag of unidentified frozen food, unlabeled. General Manager/Food Service Director stated all opened packages should be completely rewrapped in plastic wrap, labeled and dated once opened.-Upright reach in cooler, identified as #5, contained two stainless steel food containers: one labeled egg salad, covered with plastic wrap with label Enjoy By 6/28/26 and the second one labeled chicken salad, covered with plastic wrap with label Enjoy By 6/26/26. General Manager/Food Service Director stated food items labeled enjoy by should have been used by that date or thrown out.-Upright reach in cooler, identified as #6, contained an opened half gallon of orange juice with best by date of 6/5/26, expired and not dated when opened.-Upright reach in cooler, identified as #7, observed with standing water to bottom of cooler unit, approximately one-eighth (1/8) inches high, with a case of individually sealed hamburger patties, sitting in the standing water. General Manager/Food Service Director stated the case of hamburger patties should not be in standing water in the cooler, because it could cause food borne illness.During an interview on 7/06/2026 at 8:28 AM, [NAME] #1 stated when food is opened it needs to be wrapped, labeled, and dated by the staff opening it. They stated whoever is prepping in the kitchen should be checking dates. They stated it was important for resident safety, good hygiene, so no one gets sick. They stated food labeled enjoy by needs to be used by the end of the date stated, after that it needs to go in the trash to prevent food borne illness.During an interview on 07/06/2026 at 11:13 AM, General Manager/Food Service Director stated dietary staff were responsible for their stations and expected them to go through their coolers and discard any outdated, unlabeled, undated food and drink items. They stated it was important to date food items so they were not serving expired foods that could cause food borne illness. They stated they expected opened packages to be tightly rewrapped, labeled and dated, not just left ripped open, in the freezer to prevent freezer burn. They stated the Chef and themselves were responsible for overseeing the kitchen and that dietary staff did not follow protocol. They stated Dietary Supervisors were responsible for checking unit dining room refrigerators as much as they can. The General Manager/Food Service Director stated food, and drink should be dated when it is opened. They stated dietary staff should be checking for dates, labels and if not labeled, dated, food and drink items should be discarded because they do not know when it was opened or who it belongs to.During an interview on 07/07/2026 at 8:05 AM, the Administrator stated they expected policy to be followed. They stated food and drinks should be checked frequently and if it does not meet policy, it should be thrown away. They stated the dietary staff were responsible for ensuring food was dated and labeled to ensure residents are not consuming harmful food.10 New York Codes Rules and Regulations 415.14 (h)

Based on interview and record review conducted during the survey, the facility failed to ensure that residents received treatment and care in accordance with professional standards, the comprehensive resident centered care plan, and the residents' choices for three (Residents #9, #31, and #344) of three residents reviewed for quality of care. Specifically, the facility failed to ensure residents were transported to medically necessary appointments, resulting in multiple missed or significantly delayed specialists' appointments for Resident #9, Resident #31, and Resident #344. The findings are:The policy and procedure titled Resident Rights dated 06/2025, documented it was the policy that all residents are treated with dignity and respect. The policy was to promote and protect individual resident rights to have a dignified existence, self-determination and to have communication with and access to persons and services inside and outside the facility.The policy and procedure titled Activities and Appointments, Staff Assigned to Accompany Resident Out of Facility dated 07/2026, documented to determine if a staff member needed to accompany residents out of the facility for activities and appointment and provide the staff member when appropriate. The nursing supervisor/staffing office will assign nursing staff to accompany the resident. The assigned staff member was not to leave the resident unattended during the appointment.1.Resident #31 had diagnoses that included quadriplegia (paralysis affecting all four extremities), thoracic myelopathy (spinal cord compression of the spine causing neurological symptoms). The minimum data set ( a resident assessment tool) dated 05/31/2026 documented Resident #31 was cognitively intact, could understand others and could be understood by others, and had indwelling urinary catheter.A comprehensive care plan dated 3/26/2026 documented that Resident #31 had urinary incontinence and an indwelling catheter (tube inserted into the bladder to drain urine). Interventions included but were not limited to monitoring signs and symptoms of urinary tract infection, evaluating bladder for distention (when the bladder stretches due to holding excess urine) and a post voiding residual evaluation (measures the amount of urine left in the bladder immediately after urinating). Resident #31 had an altered respiratory status with no interventions activated at this time and a goal to improve/maintain their current respiratory status.The untitled closet care plan (a guide used by staff to direct care) dated 06/01/2026 documented that Resident #31's hearing ability was normal, they were incontinent of bladder and bowel, had a colostomy (artificial connection from the bowel to the skin surface) and an indwelling urinary catheter.The Cardiology (medical specialty focused on disorders of the heart and blood vessels) Encounter Note dated 06/04/2026 documented that Resident #31 denied any acute cardiac symptoms. They returned for follow up due to issues of edema (swelling) in fingers and lower extremities and shortness of breath at times. Resident #31 was instructed to follow up in one month or sooner as needed.Physician Orders dated 06/01-06/30/2026 documented Resident #31 had a urology (medical specialty focused on disorders of the urinary tract-kidneys, bladder, urethra) appointment on 06/24/2026, pulmonology (medical specialty focused on disorders of the respiratory system-lungs, airways, and breathing muscles) and cardiology appointments scheduled for 06/26/26.Resident #31's progress note dated 06/26/2026 revealed the resident expressed anger and frustration related to incomplete appointments and frustration regarding a cancelled cardiology appointment requiring rescheduling.Physicians Orders dated 07/01-07/31/2026 documented Resident #31 had a urology consult scheduled for 07/01/2026. The appointment was rescheduled for 07/08/2026.A facility document titled, Transportation List, dated 06/22/2026 documented Resident #31 had an audiologist appointment scheduled and was to be transported by a transportation company with an aide via wheelchair.A facility document titled, Transportation List, dated 06/24/2026 documented Resident #31 had a urology appointment scheduled and was to be transported within the facility to the specialty unit with an aide via wheelchair.A facility document titled, Transportation List, dated 06/26/2026 documented Resident #31 had a pulmonology and cardiologist consult appointments scheduled. Resident #31 was to be transported within the facility over to the specialty unit with an aide via wheelchair.A facility document titled, Transportation List, dated 07/01/2026 documented Resident #31 had a urology appointment. Resident #31 was to be transported within the facility over to the specialty unit with an aide via wheelchair.During an interview on 07/06/2026 at 4:02 PM, Resident #31 stated there was a lack of transport staff who were hired specifically to transport residents to appointments. They stated this caused missed appointments that included an audiology (a medical specialty focused on hearing and balance disorders) appointment on 06/22/2026, cardiologist and pulmonary appointments that were missed on 06/26/26, and urologist appointments on 06/24/2026 and on 07/01/2026 were both missed. They stated most days there were only two to three transport staff available and they often required support staff to accompany them to appointments. They stated this had been an ongoing problem and they were upset their appointments had to be rescheduled.During an interview on 07/07/2026 at 9:52 AM with Administrative Control Clerk #2 they stated Resident #31's 06/24/2026 urology appointment was missed due to staffing issues, and it was rescheduled for 07/01/2026, then cancelled again due to staffing issues, and subsequently rescheduled for 07/08/2026. They stated the resident's audiologist appointment on 06/22/2026 was cancelled due to staffing and was rescheduled for 07/17/26. They stated Resident #31 also had cardiology and pulmonary appointments scheduled for 06/26/2026 that were cancelled due to staffing but had been rescheduled. They stated they were not responsible for transport staff availability, only rescheduling appointments for residents when needed. They recalled emails instructing staff to cancel appointments but could not recall who sent them. They stated June had been a bad month pertaining to staffing, but prior to that residents were generally attending appointments without issue.During an interview on 07/07/2026 at 12:20 PM with Registered Nurse #2, they stated staff utilized whoever was available to transport residents to medical appointments. If staff were unavailable, they would reach out to family to accompany the residents on occasion. They stated Resident #31's audiologist appointment was not ordered by the physician; the resident pursued it independently, and a family member purchased the hearing aids. They stated the facility did not have enough staff to transport them without pulling a certified nurse aide off the floor. They stated the rest of the appointments were ordered by the doctor and had to be rescheduled due to staffing. They stated Resident #31 had a urology appointment due to recurring urinary tract infections but had just completed their antibiotics. They stated that Resident #31 was seeing a pulmonologist and a cardiologist due to complaints of shortness of breath. They stated these appointments were important and should not have to of been cancelled, but due to staffing they had to ensure residents on the floor were provided care.During an interview on 07/08/2026 at 8:49 AM with Registered Nurse Supervisor #5, they stated many appointments were cancelled and rescheduled due to residents who declined to go to appointments, and other times there was no staff available to take them. They stated the facility had three transporters but up to 10 to 17 appointments per day, which made it difficult to cover all appointments when they were short staffed. They stated that transport staff shortages were worse in the summer due to vacations and no coverage. They stated the facility previously had seven transporters but now they only had three. They stated they would prioritize and acknowledge the importance of attending appointments due to physician orders and the potential impact on residents' future health and cancel accordingly when staff were unavailable to transport residents to their appointments.2.Resident #344 had diagnoses including urinary retention (inability to completely empty the bladder), presence of urinary catheter (tube placed into the bladder to drain urine), and weakness. The Minimum Data Set, dated [DATE], documented they were cognitively intact, was always understood and understands others, and they had an indwelling urinary catheter.The comprehensive care plan, dated 05/20/2026, documented Resident #344 had a urinary catheter, and staff were to provide care and nursing assessments for the device.Resident #344's progress notes revealed, on 05/21/2026 the Medical Director documented, Resident #344 was admitted to the facility for post operative sub-acute rehabilitation. During their hospital stay, an indwelling urinary catheter was placed for urinary retention, and they would require a follow up with urology. On 06/02/2026 the Medical Director documented Resident #344 failed their voiding trial (removal of the urinary catheter to see if the resident was able to empty their bladder) and would follow up with urology in July.Resident #344's Physician's Orders revealed the following:-05/26/2026, a voiding trial with bladder scans every shift for 72 hours, replace catheter if retaining greater than 300 milliliters of urine.-05/28/2026, follow up with urology on 07/01/2026 at 12:15 PMA facility document titled, Transportation List, dated 07/01/2026, documented Resident #344 was scheduled for a urology appointment within the facility in the specialty unit and were to be transported via wheelchair.During an interview on 07/03/2026 at 2:00 PM, Resident #344 stated their appointment for the urologist on 07/01/2026 was rescheduled for 07/29/2026, they were told it was due to a staffing problem. They were not happy because they wanted the foley catheter removed sooner than that. They planned to be discharged on 07/22/2026 and they did not want to have the catheter at home.During an interview on 07/06/2026 at 2:48 PM, Registered Nurse #8 stated the Administrative Control Clerks (ACCs) were responsible for scheduling appointments. On 07/01/2026 all the appointments were canceled due to staffing, and Resident #344's urology appointment was rescheduled for the end of the month. They were aware the resident was unhappy about it, and they asked the provider to order another voiding trial.During an interview on 07/07/2026 at 10:25 AM, Administrator Control Clerk #4 stated that the morning of 07/01/2026 they received a message from the supervisor that all appointments for the day were canceled. They were unsure who notified them, but they rescheduled all the appointments. They stated it was very important that residents made it to all their scheduled appointments; especially the residents on the rehab unit, because those residents needed things done prior to discharge.During an interview on 07/08/2026 at 8:33 AM, Registered Nurse #9, Nursing Supervisor, stated they arranged for the appointments with the available staff on the schedule. They stated there were a few staff designated for transport, but they also utilized other certified nurse aides. On 07/01/2026 there were not enough certified nurse aides on the schedule to provide care for residents and to transport them to their appointments, so they had to prioritize resident care over appointments.During an interview on 07/08/2026 at 9:25 AM, the Director of Nursing stated Resident #344's urology appointment was important and should not have been rescheduled due to staffing.3. Resident #9 had diagnoses including type 2 diabetes mellitus, hypertension (high blood pressure) and bipolar disorder (a mental health condition causing unpredictable mood swings). The Minimum Data Set (a resident assessment tool) dated 04/04/2026 documented that Resident #9 was cognitively intact, was understood by and understands others. The resident needed supervision for transfers, moderate assistance for wheelchair transport for 150 feet, and maximal assist for toileting.The comprehensive care plan dated 07/07/2026 documented Resident #9 had a self-care deficit with interventions for physical therapy and occupational therapy quarterly screens.The untitled closet care plan dated 05/08/2026 documented Resident #9 was a fall risk; minimal assist for toileting; and a staff assist with wheelchair for off unit/long distances.The Consultation Record dated 07/15/2025 documented Resident #9 had a vulvar biopsy (an in-office procedure where a small tissue sample is removed from external genitalia) completed that day. The consultation record instructed them to follow up in one year for their annual exam.The Physician's Orders documented on 05/14/2026 Resident #9 had an order for a gynecology (medical specialty focused on women's reproductive system-uterus, ovaries, fallopian tubes) appointment on 06/29/26 at 1:15 PM.A facility document titled, Transportation List, dated 06/29/2026 documented Resident #9 had a gynecology appointment at 1:15 PM. The location of the appointment was documented on the spreadsheet along with the mode of transport being a wheelchair and instructions to bring a walker.During an interview on 07/01/2026 at 10:06 AM, Resident #9 stated that on 06/29/2026 every one's out of facility provider appointments were cancelled because of transportation issues. They stated there were no staff available to go with us to our appointments. Resident #9 stated they had an appointment for the gynecologist on 06/29/2026.During a further interview on 07/07/2026 at 8:26 AM, Resident #9 stated their cancelled 06/29/2026 gynecologist appointment was their annual appointment, they were not having any acute issues, but they did mind that the appointment was cancelled due to staffing and that the appointment needed to be rescheduled.During an interview on 07/07/2026 at 9:24 AM, Administrative Control Clerk #3 stated the process for when a resident needed to go on an outside appointment was the nursing staff would either verbally tell them a medical provider wrote an order for the consult, or they placed the paper order in their basket. They stated after the appointment was made they input the appointment into the electronic medical record as an order with the day, time and where the appointment was located. Administrative Control Clerk #3 stated the appointment was also place on the spread sheet that was in the facility shared computer drive on the transport list. After reviewing the transport list in the computer, the Administrative Control Clerk #3 stated Resident #9 had a gynecologist appointment on 6/29/2026 at 1:15 PM that was cancelled. Administrative Control Clerk #3 stated the nursing supervisor (unknown who) told them to cancel all appointments that day. They stated they were unsure why but it was probably due to staffing. They stated they usually had to cancel appointments due to low staffing probably twice a month. Administrative Control Clerk #3 stated residents outside provider appointments should never be cancelled because it was tough to get a first appointment and then it was tough to get a second appointment. Administrative Control Clerk #3 stated it was the right to go on an outside appointment and they themselves would not want to miss a scheduled appointment. During an interview on 07/07/2026 at 3:29 PM, Registered Nurse #10 Team Leader stated when a resident had an outside provider appointment staff would know because the administrative control clerk would print out the transportation list and place it in the black binder. Registered Nurse #10 stated there was also a provider order in the electronic medical record for the appointment indicating when and where it was. Registered Nurse #10 stated if staff members were needed to accompany a resident on an out-of-facility appointment would depend on that resident's transfer status and if they had outside (of the facility) travel privileges. They stated Resident #9 would need a staff member to accompany them on any outside appointment and their gynecologist appointment was cancelled on 06/29/2026. Registered Nurse #10 stated all appointments on 06/29/2026 were cancelled due to not having enough nursing staff and that cancelling outside appointments had been happening a couple times a week for three weeks. Registered Nurse #10 stated the directive to cancel the appointments came from the nursing supervisors because they had the staffing boards. They stated it was important for residents to go on their scheduled outside appointments because they could not always get the resident another appointment the next day, it may take a few weeks.During a telephone interview on 07/07/2026 at 4:34 PM, the Medical Director stated they were aware that some outside provider appointments for some of the facility residents needed to be cancelled due to staffing reasons. They stated this had been happening on some days for the last two to three weeks. The Medical Director stated they would not want any residents to miss any appointments; it was not only a disruption for the residents' schedules but also a disruption for the other providers' schedules. They stated the facility also had to prioritize resident care over outside appointments. The Medical Director stated they attended morning report and have discussed the situation. They stated on shorter staffing days, prior to doing a blanket cancelation of all outside appointments, the facility nursing staff would determine need of the more important appointments, such as follow-up orthopedic appointments versus a six month follow up on a stable resident, because they did not want any harm to come to the residents from cancelling an appointment. During an interview on 07/08/2026 at 8:22 AM, the Director of Nursing stated it was the day shift nursing supervisor's responsibility to assign which staff member was to go on a transport with a resident having an outside provider appointment. They stated the facility does not have a specific transport aide position; the nursing supervisor would choose the float aides first to go on transport. When all scheduled float aides had been exhausted then the nursing supervisor would pick a regular floor certified nurse aide to go on the transport. The Director of Nursing stated in the past two to three weeks some of the residents scheduled outside providers' appointments had been cancelled due to low staffing challenges in the facility. The Director of Nursing stated the facility had transitioned to a new pay roll system and staff had realized they can alter their schedules themselves in the new application. The Director of Nursing stated a day shift nursing supervisor took it upon themselves to start cancelling all outside appointments without their knowledge when there were not enough certified nurse aides to accompany residents on outside appointments. The Director of Nursing stated that once they became aware of situation, the nursing supervisors were no longer allowed to cancel any appointments, nursing administration was to be notified, and then nursing administration would prioritize what appointments needed to be attended based on medical necessity. The Director of Nursing stated no one's appointments should ever be cancelled due to staffing because every appointment should be necessary, if a medical provider wrote the order for that resident to see an outside provider, then there would be some level of necessity for that appointment.10 New York Codes, Rules, and Regulations (NYCRR) 415.12

Based on interviews and record review conducted during a Standard survey completed on 07/08/2026, the facility failed to ensure there was sufficient staff on a 24-hour basis to attain or maintain the highest practicable physical, mental and psychosocial well-being for residents in the facility. Specifically, there were not enough staff to transport residents to and from appointments resulting in appointments being cancelled and rescheduled. Residents #9, #31 and #344 were involved. The findings included:Refer to F 684 - Quality of CareThe facility policy and procedure titled Staffing Plan revised 06/2026, documented resident care areas are staffed with an adequate number and mix of qualified, competent licensed and assistive personnel to meet patient care needs and implement the plans of care. Staffing is based on projected activity, actual census, budgeted resident days, resident acuity and New York State Department of Health and Centers for Medicare and Medicaid Services regulations and standards. Consideration is given to changes in technology, services, patient population, case mix, the degree of complexity of care required by the residents and the scope and level of integration with other clinical services.The facility policy and procedure titled Activities and Appointments, Staff Assigned to Accompany Residents Out of Facility revised 07/2026, documented it was the policy of the nursing department to determine if a staff member needs to accompany residents out of the facility for appointments and to provide a staff member to accompany the resident when appropriate. The purpose was to ensure residents were safe and provided with needed care when out of the facility for appointments. Nursing Supervision, Team Leaders, Registered Nurses, Licensed Practical Nurses, and Administrative Control Clerks were responsible. The Nursing Supervisor/Staffing Office will assign nursing staff to accompany the resident(s). The staff member assigned is not to leave the resident unattended during the appointment. The staff member may only leave the resident while the resident is directly supervised by staff at the scheduled appointment. The nursing staff member will assist the resident(s) with the following: reaching the designated departure area, boarding and leaving the vehicle, dressing, elimination, transfer, and return to the facility neighborhood.Review of the facility job description titled Certified Nursing Assistant revised 04/2022 documented typical work activities included turns and positions patients and residents; assists in transferring, ambulating and transporting.1. Resident #31 had diagnoses that included quadriplegia (paralysis affecting all four extremities), thoracic myelopathy (spinal cord compression of the spine causing neurological symptoms), and anxiety. The Minimum Data Set (a resident assessment tool) dated 05/31/2026, Resident #31 was cognitively intact, could understand others and could be understood.During an interview on 07/06/2026 at 4:02 PM, Resident #31 stated there was a lack of transport staff who were hired specifically to transport residents to appointments. They stated this caused missed appointments that included an audiology (a medical specialty focused on hearing and balance disorders) appointment on 06/22/2026, cardiologist (medical specialty focused on disorders of the heart and blood vessels) and pulmonary (medical specialty focused on disorders of the respiratory system-lungs, airways, and breathing muscles) appointments that were missed on 06/26/26, and urologist (medical specialty focused on disorders of the urinary tract-kidneys, bladder, urethra) appointments on 06/24/2026 and on 07/01/2026 were both missed. They stated most days there were only two to three transport staff available and they often required support staff to accompany them to appointments. They stated this had been an ongoing problem and they were upset their appointments had to be rescheduled.During an interview on 07/07/2026 at 9:52 AM with Administrative Control Clerk #2 they stated Resident #31's 06/24/2026 urology appointment was missed due to staffing issues, and it was rescheduled for 07/01/2026, then cancelled again due to staffing issues, and subsequently rescheduled for 07/08/2026. They stated the resident's audiologist appointment on 06/22/2026 was cancelled due to staffing and was rescheduled for 07/17/2026. They stated Resident #31 also had cardiology and pulmonary appointments scheduled for 06/26/2026 that were cancelled due to staffing but had been rescheduled.2. Resident #344 had diagnoses including urinary retention (inability to completely empty the bladder), presence of a urinary catheter (tube placed into the bladder to drain urine), and weakness. The Minimum Data Set, dated [DATE], documented that they were cognitively intact, always understood and understand others, and they had an indwelling urinary catheter.The comprehensive care plan, dated 05/20/2026, documented Resident #344 had a urinary catheter, and staff were to provide care and nursing assessments for the device.During an interview on 07/03/2026 at 2:00 PM, Resident #344 stated their appointment for the urologist on 07/01/2026 was rescheduled for 07/29/2026, they were told it was due to a staffing problem. They planned to be discharged on 07/22/2026 and they did not want to have the catheter at home.During an interview on 07/06/2026 at 2:48 PM, Registered Nurse #8 stated on 07/01/2026 all the appointments were canceled due to staffing, and Resident #344's urology appointment was rescheduled for the end of the month. They were aware the resident was unhappy about it.3. Resident #9 had diagnoses including type 2 diabetes mellitus, hypertension (high blood pressure) and bipolar disorder (a mental health condition causing unpredictable mood swings). The Minimum Data Set (a resident assessment tool) dated 04/04/2026 documented that Resident #9 was cognitively intact, was understood by and understands others.During an interview on 07/01/2026 at 10:06 AM, Resident #9 stated that on 06/29/2026 every one's out of facility provider appointments were cancelled because of transportation issues. They stated there were no staff available to go with us to our appointments. Resident #9 stated they had an appointment for the gynecologist (medical specialty focused on women's reproductive system-uterus, ovaries, fallopian tubes) on 06/29/2026.During an interview on 07/07/2026 at 9:24 AM, Administrative Control Clerk #3 stated Resident #9 had a gynecologist appointment on 6/29/2026 at 1:15 PM that was cancelled. Administrative Control Clerk #3 stated the nursing supervisor (unknown who) told them to cancel all appointments that day. They stated they were unsure why but it was probably due to staffing. They stated they usually had to cancel appointments due to low staffing probably twice a month. Administrative Control Clerk #3 stated residents outside provider appointments should never be cancelled. It was a resident right to go on an outside appointment and they themselves would not want to miss a scheduled appointment. During an interview on 07/07/2026 at 3:29 PM, Registered Nurse #10 Team Leader stated if staff members were needed to accompany a resident on an out-of-facility appointment would depend on that resident's transfer status and if they had outside (of the facility) travel privileges. They stated Resident #9 would need a staff member to accompany them on any outside appointment and their gynecologist appointment was cancelled on 06/29/2026. Registered Nurse #10 Team Leader stated all appointments on 06/29/2026 were cancelled due to not having enough nursing staff and that cancelling of outside appointments had been happening a couple times a week for three weeks. The directive to cancel the appointments came from the nursing supervisors because they had the staffing boards. They stated it was important for residents to go on their scheduled outside appointments because they could not always get the resident another appointment the next day, it may take a few weeks.During an interview on 07/07/2026 at 1:16 PM, Nursing Staffing Office Specialist #1 stated they were responsible for the staffing schedules. They stated if there were not two certified nurse aides on each unit, then they would let the nursing supervisor know and make phone calls to get staff to come in. They stated that any staff member was able to help with transporting residents to and from appointments, but it was usually the certified nurse aide's job to transport residents. When the schedule was made for the facility, the certified nurse aides who were responsible for transporting residents were not counted on the schedule. They were on a separate schedule. If more certified nurse aides were needed for transporting residents, a call would be made to staff on the units to see if they would like to go or staff would be called on their personal phones to see if they would like to come in. Nursing Staffing Office Specialist #1 stated they were unaware that resident appointments outside of the facility were cancelled because there was not enough staff. They stated that there were times that a nursing supervisor let them know that they needed more staff, but they did not always communicate to them that more staff was needed to transport residents to appointments. They stated that transportation to appointments was a service that the facility provided to the residents and there always should have been enough staff to transport residents without pulling any staff from the units.During a telephone interview on 07/07/2026 at 4:34 PM, the Medical Director stated they were aware that some outside provider appointments for some of the facility residents needed to be cancelled due to staffing reasons. They stated this had been happening on some days for the last two (2) to three (3) weeks. The Medical Director stated they would not want any residents to miss any appointments; it was not only a disruption for the residents' schedules but also a disruption for the other providers' schedules. They stated but the facility also had to prioritize resident care over outside appointments. The Medical Director stated they do attend morning report and have discussed the situation. They stated on shorter staffing days, prior to doing a blanket cancelation of all outside appointments, the facility nursing staff would determine need of the more important appointments, such as follow orthopedic appointments versus a six month follow up on a stable resident, because they did not want any harm to come to the residents from cancelling an appointment. During an interview on 07/08/2026 at 8:57 AM Registered Nurse #9 Nursing Supervisor stated there were a few certified nurse aides who were the designated transportation certified nurse aides. They were found under the Float Pool category on the Staffing Plan by Zone sheets. Registered Nurse #9 Nursing Supervisor stated that they expected that there was enough staff in the building to transport residents to and from appointments. However, if there were not enough staff on the units, they had to prioritize resident care versus appointments. They stated if they assigned the certified nurse aide to a transport instead, there would be a chance that the residents were not up in time for their appointments to begin with. They stated it was more important for the certified nurse aide to provide resident care. After reviewing the Staffing Plan by Zone documents, Registered Nurse #9 Nursing Supervisor stated:-On 06/22/2026 Certified Nurse Aide #1 and Certified Nurse Aide #2 were designated to provide transportation to residents going to appointments. Because staffing was needed on the units, both Certified Nurse Aide #1 and #2 were instead assigned to a unit. There were no staff to provide transportation to appointments that day. -On 06/24/2026 Certified Nurse Aide #1 and Certified Nurse Aide #2 were designated to provide transportation to the residents going to appointments. Because staffing was needed on the units, both Certified Nurse Aide #1 and #2 were instead assigned to a unit. There were no staff to provide transportation to appointments that day. -On 06/26/2026 Certified Nurse Aide #1 and Certified Nurse Aide #2 were designated to provide transportation to the residents going to appointments. Because staffing was needed on the units, both Certified Nurse Aide #1 and #2 were instead assigned to a unit. There were no staff to provide transportation to appointments that day. -On 06/29/2026 Certified Nurse Aide #3 was the only staff member who was scheduled to provide transportation to residents going to appointments on that day-On 07/01/2026 Certified Nurse #1 took a resident to an appointment at 6:15 AM and Certified Nurse Aide #3 was the only other staff member who was scheduled to provide transportation to appointments. During an interview on 07/08/2026 at 9:24 AM, the Director of Nursing stated their expectation was that the facility was able to accommodate every transport whether it be by having a staff member provide the transportation or requesting family assistance with transportation to and from appointments. Ultimately the staffing office was responsible for making sure there was enough staff to provide care for the residents and provide transportation for appointments. They stated that they thought there was a breakdown in the process and noticed that within the last two or three weeks there was a problem. The Director of Nursing stated they were not sure if the staffing office was aware of how many appointments there were. The certified nurse aides that go out on transports were labelled as float aides and would then be assigned to units. When certified nurse aides were needed on the units, the float aides were used first. Historically the staffing office was not involved in the staff used for transporting residents. It was an expectation that the nursing supervisor communicated to the staffing office when there were not enough staff for transportation to and from appointments. The Director of Nursing stated they were not aware, until recently, that nursing supervisors were cancelling appointments. They stated appointments should never just be cancelled because every appointment that was made was made out of medical necessity and because those outside clinics are specialized. During an interview on 07/08/2026 at 9:30 AM the Administrator stated that their expectation was that no matter what, staffing should be able to accommodate taking residents to their appointments. They stated that the Director of Nursing, staffing specialists and nursing supervisors were responsible to ensure there was adequate staffing to care for the residents and take them to their appointments.10 New York Codes, Rules and Regulations 415.13(b)(1)(ii)

Based on interviews and record review during a survey, the facility failed to ensure residents were free from significant medication errors for one (Resident #387) of two residents reviewed. Specifically, a nurse left Resident #387's medications at their bedside and told a therapy staff member to ensure the resident took the medications and left the room. The therapy staff member encouraged the resident to take their medications and the resident took their medications orally when they were ordered to be administered via their Percutaneous Endoscopic Gastrostomy (a feeding tube inserted through the abdominal wall into the stomach) tube. Additionally, the nurse documented the medications were administered as ordered via the feeding tube. The findings include:Refer to F658 scope and severity = DThe policy and procedure titled Medication: Rules of Administration, dated 02/2026, documented the purpose of the policy was to abide by generally accepted professional standards and New York State laws governing medication administration. Only licensed nursing personnel are assigned the responsibility of administering medications. Always abide by the rights of medication administration, including but not limited to, right resident, and right route. All medications once prepared or poured can only be administered by the nurse that prepared them, and the nurse is never to leave any medications unattended. Additionally, gastric tube medications will be administered by gravity and a 30 milliliter pre and post medication flush with water will be completed.Resident #387 had diagnoses including paralysis of vocal cords, anxiety, and the presence of a percutaneous endoscopic gastrostomy. The Minimum Data Set (a resident assessment tool) dated 10/21/2025, documented that they were severely cognitively impaired, and they were always understood by others and usually understand others. Resident #387 had the presence of a feeding tube, and the eating assessment was not attempted due to a medical condition or safety concerns.Resident #387's General Care Plan, dated 10/14/2025, documented the presence of a feeding tube.Resident #387's Physician's Orders, dated 11/02/2025, documented an order for enteral feed placement check every shift, regular liquids for pleasure, and medications were to be administered via the feeding tube. There was no order for the medications to be administered together.The Medication, Treatment and Task Administration Record Report dated November 2025, documented on 11/04/2025, Resident #387's 9:00 AM medications were signed as administered by Licensed Practical Nurse #2. The 9:00 AM medications were ordered to be administered via the resident's feeding tube and included the following:Dilantin (used to treat seizures) 125 milligrams per 1 milliliter- give 150 milligramsJardiance (used to lower blood sugar)10 milligramsLexapro 10 (used to treat depression) milligramsLipitor 40 (used to lower cholesterol) milligramsLosartan (used to lower blood pressure) 100 milligramsMetoprolol (used to lower heart rate and blood pressure) 25 milligramsSeroquel (used to treat anxiety) 25 milligramsVimpat (used to control seizures) 150 milligramsVitamin D2 (a supplement) 100 unitsMiralax powder (used to treat/prevent constipation) 17 grams Review of the facility Grievance Form, dated 11/06/2025, documented the family of Resident #387 informed the nurse manager that on 11/04/2025 they entered their family's room and Occupational Therapy Assistant #1 told them the resident just took their medication, that the nurse left in the room. The family was concerned because Resident #387 should have taken their medication through their feeding tube. They stated the resident started coughing, but no harm was done. An internal investigation was completed and there was a human resource meeting with Licensed Practical Nurse #2 and Occupational Therapy Assistant #1. Both staff received disciplinary action and re-education. Licensed Practical Nurse #2 received a Letter of Counseling that documented they failed to secure medication, leaving it unattended in a resident's room. This action constitutes a violation of the facility's Medication: Rules of Administration policy. Occupational Therapy Assistant #1 received a Performance Improvement Form, documenting they performed outside their scope of practice by participating in the administration of medication to a resident via the wrong route. During an interview on 07/06/2026, Registered Nurse #13, Assistant Director of Nursing, stated they completed the investigation into the event that occurred on 11/04/2025. They interviewed the staff and reviewed the unit security video. They stated Licensed Practical Nurse #2 told them Resident #387 was busy with occupational therapy, so they left the medication in the resident's room, they stated the medications were crushed in a cup of Miralax. Occupational Therapy Assistant #1 told them they handed Resident #387 the cup of medication, and they drank it. The video showed the nurse enter the room with 2 water sized cups, and shortly after left the room with one cup. They stated they no longer had access to the video footage. Registered Nurse #13 stated both staff were disciplined. In an additional interview on 07/07/2026 at 9:27 AM, Registered Nurse #13 Assistant Director of Nursing stated it was the 9:00 AM medications that were administered. They stated the nurse should not have signed that the medications were administered because they did not administer them.During an interview on 07/07/2026, Licensed Practical Nurse #3 stated that medication should not be left at the bedside. If a resident was ordered their medication through the feeding tube, it would be potentially dangerous for them to take them orally. They stated that would be a medication error because the nurse did not follow the rights of medication administration.During an interview on 07/07/2026, Registered Nurse #10 Team Leader, stated that the nurse should not have left the medication in the room, and the occupational therapy assistant should not have handed them to the resident. They stated that feeding tube medications should be administered individually, with a water flush between each medication, unless the provider ordered they could be combined. They stated Resident #387 did not have that order. Registered Nurse #10 Team Leader stated Resident #387 was ordered regular liquids for pleasure, so the risk of them choking was low, however if they were crushed into a cup of liquid, it would probably be gritty, taste bad and could induce a cough. They stated after the medication error was reported, all nursing staff completed an education on the policy for medication administration.During an interview on 07/07/2026 at 11:27 AM, Physician's Assistant #1 stated the nurse should not have left the medication at the bedside, and the medication should have been administered via the feeding tube. They stated Resident #387 was allowed regular liquids for pleasure, so there was a low risk for them being harmed by taking the medications orally. Physician's Assistant #1 stated that Dilantin, that was combined with the others, should have been administered separately, because other medications could cause it to be less effective.During an interview on 07/07/2026 at 12:17 PM, Occupational Therapy Assistant #1 stated on 11/04/2026 they were completing a session with Resident #387 when the nurse placed the medication cup in the room, told them, Make sure they take these and walked out. They stated they told the resident, Don't forget to take your meds. They recalled the resident asked for a cup of water, so they left to get that. When they returned the family was there. The family told them the resident should have taken their meds through the feeding tube, and not orally, so they reported it to the supervisor because they were unable to locate Licensed Practical Nurse #2. They knew they were not allowed to administer medications. They did not feel they administered the resident's medications, just encouraged them to take them.During an interview on 07/07/2026 at 12:26 PM, Speech Therapist #1 stated Resident #387 had the feeding tube for weight loss, and they were ordered regular liquids for oral gratification, so they were at a low risk for aspiration (inhalation of a substance into the airway) or harm from swallowing the medications orally.During an interview on 07/07/2026 at 2:39 PM, The Director of Nursing stated they expected nurses to follow the five rights of passing medication. Their expectation was that the nurse was to stay in the room while the residents took their medication and it was not acceptable to leave the medication in the room for any length of time. They stated it was not acceptable to leave the medication and go back to check if the medication was consumed by the resident, because it was not known if the resident took the medication, hid the medication or if another resident wandered into the room and took the medication. The Director of Nursing stated that there were no residents at the facility who had an order to self-administer medications. They stated it was a safety risk if a resident choked on the medication, and the nurse was not in the room with them. It was expected that the nurse witnesses the resident take their medications then document it in the medical record. The Director of Nursing also stated that a resident with orders for their medications to be administered via their feeding tube should not take their medications orally, and especially not if the nurse wasn't present. They stated there was a medication error because it was the wrong route, and the occupational therapy assistant was not allowed to administer medications. 10 New York Codes, Rules Regulations 415.12 (m)(2)

Based on observation, interview and record review conducted during the survey, the facility failed to ensure that drugs and biologics were securely stored in accordance with State and Federal laws for two (Residents #242 and #269) of two residents reviewed. Specifically, Residents #242 and #269 had medications stored and unsecured at their bedside. Residents #35, #68, #87, #110, #127, #233, #247 and #251 were also involved.The findings include:Refer to F 658 - Services Provided Meet Professional StandardsThe facility policy and procedure titled Medication: Storage of Medications and Treatments revised 09/2025 documented medications/treatments were stored in a safe and secure manner and accessible only to authorized personnel. Registered Nurses, Licensed Practical Nurses and Pharmacy were responsible.The facility policy and procedure titled Medication: Rules of Administration, General revised 02/2026 documented the purpose was to abide by generally accepted professional standards and New York State Laws governing medication administration. Registered Nurses, Licensed Practical Nurses, Medical Team, and Pharmacy were responsible. The nurse was never to leave any medications unattended.1. Resident #242 had diagnoses that included dementia, hypertension (high blood pressure), and depression. The Minimum Data Set (a resident assessment tool) dated 04/05/2026 documented Resident #242 was understood, understands others and was cognitively intact.Review of Resident #242's Plan of Care - General Care Plan last reviewed 05/01/2026 lacked documented evidence that Resident #242 could self-administer medication or have medications left at their bedside. Resident #242 was noncompliant related to impaired ability to perform tasks and knowledge deficit evidenced by progression of disease process. Interventions included reinforce positive behavior.Review of the Physician's Orders dated 07/07/2026 lacked documented evidence of an order to self-administer medication or leave medications at the bedside. Orders scheduled at 9:00 AM included an order for Aspirin 81 milligrams daily, Depakote (a seizure medication) 250 milligrams two tablets daily, Escitalopram (an antidepressant) 10 milligrams daily, Famotidine (a heartburn medication) 20 milligrams twice a day, Folic Acid (a vitamin) 1 milligram daily, Metoprolol Succinate Extended Release (a blood pressure medication) 25 milligrams half a tablet daily.During an observation and interview on 06/30/2026 at 8:57 AM, Resident #242 was self-ambulating in their room. On the over the bed table there were six- and one-half tablets of medication inside a medication cup. Resident #242 stated the nurses normally leave the medications for them to take. Licensed Practical Nurse #1 brought in a meal tray and while putting down the meal tray, they picked up the medication cup of tablets and left the room.2. Resident #269 had diagnoses that included delirium (a sudden, temporary state of severe confusion), dementia, and type 2 diabetes mellitus. The Minimum Data Set, dated [DATE] documented Resident #269 was understood, understands others and was cognitively intact.Review of Resident #269's Plan of Care - General Care Plan last reviewed on 04/04/2026 lacked documented evidence that Resident #269 could self-administer medication or have medications left at their bedside. Resident #269 had a knowledge deficit related to their diagnosis, ineffective past teaching, evidenced by verbalizing inaccurate information and inaccurate task performance. Interventions included family/responsible party notification.Review of the Physician's Orders dated 07/07/2026 documented an order started on 10/23/2025 for medication monitoring, watch resident take medications as they have been attempting to throw them away. Document if the resident did not take or refused medications and notify the provider every shift. Orders scheduled at 9:00 AM included Amlodipine (a blood pressure medication) 10 milligrams daily, Aspirin 81 milligrams, Ferrex (an iron supplement) 150 milligram capsule daily, Gabapentin (a medication used for seizures or nerve pain) 300 milligram capsule twice a day, Isosorbide Extended Release (a blood pressure medication) 60 milligram tablet daily, Jardiance (a diabetic medication) 10 milligram tablet daily, Lactobacillus (a probiotic) 1 million units daily, Lisinopril (a blood pressure medication) 10 milligram tablet daily, Magnesium Oxide (a supplement used to treat low magnesium levels) 400 milligram tablet twice a day, and Pantoprazole (a heartburn medication) 50 milligrams twice a day.During an observation and interview on 06/30/2026 at 9:26 AM, Resident # 269 was in their room. On their nightstand there was a mix of six capsules and tablets in a medication cup. Resident #269 stated their morning medications were in the medication cup, and they thought the nurse usually stays with them while they take them.A resident council meeting was conducted on 07/01/2026 at 10:30 AM. Residents #35, #68, #87, #110, #127, #233, #247 and #251 were present. The residents stated that there were times when the nurse would leave the medications in their room and leave without watching if they took their medications.During an interview on 07/06/2026 at 2:41 PM, Licensed Practical Nurse #1 stated that they were responsible for passing the morning medications on 06/30/2026 to Resident #242 and Resident #269. They had taken the medications out of Resident #242's room when they brought them in their meal tray. Licensed Practical Nurse #1 stated that they left the medications in the room for Resident #242 because that resident could be behavioral. They stated when medications were brought into the room sometimes Resident #242 did not like to take them right away and they would become angry if the medications were taken out of the room. Licensed Practical Nurse #1 stated that Resident #269 acted the same as Resident #242. They stated that they typically would leave the medications and go back every once in a while, to check if they took their medications. Licensed Practical Nurse #1 stated that both Resident #242 and Resident #269 knew that they needed to take their medications, and they trusted that they would take them. During an interview on 07/07/2026 at 10:27 AM, Registered Nurse #7 Team Leader stated that they expected the nurse who was passing medications to stay with the resident they were giving the medications to. They stated leaving a medicine cup of medication for any length of time in the room with a resident was unacceptable because there was a potential that the resident would hide the medications when the nurse was not looking or they could dump the medication in the garbage. They stated that specifically Resident # 242 had tremors and could drop the medication or would fall back to sleep and just not take them. Resident #269 was a known hoarder and there was a possibility that they would hide their medications somewhere in the room and not take them when they were supposed to.During an interview on 07/07/2026 at 2:39 PM, the Director of Nursing stated they expected nurses to follow the five rights of passing medication. Their expectation was that the nurse was to stay in the room while the residents took their medication and it was not acceptable to leave the medication in the room for any length of time. They stated it was not acceptable to leave the medication and go back to check if the medication was consumed by the resident either because it was not known if the resident took the medication, hid the medication or if another resident wandered into the room and took the medication. The Director of Nursing stated that there were no residents at the facility who had an order to self-administer medications. It was a safety risk if a resident choked on the medication, and the nurse was not in the room with them. It was expected that the nurse witnessed the residents take their medications. 10 New York Code Rules and Regulations 415.18 (e) (1)

ensure that services provided by the facility met the current professional standards of quality for three (Residents # 242, 269, and 387) of three residents reviewed. Specifically, medications were left at residents' bedside and the nurses falsely documented they were administered in the medical record (#242, #269, #387). In addition, Resident #387's medications were administered via the wrong route by an unauthorized employee. Residents #35, #68, #87, #110, #127, #233, #247 and #251 also involved.The findings include:Refer to:F761 scope and severity = DF760 scope and severity = DThe facility policy and procedure titled Medication: Rules of Administration dated 02/2026 documented the purpose of the policy was to abide by generally accepted professional standards and New York State laws governing medication administration. Only licensed nursing personnel were assigned the responsibility of administering medications. Always abide by the rights of medication administration, including but not limited to, right resident, and right route. All medications once prepared or poured can only be administered by the nurse that prepared them, and the nurse was never to leave any medications unattended. Additionally, gastric tube (a feeding tube inserted through the abdominal wall into the stomach for nutrition) medications will be administered by gravity and a 30 milliliter pre and post medication flush with water will be completed. 1. Resident #387 had diagnoses including paralysis of vocal cords (voice box), anxiety, and the presence of a percutaneous endoscopic gastrostomy. The Minimum Data Set (a resident assessment tool) dated 10/21/2025 documented they were severely cognitively impaired. Resident #387 had the presence of a feeding tube, and the eating assessment was not attempted due to a medical condition or safety concerns.Resident #387's General Care Plan (care plan) dated 10/14/2025, documented the resident had a feeding tube.Physician's Orders dated 11/02/2025, documented an order for enteral feed placement check every shift, and regular liquids for pleasure, and medications were to be administered via the feeding tube. There was no documented order for the medications to be administered together.The Medication, Treatment and Task Administration Record Report dated November 2025, documented on 11/04/2025, Resident #387's 9:00 AM medications were signed as administered by Licensed Practical Nurse #2.Review of the facility Grievance Form, dated 11/06/2025, documented the family of Resident #387 informed the nurse manager that on 11/04/2025 they entered their family's room and Occupational Therapy Assistant #1 told them the resident just took their medications that the nurse left in the room. The family member was concerned because Resident #387 took their medications through their feeding tube. They stated the resident started coughing, but no harm was done. An internal investigation was completed and there was a human resource meeting with Licensed Practical Nurse #2 and Occupational Therapy Assistant #1. Both staff received disciplinary action and re-education.During an interview on 07/06/2026, Assistant Director of Nursing Registered Nurse #13 stated they did the investigation into the incident on 11/04/2025. They interviewed the staff and reviewed the unit security video. They stated Licensed Practical Nurse #2 told them Resident #387 was busy with occupational therapy, so they left the medications in the room, they stated the medications were crushed in Miralax. Occupational Therapy Assistant #1 told them they handed Resident #387 the cup of medication, and they drank it. The video showed the nurse enter the room with 2 water sized cups, and shortly after left with one cup. They stated they no longer had access to the video footage. Registered Nurse #13 stated both staff were disciplined. In an additional interview on 07/07/2026, Registered Nurse #13 stated it was the 9:00 AM medications that were administered. They stated the nurse should not have signed that the medications were administered because they did not administer them. Both staff received disciplinary action and re-education. Licensed Practical Nurse #2 received a Letter of Counseling that documented they failed to secure medication, leaving it unattended in a resident's room. This action constitutes a violation of the facility's Medication: Rules of Administration policy. Occupational Therapy Assistant #1 received a Performance Improvement Form, documenting they performed outside their scope of practice by participating in the administration of medication to a resident via the wrong route.During an interview on 07/07/2026, Licensed Practical Nurse #3 stated that medications should not be left at the bedside. If a resident was ordered their medications through the feeding tube, it would be potentially dangerous for them to take them orally. Licensed Practical Nurse #2 was not available for interview at the time of survey. During an interview on 07/07/2026, Team Lead Registered Nurse #10 stated that the nurse should not have left the medications in the room, and the occupational therapist should not have handed them to the resident. They stated that feeding tube medications should be administered individually, with a water flush between each medication, unless the provider ordered that they could be combined. During an interview on 07/07/2026 at 11:27 AM, Physician's Assistant #1 stated that the nurse should not have left the medication at the bedside, and the medications should have been administered via the feeding tube. They stated Resident #387 was allowed regular liquids for pleasure, so there was a low risk for them being harmed by taking the medications orally. Physician's Assistant #1 stated that one of the medications, that was combined with the others, should have been administered separately, because other medications could cause it to be less effective. They stated there were no adverse effects for the resident after the medication error. Physician's Assistant #1 stated the occupational therapist should not have provided the medications. During an interview on 07/07/2026 at 12:17 PM, Occupational Therapy Assistant #1 stated on 11/04/2026 they were completing a session with Resident #387 when the nurse placed the medication cup in the room and told them, Make sure they take these and walked out. They recalled the resident asked for a cup of water, so they left to get that, and when they came back the family was there. When they told them the resident took their meds through the feeding tube, they went and told the supervisor. They stated they were not allowed to administer medications. They did not feel they administered the residents' medications but encouraged them to take them and figured the nurse did all the checks.2. Resident #242 had diagnoses that included dementia, hypertension (high blood pressure), and depression. The Minimum Data Set, dated [DATE] documented Resident #242 was cognitively intact.The Plan of Care - General Care Plan, last reviewed 05/01/2026 lacked documented evidence that Resident #242 could self-administer medication or have medications left at their bedside. The Physician's Orders dated 07/07/2026, lacked documented evidence of an order to self-administer medication and to leave medications at the bedside. The Medication, Treatment and Task Administration Record Report dated 06/01/2026-06/30/2026 documented Resident #242's 9:00 AM medications were signed by Licensed Practical Nurse #1 on 06/30/2026.Resident #269 had diagnoses that included delirium (a sudden, temporary state of severe confusion), dementia, and type 2 diabetes mellitus. The Minimum Data Set, dated [DATE] documented Resident #269 was cognitively intact.The Plan of Care - General Care Plan last reviewed on 04/04/2026 lacked documented evidence that Resident #269 could self-administer medication and have medications left at their bedside. The Physician's Orders dated 07/07/2026 documented Resident #269's order started on 10/23/2025: Medication Monitoring: Please watch resident take medications as they have been attempting to throw them away. Document if the resident did not take or refused medications and notify the provider every shift.The Medication, Treatment and Task Administration Record Report dated 06/01/2026-06/30/2026 documented Resident #269's 9:00 AM medications were signed by Licensed Practical Nurse #1 on 06/30/2026.During an observation and interview on 06/30/2026 at 8:57 AM, Resident #242 was self-ambulating in their room. On the over the bed table there were six and one half tablets of medication in a medication cup. Resident #242 stated the nurses normally leave the medications in here for them to take. Licensed Practical Nurse #1 brought in a meal tray and while putting down the meal tray, they picked up the medication cup of tablets and left the room.During an observation and interview on 06/30/2026 at 9:26 AM, Resident # 269 was in their room. On their nightstand there was a mix of six capsules and tablets in a medicine cup. Resident #269 stated their morning medications were in the medication cup, and they thought the nurse usually stays with them while they take them.A resident council meeting was conducted on 07/01/2026 at 10:30 AM. Residents #35, #68, #87, #110, #127, #233, #247 and #251 were present. The residents stated that there were times when the nurse would leave the medications in their room and leave without watching if they took their medications.During an interview on 07/06/2026 at 2:41 PM, Licensed Practical Nurse #1 stated that they were responsible for passing medications on 06/30/2026 to Resident # 242 and Resident #269. They had taken the medications out of Resident #242's room when they brought them in their meal tray. Licensed Practical Nurse #1 stated that they did leave the medications in the room for Resident #242 because that resident could be behavioral. They stated when medications were brought into the room sometimes Resident #242 did not like to take them right away and they would become angry if the medications were taken out of the room. Licensed Practical Nurse #1 stated that Resident #269 acted the same as Resident #242. They stated that they typically would leave the medications and go back every once in a while, to check if they took their medications. Licensed Practical Nurse #1 stated that both Resident #242 and Resident #269 knew that they needed to take their medications, and they trusted that they would take them.During an interview on 07/07/2026 at 10:27 AM, Registered Nurse #7 Team Leader stated that they expected the nurse who was passing medications to stay with the resident they were giving the medications to. They stated leaving a medicine cup of medication for any length of time in the room with a resident was unacceptable. During an interview on 07/07/2026 at 2:39 PM, the Director of Nursing stated they expected nurses to follow the five rights of passing medication. Their expectation was that the nurse was to stay in the room while the residents took their medication and it was not acceptable to leave the medication in the room for any length of time. They stated it was not acceptable to leave the medication and go back to check if the medication was consumed by the resident either because it was not known if the resident took the medication, hid the medication or if another resident wandered into the room and took the medication. The Director of Nursing stated that there were no residents at the facility who had an order to self-administer medications. They stated it was a safety risk, God forbid the resident choke on the medication, and the nurse was not in the room with them. It was expected that the nurse witnesses the resident take their medications then document it in the medical record. The Director of Nursing also stated that a resident with orders for their medications to be administered via their feeding tube should not take their medications orally, and especially not if the nurse wasn't present. They stated that there was a medication error because it was the wrong route, and the occupational therapy assistant was not allowed to administer medications.10 New York Code Rules Regulations 415.11(c)(3)(i)

Based on interviews and record reviews conducted during survey, the facility failed to ensure that each residents' environment remained as free of accidents as possible and that each resident received adequate supervision and assistance devices to prevent accidents for one (1) (Resident #1) of three (3) residents reviewed for accidents. Specifically, on 09/17/2025, the facility failed to use two (2)-person bed mobility assistance, for overall rolling bed mobility, resulting in Resident #1 falling to the floor, sustaining an acute post-traumatic subdural hematoma (collection of blood that forms between the brain and its outer covering, often due to head trauma), and requiring hospitalization. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy.The findings include: The facility policy titled Comprehensive Care Plan, updated 01/2026, documented the nursing home will develop and maintain a comprehensive care plan for each resident to meet a resident's medical, nursing, mental, and psychosocial needs as identified in the comprehensive assessment. The purpose was to provide a method of communication to enhance staff's ability to provide systemic, comprehensive, integrated, and coordinated care in accordance with resident's specific needs. The facility policy titled Closet Care Plan, dated 07/2025 documented the purpose was to provide a document with care instructions, ready and available in the resident's room, to any caregiver based on the comprehensive care plan. All caregivers are trained to check the closet care plan prior to assisting any resident. All caregivers assigned to care for residents are responsible for following the closet care plan. Resident #1 had diagnoses including chronic respiratory failure, nontraumatic intracerebral hemorrhage (type of stroke characterized by bleeding within the brain due to a ruptured blood vessel), and hypertension (high blood pressure). The Minimum Data Set (a resident assessment tool) dated 07/23/2025, documented the resident was comatose (persistent vegetative state/no discernible consciousness), and was dependent (helper does all of the effort, resident does none of the effort to complete the activity or the assistance of two (2) or more helpers are required for the resident to complete the activity) for the ability to roll from lying on back to left and right side. The Closet Care Plan (guide used by staff to provide care) dated 07/29/2025 documented that Resident #1 required the assistance of two (2) staff members for bed mobility (overall rolling). The Incident/Accident Form dated 09/17/2025 documented that Resident #1 fell out of bed when Certified Nurse Aide #1 was providing hands on care and rolling the resident. The Employee Statement, signed by Certified Nurse Aide #1 and dated 09/17/2025 at 9:22 AM, documented that Resident #1 fell out of bed, when they (Certified Nurse Aide #1) were providing personal/incontinent care for Resident #1. They tried to stop the fall but were unsuccessful. Certified Nurse Aide #1 documented there were no other staff members in the room when Resident #1 fell. The Human Resources Performance Improvement Form, signed by Certified Nurse Aide #1 and dated 09/23/2025 documented that Certified Nurse Aide #1 received a one (1)-day suspension. The Report Details documented on 09/17/2025 that Certified Nurse Aide #1 failed to follow the resident's care plan by providing care without the required assistance of a second staff member as outlined in the care plan. The facility policy states, All caregivers assigned to care for residents are responsible for following the Closet Care Plan and for reporting any concerns regarding its appropriateness or the need for changes to the nurse. As a result of the deviation from the care plan, the resident fell from the bed, sustained an injury, and required hospitalization. The hospital History and Physical dated 10/15/2025 documented Resident #1 presented to the emergency department on 09/17/2025 from the nursing home for evaluation of a head injury after being rolled on their left side, rolling out of bed, and striking their head on the floor. A computed topography scan (CT scan, medical imaging procedure) showed bilateral subdural hematomas and Resident #1 was admitted to the trauma intensive care unit. During an interview on 04/15/2026 at 10:58 AM, Certified Nurse Aide #1 stated on 09/17/2025, they were providing care for Resident #1 without assistance from another staff member, and the resident rolled out of the bed. They stated they were aware Resident #1 required the assistance of two (2) members but were just trying to get the resident done. During an interview on 04/15/2026 at 11:02 AM, Registered Nurse #1 Team Leader stated staff were expected to check and follow the Closet Care Plan prior to providing care. During an interview on 04/15/2026 at 11:32 AM, Licensed Practical Nurse #1 stated they responded to Resident #1's room on 09/17/2025 after the resident had fallen, they were unaware Certified Nurse Aide #1 did not have a second staff member to assist, and Certified Nurse Aide #1 did not ask them to assist with Resident #1. During an interview on 04/15/2026 at 11:47 AM, the Assistant Director of Nursing stated they expected staff to follow the Closet Care Plan and Resident #1 was injured when Certified Nurse Aide #1 did not follow the care plan. During an interview on 04/15/2026 at 11:55 AM, the Acting Administrator stated staff were expected to follow the care plan. On 09/17/2026, Certified Nurse Aide #1 did not have a second staff member assisting with the care of Resident #1. The resident fell out of bed, was transferred to the hospital, and sustained a subdural hematoma. During an interview on 04/15/2026 at 12:16 PM, the Medical Director stated they expected staff to follow protocol and the care plan. The Medical Director stated on 09/17/2025 they responded to an Adult Medical Emergency in Resident #1's room. Resident #1 was lying on the floor next to the bed and emergency medical services were called. The Medical Director also stated that the acute subdural hematomas were likely the result of the fall, and that the fall caused Resident #1 harm. 10 New York Code Rules Regulations (NYCRR) 415.12(h)(2)

Based on video surveillance, interviews, and record review conducted during the survey, the facility failed to protect the residents from physical, mental and verbal abuse by staff for one (1) (Resident #1) of three (3) residents reviewed for abuse. Specifically, on 12/08/2025, Certified Nurse Aide #1 was observed striking Resident #1, which resulted in a red mark to the resident's cheek. Certified Nurse Aide #1 was also witnessed using profane language directed towards the resident at the time of the incident, in response to the resident's behavior. Using the reasonable person concept, as referenced on the Centers for Medicare and Medicaid Services Psychosocial Outcome Severity guide, it was determined psychosocial harm occurred as a result of the physical abuse since there is an expectation that the resident would not be slapped in the face in the facility, that is not Immediate Jeopardy.The findings are: The policy and procedure titled Abuse Prevention, Investigation and Reporting dated 04/2025 documented the facility will provide a safe, abuse free environment to residents and to comply with state and federal regulations regarding abuse prevention, investigation, and reporting. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Physical abuse included but is not limited to, hitting, slapping, and kicking. Resident #1 had diagnoses including alcoholic cirrhosis (stage of alcohol related liver disease where the liver has become significantly scarred), chronic kidney disease (kidneys damaged more than a few months), and chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs causing inflammation in airways that limit air flow into and out of the lungs). The Minimum Data Set (a resident assessment tool) dated 11/28/2025 documented Resident #1 was moderately cognitively impaired, was usually understood and sometimes understands others. Resident #1 had verbal and physical behaviors directed at others. The Closet Care Plan (guide which is placed in the residents' closet and used by staff to provide care) dated 12/07/2025 documented Resident #1 could be verbally and physically aggressive. Resident #1 was combative with hands on care and frequently attempted to self-transfer. The Closet Care Plan documented to separate and protect; report behavior changes; report altercations and provide a quiet environment. The facility investigation completed by the Interim Director of Nursing dated 12/08/2025 documented an altercation between Resident #1 and Certified Nurse Aide #1 occurred. Resident #1 was agitated and attempted to self-transfer out of the recliner. Certified Nurse Aide #1 attempted to settle Resident #1 so they would not fall again. Resident #1 then struck Certified Nurse Aide #1 in the shoulder. Certified Nurse Aide #1 responded and struck Resident #1 in the face. Certified Nurse Aide #1 immediately reported the altercation to Registered Nurse Supervisor #2. Resident #1 had a quarter-sized red mark to their left cheek which had resolved by 12/09/2025. No additional injuries were noted and no psychological harm. The facility concluded physical abuse occurred. Review of video surveillance without audio dated 12/08/2025 at 9:20 PM revealed Certified Nurse Aide #2 and Register Nurse #1 were at the nurse's station on the Canal Unit. Certified Nurse Aide #2 was sitting in a chair in front of the nurse's station looking toward the television, and Registered Nurse #1 was standing and moving about behind the nurse's station. Resident #1 was just across from the nurse's station sitting in a recliner chair with their feet elevated facing the television. Resident #1 could be seen leaning over the right side of the recliner and fidgeting with the recliner lever (handle that puts the feet up and down). Certified Nurse Aide #1 who was seated near Resident #1 at a table against the wall by the television stood up from their chair and approached Resident #1 in an attempt to re-position Resident #1. Resident #1 struck out at Certified Nurse Aide #1 making contact. Certified Nurse Aide #1 reacted by grabbing and holding the residents right wrist with their left hand and slapped Resident #1 in the face with their right hand. There was no audible sound on the video, but Certified Nurse Aide #1 appeared to say something to the resident. Registered Nurse #1 glanced over and moved around from behind the nurses' desk and left out of camera view. Certified Nurse Aide #1 quickly backed away from the resident, returned to the table against the wall for a few seconds, then left the unit and out of camera view. Review of Behavior Notes dated 12/09/2025 through 12/12/2025 documented there were no changes to Resident #1's behaviors after the altercation. During a telephone interview on 12/16/2025 at 10:24 AM, Registered Nurse #1 stated Certified Nurse Aide #1 was aggravated because the unit was hectic, and Resident #1 had fallen previously that day and kept trying to get out of the recliner. Registered Nurse #1 stated they heard a smack but did not see the slap. Registered Nurse #1 stated they heard Certified Nurse Aide #1 say Don't ever put your expletive hands on me again. Certified Nurse Aide #1 had stated Resident #1 hit them first. Certified Nurse Aide #1 left the unit after the altercation and reported themselves to Registered Nurse Supervisor #2. The slap was believed to be a reflexive reaction to Resident #1's actions, but was unacceptable, and was physical abuse. Certified Nurse Aide #1 should have taken a step back and calmed down instead of reacting. During a telephone interview on 12/16/2025 at 11:15 AM, Certified Nurse Aide #1 stated that Resident #1 struck them in the shoulder during repositioning, they reacted and slapped Resident #1 in the face. Resident #1 had a small red mark on their left cheek. Certified Nurse Aide #1 denied swearing at Resident #1 and stated they should have not reacted that way and should have walked away. Certified Nurse Aide #1 stated they immediately reported the altercation to Registered Nurse Supervisor #2, they gathered their belongings from the unit, had no other contact with residents, was sent home after writing a statement, and then they were terminated from the facility. During a telephone interview on 12/16/2025 at 1:14 PM, Certified Nurse Aide #3 stated they were in the servery (room from which meals are served) approximately 25 feet away and heard Certified Nurse Aide #1 slap and tell Resident #1 not to ever touch them again. Certified Nurse Aide #3 did not hear the profane language. Certified Nurse Aide #1 should have reported Resident #1's behavior to Registered Nurse #2, stepped back and took a deep breath. Slapping Resident #1 was inappropriate and was physical abuse. During a telephone interview on 12/16/2025 at 2:10 PM, Registered Nurse Supervisor #2 stated on 12/08/2025 at 9:33 PM, Certified Nurse Aide #1 walked into the supervisor's office and stated they had just slapped Resident #1 and that they had not done it on purpose. Registered Nurse Supervisor #2 immediately reported the slap to the Interim Administrator because slapping a resident was physical abuse. Certified Nurse Aide #1 should have taken a time out or had someone else take care of Resident #1 if they were aggravated. Resident #1 had a one-and-a-half-inch red mark on their left cheek. Resident #1 told Registered Nurse Supervisor #2 they were not going to talk about it when asked about the altercation with Certified Nurse Aide #1. Several attempts were made via telephone to contact Resident #1's responsible party without success on 12/30/2025 at 9:45AM and 2:48 PM, and on 12/31/2025 at 9:28 AM. During an interview on 12/16/2025 at 3:15 PM, the Interim Director of Nursing stated Certified Nurse Aide #1 admitted they had slapped Resident #1 in the face as a spontaneous response, but it should not have been the first response. Unfortunately, Certified Nurse Aide #1 hit Resident #1, which was physical abuse. Resident #1 was assessed and interviewed by Registered Nurse Supervisor #2 and monitored every shift and daily for behaviors. There were no documented negative outcomes, and it was determined that no psychosocial harm occurred. During an interview on 12/16/2025 at 3:30 PM, the Interim Administrator stated the abuse was verified through video footage. Certified Nurse Aide #1 had de-escalation training within the last few weeks and their actions were unacceptable. Behaviors were common in the facility. The slap was a reflex but met the definition of physical abuse. During a telephone interview on 12/30/2025 at 8:30 AM, Certified Nurse Aide #2 stated on 12/08/2025, Resident #1 slid out of their recliner at 9:00 PM. At 9:30 PM Resident #1 grabbed the handle on the side of the recliner and then witnessed Certified Nurse Aide #1 walk over to Resident #1 and bend down to remove Resident #1's hand from the handle. Resident #1 then punched Certified Nurse Aide #1 in the face. Certified Nurse Aide #1 reacted and slapped Resident #1 on their left cheek and told Resident #1 Not to expletive put your hands on them again. A few moments after the altercation, Certified Nurse Aide #1 left the unit. Resident #1 could get aggressive. Certified Nurse Aide #1 should not have hit Resident #1 back. Resident #1 was here to be cared for, not to be verbally and physically abused. During a telephone interview on 12/30/2025 at 9:51 AM, Registered Nurse #3 stated they were in the hall when they heard a pop, and Registered Nurse #1 had walked over to them and told them Certified Nurse Aide #1 just smacked Resident #1 in the face. Certified Nurse Aide #1 then walked off the unit. They stated that Registered Nurse #1 called Registered Nurse Supervisor #2 to report the altercation, and Registered Nurse Supervisor #2 informed Registered Nurse #1 that Certified Nurse Aide #1 just self-reported the incident. Certified Nurse Aide #1 should have de-escalated the situation and reapproached the resident later instead of reacting that way. During a telephone interview on 12/30/2025 at 2:50 PM, the Medical Director stated they heard about the staff to resident altercation on 12/08/2025 from the Interim Administrator. Resident #1 hit a staff member, and the staff member hit Resident #1 back causing redness to Resident #1's left cheek. There was no bruising, no pain therefore was not harm. Certified Nurse Aide #1's reactions were wrong and inappropriate. During a telephone interview on 12/30/2025 at 10:45 AM, Social Worker #1 stated Resident #1 was monitored every shift and had no negative impact from the altercation with Certified Nurse Aide #1. The staff should not be cursing and putting their hands on residents. During a telephone interview on 12/30/2025 at 3:08 PM, Physician Assistant #1 stated they saw Resident #1 on 12/09/2025 and was aware that Resident #1 was agitated and hit Certified Nurse Aide #1 on 12/08/2025. Certified Nurse Aide #1 then became agitated and hit Resident #1 back. The incident resulted in a quarter sized red mark on their face. There was no appreciable injury (a tangible, real harm that is more than minor or speculative, triggering legal action) or they would have documented it. Any reddened area that resulted from an altercation would be considered an injury and would be harm regardless of the duration. During a telephone interview on 12/31/2025 at 11:05 AM, the Interim Director of Nursing stated there was no way to determine if the redness was caused from a fall or flailing around in the recliner. It was hard to say if the red mark was caused from the slap and was not considered harmful. The area did not develop into a bruise and resolved quickly. During a telephone interview on 12/31/2025 at 12:45 PM, the Interim Administrator stated if a finger or handprint was visible on Resident #1's skin then they'd consider the injury harmful. The area of redness resolved quickly, and they were not certain if it was from the slap or self- inflicted. Certified Nurse Aide #1 swearing at Resident #1 was verbal abuse and unacceptable. Certified Nurse Aide #1 should have been aware of their own triggers and had a co-worker step in if they were aggravated instead of taking their agitation out on Resident #1. 10NYCRR 415.4(b)(1)(i)

Based on interview, and record review conducted a Compliant investigation (Complaint # NY00339904) during the Standard survey completed on 8/26/24, the facility and pharmacy services did not effectively implement processes to acquire, dispense and administer medications to meet the needs of each resident. Specifically, one (Resident #260) of four residents reviewed for controlled substances was not administered a regularly scheduled controlled antiseizure medication as ordered and missed a total of 5 doses. Subsequently, the resident experienced seizure activity was transferred to the hospital. Additionally, facility staff did not notify the provider of the unavailability of the medication, and the pharmacy provider did not notify the medical provider that only a 14-day supply of the mediation was dispensed versus the 30-day as ordered. The finding is: The policy titled Controlled Substances with an effective date of 9/2021 documented an official NYS (New York State) triplicate script must state the number of tabs or the number of days and number of refills. The 11:00 PM -7:00 AM shift nurse will check all controlled substances for needed re-fills weekly. Any controlled substances with less than one week supply will be placed on the Controlled Substance Re-Order Form. The 11:00 PM -7:00 AM shift supervisor will collect the forms and bring them to the Nursing Administration Office. The Assistant Director of Nursing (ADON)/designee will give them to the prescriber so that prescriptions will be written. The prescriber will bring the prescriptions to the Nursing Supervisor who will make copies of the controlled substance prescriptions and will enter in the Nursing Supervisor Logbook. The pharmacy courier will pick up the signed prescriptions from the Nursing Supervisor with the next controlled substance delivery. The policy titled Physician Services and Philosophy with an effective date of 8/2019, documented the licensed nursing staff notifies the Attending Physician/Nurse Practitioner/Physician Assistant for required, issuance/review of medical orders; when emergency orders are necessary, or if the plan of care is creating adverse reactions. A Licensed Nurse records notification of the Physician/Nurse Practitioner/Physician Assistant in the resident's medical record. The policy titled Medication and Treatment Administration Record with an effective date of 7/2023 documented the facilities purpose is to assure accurate administration of medications and treatments. The policy titled Medication Ordering, Credits and Delivery of Prescription Medication and Treatments with an effective date of 9/2021 documented the purpose is to ensure that orders for prescription medications are faxed or sent to the Vendor Pharmacy and the prescribed medications are obtained and administered in a timely manner. If the medication is not available from the pharmacy but the time the next scheduled dose, the nurse must contact the Nursing Supervisor to review if the medication can be obtained from the Emergency Box. If the medication cannot be obtained from the Emergency Box and is not available from the Vendor Pharmacy, the nurse will contact the Medical Team for orders. Additionally, each nurse passing medication daily is responsible for the reordering of prescriptions medications. The nurse must be aware of the remaining doses when punching out the doses to be administered. The EMAR (electronic medical record) will indicate if the reorder is accepted or if it is too soon to order. The system will also indicate If medication has already been re-ordered. Resident #260 had diagnoses that included cerebral infarction (stroke), epilepsy (seizure disorder), and metabolic encephalopathy (chemical imbalance in the blood that effects the brain). The Minimum Data Set (a resident assessment tool) dated 3/28/24 documented Resident #260 was severely cognitively impaired, usually understands and was sometimes understood. Review of facility submitted Investigation 5 Day Report, dated 4/29/24 at 4:17 PM, documented Resident #260 had active seizure activity on 4/22/24 at 8:40 AM causing them to be sent to the emergency room for further evaluation and treatment. Facility Investigation documented Resident #260 ran out of seizure medication awaiting it to arrive from pharmacy. The medication, Briviact (controlled antiseizure medication), was ordered through the electronic medication administration record on 4/16/24. The provider received the renewal order that was placed on 4/16/24 but did not renew the prescription due to ordering 60 tablets of this medication on 4/2/24. On 4/3/24, pharmacy sent a 14-day supply (28 tablets) due to insurance stipulations. On 4/19/24, Resident #260 was completely out of their seizure medication. The active physician's orders dated 12/19/23 documented Resident #260 was to receive Briviact 50 milligrams (mg) 1 tab twice daily. Review of electronic pharmacy receipt provided by the Director of Nursing documented Resident #260's Briviact was for a 30-day supply (28 tablets), and on 4/3/24 a 14-day supply (28 tablets) was sent. Review of medication administration record dated 4/19/24 through 4/21/24 revealed over a period of 2.5 days a total of 5 doses of Briviact were not administered as ordered by the medical provider due to its unavailability. Review of 24 Hour Interdisciplinary Report dated 4/19/25, 4/20/24, and 4/21/24 revealed there was no evidence that Resident #260 was added to the report sheet regarding the unavailability of the Briviact, to monitor for seizure activity or that the provider and pharmacy were notified. The 24- Hour Interdisciplinary Report dated 4/22/24 documented Resident #260 was sent out to emergency room for seizure activity at 9:20 AM. The resident returned from the hospital on the 3:00 PM to 11:00 PM shift with an order to continue taking Briviact 50 milligrams by mouth twice a day. Review of the Nursing progress note dated 4/22/24 at 12:08 PM, Registered Nurse #1 documented at 8:40 AM Resident #260 was being provided hands on care when they started to have emesis described as clear mucous and became sweaty. This writer entered the room and Resident #260 appeared to be actively seizing, the resident's body stiffened, started convulsing, and resident was unresponsive to name. This lasted for approximately 90 seconds. Resident #260 started to return to baseline, and the provider was contacted, per provider no Ativan (medication that acts on the brain and nerves to produce a calming effect that relieves symptoms of anxiety) was needed because Resident #260 was returning to baseline. Resident #260 then appeared to be in distress, was no longer responsive and began to tremor. The provider was contacted again, and an order was given to send Resident #260 out to emergency room for evaluation. Emergency medical services were contacted, and upon arrival administered an injection. Resident #260 was transferred by ambulance to the emergency room for evaluation. Upon retrieving residents' packet to be sent out, a review of medication administration record showed Resident #260 had missed 5 doses of seizure medication. Review of Physician progress note dated 4/23/24, Physician Assistant #1 documented Resident #260 sent to emergency department yesterday for breakthrough seizure activity. On review patient reportedly had not received their Briviact since April 19th, 2024. On review of (mobile prescription software), a 30-day supply (60 tabs) was on April 3rd with anticipated coverage through 5/3/24. Investigation unearthed that pharmacy had sent over a 14-day supply due to medication being a brand name. This had not been reported to me previously. Does not appear that a call out was placed to notify provider (myself) or supervising physician of this discrepancy or to notify that their final doses had been utilized. During an interview on 8/23/24 at 8:32 AM, Licensed Practical Nurse #1 stated they worked the 7:00 AM to 3:00 PM shift on 4/19/24 and administered the last dose of Briviact to Resident #260. Licensed Practical Nurse #1 stated the medication was written on the re-order form on Tuesday 4/16/24 so they were expecting it to come from pharmacy. Licensed Practical Nurse #1 stated they called pharmacy and pharmacy stated it was an insurance and provider issue. They reported this to the team leader, Registered Nurse #1 and It was out of their hands now. Licensed Practical Nurse #1 stated they returned to work on Saturday 4/20/24, and the medication still had not been delivered. The overnight staff said, it was being handled, the doctor had said something I think. Licensed Practical Nurse #1 stated they assumed the doctor did what they needed to do, and that pharmacy was sending the medication. Licensed Practical Nurse #1 stated Resident #260 was stable throughout the weekend and had no changes in their vital signs. Licensed Practical Nurse #1 stated there was a communication issue that led to Resident #260 not receiving it as ordered. Licensed Practical Nurse #1 stated any nurse can put a call out to the provider regarding medication. During a telephone interview on 8/23/24 at 9:51 AM, Registered Nurse #1 Team Leader stated they were never made aware prior to Resident #260 having a seizure that they were out of Briviact. Registered Nurse #1 stated it was the nurse passing the medication who was responsible for contacting the pharmacy and/or the provider if it was unavailable. If the Licensed Practical Nurses were unable to get a hold of the provider, then they should report it to the Nursing Supervisor. During a telephone interview on 8/23/24 at 10:21 AM, Pharmacy Consultant stated Briviact was a brand name medication and only sent in a 14-day supply. The physician would have to write a script and between nursing and pharmacy, they would communicate and get refills. During a telephone interview on 8/23/24 at 10:45 AM, the Medical Director stated the procedure for when a medication was unavailable in the facility the nurse should notify the provider and then the provider will respond with a new order, a substitution in the interim, or tell them to call the pharmacy. If it was an insurance issue, there was a team that deals specifically with that. The provider cannot give an order if they were not aware the medication was unavailable. During a telephone interview on 8/23/24 at 10:58 AM, Physician Assistant #1 stated if a medication was a controlled substance or as needed, they were sent in 14-day supplies. The nurse will send a notification and the provider will determine if the order was okay to be renewed. Sometimes controlled substances were sent in a 14-day supply for insurance reasons. This is something pharmacy needs to articulate to them so that the providers can refill appropriately. Physician Assistant #1 stated the nurse were responsible for determining the count for controlled substances and should reach out and let the provider know when a refill was needed. Physician Assistant #1 stated they most definitely expect to be updated when a resident is out of a controlled substance, especially one like Briviact. In the incident with Resident #260, there was a miscommunication issue. Physician Assistant #1 stated if they would have been made aware Resident #260 hadn't received their seizure medication, they would have put an order in themselves and had pharmacy send it over urgently and would have had Ativan on board in case they developed a seizure in the interim. During a telephone interview on 8/23/24 at 11:08 AM, the Pharmacist stated Briviact was a brand name medication. Since the original order date of 12/19/23, Briviact had been sent in a 14-day supply for Resident #260. Pharmacist stated a prescription was written on 4/3/24 for a 30-day supply but the system only allowed a 14-day supply to be provided. The Pharmacist stated there were no notes indicating the facility attempted to call and no refill requests were received between 4/2/24 and 4/22/24. The Pharmacist stated usually a 30-day prescription will be written and then they provider will replenish the prescription every 14 days. The facility will usually call or send a refill sheet when a refill was needed. The Pharmacist stated there were no alerts to the provider from the pharmacy to let them know a 14-day supply was sent instead of a 30-day supply that was ordered. During a telephone interview on 8/23/24 at 11:41 AM, Registered Nurse #2 stated they worked the 3:00 PM to 11:00 PM shift on April 20th and 21st, 2024. When they received report from the 7:00 AM to 3:00 PM shift on April 20th, they were told the medication Briviact was unavailable in the facility. Registered Nurse #2 stated Licensed Practical Nurse #1 told them they had called pharmacy, and the medication was on its way. When it did not arrive on the run that night, Registered Nurse #2 stated they called pharmacy and was told it was on its way. Registered Nurse #2 stated they wrote on the report sheet that they were waiting for the medication. Registered Nurse #2 stated they came in Monday, April 22nd, and was informed Resident #260 had a seizure and was sent out to the hospital because their seizure medication never came. Registered Nurse #2 stated they should not have taken the day shift nurse word for it and should have called the provider themselves. During a telephone interview on 8/23/24 at 3:35 PM, Registered Nurse #4 Nursing Supervisor stated they were the supervisor on Sunday 4/21/24 from 7:00 AM to 11:00 PM and was not made aware that Resident #260 was out of their seizure medication. Registered Nurse #4 stated if they were made aware then they would have notified the on-call provider and got an order right away. Registered Nurse #4 stated they should have been made aware that the medication was unavailable. During a telephone interview on 8/23/24 at 4:00 PM, Registered Nurse #5 Nursing Supervisor stated they were the supervisor on Saturday 4/20/24 from 3:00 PM to 11:00 PM. Registered Nurse #5 stated they were never made aware that Resident #260 was out of their seizure medication. Registered Nurse #5 stated they should have been aware that the seizure medication was not available. Registered Nurse #5 stated that if they were made aware they would have contacted the on-call provider and sent out an urgent notification to them. During an interview on 8/26/24 at 10:29 AM, the Director of Nursing stated they were aware Resident #260 had missed a few doses of their seizure medication which resulted in Resident #260 having a seizure and being sent out to the hospital. The Director of Nursing stated the process for when a medication was not available in the facility was to call pharmacy. The Director of Nursing stated they expect staff to report off to the next shift if a medication was not available and have them follow up with pharmacy. If pharmacy cannot give a reason, notify the Nursing Supervisor who would make a call to the provider for further guidance. During an interview on 8/26/23 at 10:52 AM, Licensed Practical Nurse #3 stated they worked Monday 4/22/24 7:00 AM to 3:00 PM and was Resident #260's nurse. Licensed Practical Nurse #3 stated that morning the Certified Nurse Aide alerted to them, and Registered Nurse #1, that Resident #260 wasn't quite themselves. Registered Nurse #1 went in to Resident #260's room to assess them. Licensed Practical Nurse #3 stated when they entered the room, Resident #260 wasn't talking and was not at their baseline. Resident #260 was then sent out to the hospital. Based on the following corrective actions it was determined the facility implemented corrective actions to correct the non-compliance prior to the start of survey teams' entrance to the facility on [DATE] at 8:30 AM: -On 4/23/24 a Special Quality Assurance Performance Improvement meeting was held to determine the root cause and to put a prevention plan into place. - Director of Nursing completed a facility wide audit on all controlled medications being readily available to the residents. - Briviact was added to the facilities emergency Pyxis system (automated dispensing system) - Policies and Procedures were reviewed and revised - As of 6/21/24 facility wide nurse education was completed along with facility wide competency quizzes, and specific staff counseling completed. During the Standard survey completed on 8/26/24 it was verified through observations, staff interviews and record review the facility implemented their plan, re-educated their nursing staff on the process for notifications to pharmacy and providers, acquiring medications, process for medications that maybe unavailable. NYRCC 415.18 (a)(2)

Based on observation, interview, and record review conducted during a Standard survey completed on 8/26/24, it was determined the facility did not ensure residents received routine dental services to meet the needs of each resident for two (Residents #10, #112) of three residents reviewed. Specifically, Resident #10 had been missing dentures since 10/28/20 and was not provided with timely follow up appointments for denture replacement. There were no dental consults completed after 10/20 through 08/24. Additionally, Resident #112 had a delay in receiving routine dental services on admission, there was no physician order for dental consults and had not received a dental consult until 1/3/24. The findings are: The policy and procedure titled Dental Services dated 8/2021 documented that it was the responsibility of nursing staff, vendor dental services and the medical team to coordinate dental care for residents. All residents are referred to the Dental Clinic and seen within 30 days of admission. Recommendations for dental care and follow up are documented in the Vendor Dental Service's electronic medical record. A paper copy of this documentation will be kept in the resident's paper medical record. 1. Resident #10 had diagnoses that included cerebral palsy (condition that affects movements and posture), epilepsy (seizure disorder), and neuromuscular dysfunction of bladder (nerves and muscles of urinary system don't work together causing urinary tract dysfunction). The Minimum Data Set (a resident assessment tool) dated 6/12/24 documented Resident #10 was cognitively intact, was understood and understands. The assessment documented the resident was edentulous (without teeth). The Minimum Data Set Care Area assessment dated [DATE] had a note which documented Resident #10 was noted as edentulous but had full upper and lower dentures. Dental consult per policy and as needed. The comprehensive care plan dated 4/28/23 (current) documented Resident #10 required supervision with oral hygiene, removing/placing dentures in mouth, and managing denture soaking and rinsing. Additionally, the comprehensive care plan documented Resident #10 was on a modified diet of soft consistency food due to dysphagia (difficulty swallowing). The closet care plan (a guide used by staff to provide care) dated 8/22/24 documented Resident #10 had no dental appliances. The active physician's order dated 10/16/17 documented Resident #10 was to have a dental consult as needed. The dental consult note dated 10/28/20 documented Resident #10 was seen for a periodic oral exam. Resident had lost complete maxillary (upper) denture and had not worn mandibular (lower) complete denture. Primary impressions were to be taken at next visit. Review of the schedule list of residents to be seen by the onsite dentist from 11/9/22 to 7/17/24, provided by the Administrative Control Clerk Supervisor on 8/26/23 at 10:30 AM, revealed Resident #10 was not seen by the dentist between those dates. During an observation and interview on 8/23/24 at 8:47 AM, Resident #10 was sitting up in their bed with no dentures present. Resident #10 stated they have issues with chewing and were unable to eat properly due to missing dentures. Resident #10 stated they had a pair of dentures (uppers/lowers) when they arrived at the facility, but the dentures were lost at some point. Resident #10 stated they had seen the dentist and had a sore in their mouth, so impressions were not taken at that visit, and they were supposed to follow up but has not yet. During a telephone interview on 8/23/24 at 10:08 AM, Registered Nurse #1 stated Resident #10 had dentures at one point but could not remember when they were lost. Registered Nurse #1 stated Administrative Control Clerks were responsible for scheduling appointments and follow ups. Registered Nurse #1 stated there was an in-house dentist and residents go on a list to be seen by the dentist when needed. During an interview on 8/23/24 at 12:12 PM, the Administrative Control Clerk Supervisor reviewed Resident #10's electronic medical record and was unable to find any dental consults. Administrative Control Clerk Supervisor stated they were going to look for Resident #10's dental consults. During a telephone interview on 8/26/24 at 9:16 AM, the Director of Ambulatory Services for the Dental Clinic stated Resident #10 was last seen by the dentist on 10/28/20. The Director of Ambulatory Services for the Dental Clinic stated there were not any dental consults for Resident #10 after 10/28/20. During an interview on 8/26/24 at 9:24 AM, the Administrative Control Clerk Supervisor stated Resident #10's chart may have been thinned and they would check in medical records for any more dental consults. Administrative Control Clerk Supervisor returned and stated they were unable to locate any dental consults for Resident #10 after 10/28/20. During an interview on 8/26/24 at 10:30 AM, the Administrative Control Clerk Supervisor stated that on admission the nurses would be responsible for obtaining an order for dental consults and would then enter the order in the electronic medical record. The Administrative Control Clerk Supervisor stated that once the order was placed in the electronic medical record it would automatically print to their office and they would be responsible to schedule residents on the dental list to be seen. During an interview on 8/26/24 at 10:36 AM, the Director of Nursing reviewed the dental policy and stated all residents should be seen upon admission and annually by the dentist. The Director of Nursing stated they expected Team Leaders and Administrative Control Clerks to work together and make sure all residents were being seen by the dentist appropriately. Nursing staff should follow up and contact the dentist as needed. The Director of Nursing stated Resident #10 should be seen immediately by the dentist due to them not being seen since 2020. It was important for dental hygiene and dignity. 2. Resident #112 was admitted to the facility on [DATE] with diagnoses of dementia, epilepsy (disease that causes seizures), and glaucoma (eye disease that causes vision loss). The Minimum Data Set, dated dated dated [DATE] documented Resident #112 had moderate cognitive impairment was usually understood and usually understands. The assessment documented the resident required partial/moderate assistance (staff provides less than half the effort) from staff for oral hygiene. Additionally, review of Resident #112's Minimum Data Set, dated dated dated [DATE] revealed that Resident #112 was edentulous, at risk of altered nutritional status related to missing teeth and did not wear dentures. Review of the comprehensive care plan with a last review date 2/27/24 and identified as active documented dental care with interventions that included nursing to provide/encourage oral hygiene and assess condition of oral cavity. There was no documented evidence resident had dental services as needed. Review of the closet care plan dated 6/13/24 documented Resident #112 had no dental appliances, required minimum assistance with oral care, and received a regular consistency diet. The electronic and paper medical record for Resident #112 dated 11/8/22 through 8/22/24 documented they had been seen by the dental clinic for a comprehensive oral exam on 1/3/24. There was no evidence of any prior dental evaluations documented in the medical record, and no evidence Resident #112 refused dental consults. Review of Resident #112's physician orders from 11/8/22 through 8/22/24 revealed there was no physician order in place for dental consults. Additionally, the electronic and paper medical record lacked dental consents, declinations, and/or refusals for dental services. Review of the schedule list of residents to be seen by the onsite dentist from 11/9/22 to 12/27/23 provided by the Administrative Control Clerk Supervisor on 8/26/24 at 10:30 AM, revealed that Resident #112 was not seen for an admission dental consult. During an interview on 8/21/24 at 9:36 AM, Resident #112 stated they had some difficulty chewing certain foods and was not aware if they were on a special diet. Resident #112 stated they had dentures at home and would like to have them at the facility. During a telephone interview on 8/26/24 at 9:16 AM, the Director of Ambulatory Services for the Dental Clinic stated that Resident #112 had not been seen in 2022 or 2023 for a routine dental exam. They stated if a resident had refused, refusals would be documented in their medical record under dental consults. During an interview on 8/26/24 at 10:30 AM, the Administrative Control Clerk Supervisor reviewed Resident #112's electronic medical record and stated that Resident #112 did not have a dental consult order upon admission and did not have a dental consult order in place when the resident was seen and should have. During an interview on 8/26/24 at 10:45 AM, Registered Nurse #8 stated that on admission dental consults were a part of the ancillary orders and would be entered into the electronic medical record. They stated the registered nurse or nurse completing the admission would be responsible for entering those ancillary orders. Registered Nurse #8 stated that the Administrative Control Clerks would be responsible for scheduling dental visits. Registered Nurse #8 stated there should be a physician's order for dental consults. During an interview on 8/26/24 at 12:00 PM, the Assistant Director of Nursing #1 stated they were unaware of the process for obtaining dental consents and declinations. They were not aware of any resident dental care concerns and was unsure if there should be a physician order for dental consults. During an interview on 8/26/24 at 12:03 PM, the Operations Manager stated an order for dental consults were part of the standing admission orders that the providers would sign. They stated that all residents would be scheduled to be seen by dentist for admission, annually, and for any concerns. They stated that resident refusals should be documented in the medical record. During an interview on 8/26/24 at 12:35 AM, the Director of Nursing stated Resident #112 should have been seen by the dentist within 30 days of admission and annually. The Director of Nursing stated that dental consults were part of the batch orders entered on admission by the nurses. Resident #112 should have had a physician order for dental consult on admission and for the dental consult received on 1/3/24. NYCRR10 415.17 (c)

Based on observation, interview, and record review conducted during a Compliant investigation (Complaint # NY00339904) during the Standard survey completed on 8/26/24 the facility did not ensure that its residents were free of significant medication errors for one (Resident #260) of three residents reviewed for anti-seizure medications. Specifically, Resident #260 was not administered 5 doses of their anti-seizure medication. This resulted in a significant medication error for Resident #260. The resident had seizure activity and was transferred hospital for evaluation and treatment. The finding is: Refer to F 755 Pharmacy Services/procedures, scope and severity F. The facility policy titled Medication and Treatment Administration Record with an effective date of 7/2023 documented the purpose is to assure accurate administration of medication and treatments. The policy titled Physician Services and Philosophy with an effective date of 8/2019, documented the licensed nursing staff notifies the Attending Physician/Nurse Practitioner/Physician Assistant for required, issuance/review of medical orders; when emergency orders are necessary, or if the plan of care is creating adverse reactions. A Licensed Nurse records notification of the Physician/Nurse Practitioner/Physician Assistant in the resident's medical record. Resident #260 had diagnoses that included cerebral infarction (stroke), epilepsy (seizure disorder), and metabolic encephalopathy (chemical imbalance in the blood that affects the brain). The Minimum Data Set (a resident assessment Tool) dated 3/28/24 documented Resident #260 was severely cognitively impaired, usually understands and was sometimes understood. The active physician's orders dated 12/19/23 documented Resident #260 was to receive Briviact (controlled anti-seizure medication) 50 milligrams (mg) 1 tab twice daily. Resident #260's medication, treatment, and task administration record report for April 2024 documented that Briviact 50 milligrams was not administered as ordered and scheduled on 4/19/24 at 4:03 PM, 4/20/24 at 9:04 AM, 4/20/24 at 4:54 PM, 4/21/24 at 9:43 and on 4/21/24 at 4:28 PM because the medication was unavailable. Review of 24-Hour Interdisciplinary Report dated 4/22/24 documented Resident #260 was sent out to emergency room for seizure activity at 9:20 AM. Review of Nursing progress note dated 4/22/24 at 12:08 PM, Registered Nurse #1 documented at 8:40 AM Resident #260 was being provided hands on care when they started to have emesis described as clear mucous and became sweaty. This writer entered the room and Resident #260 appeared to be actively seizing, residents body stiffened, started convulsing, and resident was unresponsive to name. This lasted for approximately 90 seconds. Resident #260 started to return to baseline, and the provider was contacted, per provider no Ativan was needed because Resident #260 was returning to baseline. Approximately 2 minutes later Resident #260 then appeared to be in distress, was no longer responsive and began to tremor. The Physican was again contacted with an order given to send tote hospital. Review of Physician progress note dated 4/23/24, Physician Assistant #1 documented Resident #260 was sent to emergency department yesterday for breakthrough seizure activity. On review, the resident reportedly had not received their Briviact since April 19th, 2024. They received 10 mg Versed (antiseizure medication) during transportation via emergency medical services. On initial evaluation they were responsive to painful stimuli only. They had 1 gram of Keppra (antiseizure medication) and 1 liter of fluids intravenously. Review of facility submitted Investigation 5 Day Report, dated 4/29/24 at 4:17 PM, documented Resident #260 had active seizure activity on 4/22/24 at 8:40 AM causing them to be sent to the emergency room for further evaluation and treatment. On 4/19/24, Resident #260 was completely out of their seizure medication. During an interview on 8/23/24 at 8:32 AM, Licensed Practical Nurse #1 stated they worked the 7-3 shift on 4/19/24 and administered the last dose of Briviact to Resident #260. Licensed Practical Nurse #1 stated the medication was written on the re-order form on Tuesday 4/16/24 so they were expecting it to come from pharmacy. They called pharmacy on 4/19/24 and pharmacy stated it was an insurance and provider issue. They reported this to the team leader, Registered Nurse #1. It was out of their hands now. Licensed Practical Nurse #1 stated they returned to work on Saturday 4/20/24, and the medication still had not been delivered. The overnight staff said, it was being handled, the doctor had said something I think. Licensed Practical Nurse #1 stated they assumed the doctor did what they needed to do, and that pharmacy was sending the medication. Licensed Practical Nurse #1 stated Resident #260 was stable throughout the weekend and had no changes in their vital signs. Licensed Practical Nurse #1 stated Briviact was an important medication and there was a communication issue that led to Resident #260 not receiving it as ordered. During a telephone interview on 8/23/24 at 9:51 AM, Registered Nurse #1 stated they were never made aware prior to Resident #260 having a seizure that they were out of the medication. Registered Nurse #1 stated Briviact was an important medication and Resident #260 was at risk for having a seizure if they missed any doses. During a telephone interview on 8/23/24 at 10:21 AM, Pharmacy Consultant stated if a resident had epilepsy and missed a few doses of the medication it would not be ideal, they could have refractory seizures. Pharmacy Consultant stated it was not ideal for seizure medications to abruptly stop and Resident #260 missing 5 doses of their Briviact put them at risk for having a seizure. Even if someone has never had a seizure and was on a seizure medication and missed doses, they could have a rebound seizure. During a telephone interview on 8/23/24 at 10:45 AM, Medical Director stated a seizure medication was one that was important and should be given as ordered. Missed doses of a seizure medication puts any person at risk for having seizures. During a telephone interview on 8/23/24 at 10:58 AM, Physician Assistant #1 stated Briviact was an important medication and without it a person was at risk for break through seizures. Physician Assistant #1 stated they would expect to be updated if a resident missed a dose of their seizure medication as soon as possible. Any more than 2 days maximum without receiving the seizure medication would be too far. In the incident with Resident #260, there was a miscommunication issue. Physician Assistant #1 stated Resident #260 experienced a seizure from missing doses of their seizure medication and was sent out to the hospital appropriately. Physician Assistant #1 stated because Resident #260 had a history of stroke and seizure disorder, missing doses of their seizure medication could be potentially harmful, but not life threatening. During a telephone interview on 8/23/24 at 11:08 AM, the Pharmacist stated the half-life (how long a drug remains in the blood) of Briviact for people 65 and younger was 9.0 hours. If someone were to miss 5 doses of their Briviact they were at risk for a partial onset seizure. If someone was on a seizure medication and missed any dose they were at risk for seizures. They're in the possibility of having a seizure, whether they have had one or not. During a telephone interview on 8/23/24 at 11:41 AM, Registered Nurse #2 stated they worked the 3:00 PM-11:00 PM shift on April 20th and 21st, 2024. When they received report from the 7-3 shift on April 20th, they were told the medication Briviact was unavailable in the facility. Registered Nurse #2 stated Licensed Practical Nurse #1 told them they had called pharmacy, and the medication was on its way. Registered Nurse #2 stated they should not have taken the day shift nurse word for it and should have called the provider themselves. Registered Nurse #2 stated Resident #260 was at risk for having seizures without the medication. During a telephone interview on 8/23/24 at 3:35 PM, Registered Nurse #4 stated they were the nursing supervisor on Sunday 4/21/24 from 7:00 AM to 11:00 PM and they should have been made aware that the medication was unavailable. Registered Nurse # stated a seizure medication is very important and puts the resident at risk for having a seizure if they miss a dose. During a telephone interview on 8/23/24 at 4:00 PM, Registered Nurse #5 stated they were the nursing supervisor on Saturday 4/20/24 from 3:00 to 11:00 PM. Registered Nurse #5 stated they were never made aware that Resident #260 was out of their seizure medication and should have been. Registered Nurse #5 stated a seizure medication was very important and puts that person at risk for having a seizure if they miss a dose. During an interview on 8/26/24 at 10:29 AM, the Director of Nursing stated they were aware Resident #260 had missed a few doses of their seizure medication and that resulted in Resident #260 having a seizure and being sent out to the hospital. The Director of Nursing stated even one dose of a seizure medication was too many to miss, it puts the patient at risk for having a seizure. Based on the following corrective actions it was determined the facility implemented corrective actions to correct the non-compliance prior to the start of survey teams' entrance to the facility on [DATE] at 8:30 AM: -On 4/23/24 a Special Quality Assurance Performance Improvement meeting was held to determine the root cause and to put a prevention plan into place. - Director of Nursing completed a facility wide audit on all controlled medications being readily available to the residents. - Briviact was added to the facilities emergency Pyxis system (automated dispensing system) - Policies and Procedures were reviewed and revised - As of 6/21/24 facility wide nurse education was completed along with facility wide competency quizzes, and specific staff counseling completed. During the Standard survey completed on 8/26/24 it was verified through observations, staff interviews and record review the facility implemented their plan, re-educated their nursing staff on the process for notifications to pharmacy and providers, acquiring medications, process for medications that maybe unavailable. NYRCC 415. 12 (m)(2)

Based on observation, interview, and record review conducted during the Standard Survey completed on 8/26/24, the facility did not ensure that each resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for one (Resident #314) of six residents reviewed. Specifically, Resident #314 was observed with dark brown debris under their fingernails on both hands and eating with their hands. The finding is: The policy titled Activities of Daily Living with an effective date of 2/2024, documented individual care plan interventions will be developed and implemented to encourage self-performance at the resident's highest functional level. The policy titled Grooming, AM (morning) and PM (evening) Care with an effective date of 1/2024 documented the caregiver assigned was responsible to see that care has been given in accordance with the resident's individual plan of care. Any deviation will be reported to the nurse. AM care includes nail care. The policy titled Nail Care, effective 8/2021, documented nail care is provided weekly on bath days and as needed. Resident #314 had diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), alcohol abuse, and neutropenia (abnormally low white blood cell count). The Minimum Data Set) a resident assessment tool) dated 7/20/24 documented Resident #314 was moderately cognitively impaired, was sometimes understood and sometimes understands. Additionally, the Minimum Data Set documented that Resident #314 required supervision of one staff for personal hygiene and a moderate assist of one staff for bathing. The closet care plan (a guide used by staff to provide care) dated 5/14/24, documented Resident #314 required assistance from staff with grooming. Additionally, the closet care plan documented Resident #314 eats with their fingers intermittently. Review of nursing behavior notes dated 7/12/24 to 8/21/24 documented Resident #314 had no behaviors pertaining to hands on care. During an observation on 8/20/24 at 9:36 AM, Resident #314 was lying in bed eating a hardboiled egg with their hands. there was dark brown debris was observed under all nails on both hands. During an observation on 8/22/24 at 12:27 PM, Resident #314 was sitting at a table in the dining room eating vegetables with their hands. Resident #314's fingers went into their mouth while taking bites. Dark brown debris remained under nails on both hands. During an interview on 8/22/24 at 1:08 PM, Certified Nurse Aide #2 stated they were assigned as Resident #314's Certified Nurse Aide that morning. Certified Nurse Aide #2 stated Resident #314's morning care included nail care, but they had not provided it to them on this date. Certified Nurse Aide #2 stated nail care was provided as needed and on shower days. Certified Nurse Aide #2 then observed Resident #314's nails with dark brown debris under them and stated their nails needed to be cleaned. Certified Nurse Aide #2 stated nails should be kept clean for infection control reasons, especially if the resident eats with their hands. During an interview on 8/2/24 at 1:13 PM, Licensed Practical Nurse #4 stated Certified Nurse Aides were responsible for trimming and cleaning nails on shower days and as needed. Licensed Practical Nurse #4 stated Resident #314's nails should be cleaned every day, especially if the resident eats with their hands. It is a huge infection control issue. During a telephone interview on 8/23/24 at 10:15 AM, Registered Nurse #1 stated Resident #314 had no history of refusing nail care. Registered Nurse #1 stated they expected the Certified Nurse Aides to do nail care on shower days and as needed. Registered Nurse #1 stated it was an infection control issue to have debris under the nails, especially if the resident eats with their hands. During an interview on 8/26/24 at 10:34 AM, the Director of Nursing stated they expected staff to perform basic activities of daily living based on each resident's care plan, such as nail care. The Director of Nursing stated that if residents eat with their hands, they expected staff to wash the resident's hands and nails prior to eating. Having debris under nails while eating puts that resident at risk for developing an infection. NYCRR 415.12 (a)(3)

Based on interview, and record review conducted during a Complaint investigation (Complaint #NY00321223) during the Standard survey completed on 8/26/24, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #73) of seven residents reviewed. Specifically, Certified Nurse Aide #3 did not provide/utilize a calf board per the plan of care and the resident sustained an injury to their toe/s. The finding is: The policy and procedure titled Closest Care Plan with an effective date of 11/2019, documented the purpose of the closet care plan was to provide care instructions, ready and available in the resident's room, to any caregiver based on the comprehensive care plan team. The policy documented that all caregivers were trained to check the closet care plan prior to assisting any resident. All caregivers assigned to care for residents were responsible for following the closet care plan and to report any concerns with the appropriateness of or need for changes to the nurse. Resident #73 had diagnoses including diabetes mellitus, paraplegia (loss of motor function in the lower half of the body), and traumatic brain injury. The Minimum Data Set (MDS- a resident assessment tool) dated 7/12/23 documented the resident had moderate cognitive impairment, usually understands, and was usually understood. The Minimum Data Set documented that Resident #73 required an assist of one a few times during the 7-day look back period for locomotion. The Comprehensive Care Plan initiated on 1/11/14 documented Resident #73 documented that Resident #73 had self-care deficit and interventions included therapy screens, evaluations, and discharge summaries. The closet care plan (a guide used by staff to provide care) dated 5/9/23 documented Resident #73 was non-ambulatory and required a staff assist for wheelchair mobility in a reclining wheelchair. The closet care plan documented that Resident #73 was to have a calf support, bilateral extending leg rests when in their wheelchair. The Incident/Accident form dated 8/1/23, Licensed Practical Nurse #6 documented at 3:10 PM Resident #73 was rolling self in their wheelchair as their foot fell off the wheelchair pedal. That resulted in Resident #73's toenail to become dislodged from the big toe. It was documented that Resident #73's big toe, and second toe were bleeding. The form documented that an occupational therapy order was requested for a calf board. Review of a Progress Note dated 8/1/23 at 4:04 PM, Licensed Practical Nurse #6 documented Resident #73 was moving forward in their wheelchair as their foot fell off the pedal simultaneously resulting in the nail on their big toe to become dislodged and then bleed. Review of the OT COC Screen note dated 8/2/23 at 10:33 AM, the Director of Rehab Services documented that Resident #73 was assessed due to an incident and accident from a toe bleed. It was documented that Resident #73 was re-issued a blue foot board and black calf support. Review of an untitled investigation report dated 8/8/23 at 12:53 PM, documented that Resident #73 had an injury to the nail on their left great toe that was lifted from their nail bed causing it to bleed. The investigation documented on 8/1/23 Resident #73 self-propelled to the nursing station stating they were bleeding. The investigation documented that Resident #73's great toe was bleeding and it appeared that their left leg had fallen in-between their wheelchair leg rests. The investigation documented after Resident #73 foot fell from the foot pedal, they continued to self-propelled their wheelchair, dragging their left foot under the wheelchair. The investigation documented that the facility employee assigned to Resident #73 did not notice the resident was care planned for a calf support and that employee reported that there was not a calf support in Resident #73's room the day of the incident. The investigation documented that the incident was a care plan violation. During an interview on 8/23/24 at 4:13 PM, Certified Nurse Aide #3 stated they were the staff member assigned to Resident #73 on 8/1/23 when the resident sustained an injury to their toe. Certified Nursing Assistant #3 stated when they got Resident #73 out of bed and placed them into their wheelchair, the wheelchair did not have a calf board. They stated they applied blue booties to Resident #73's feet. They stated at the time of the incident they were not aware that Resident #73 was to have a calf board in place and would have had they read Resident #73's care plan posted on their bathroom door prior to getting them out of bed. During an interview on 8/26/24 at 8:12 AM, the Director of Rehab Services stated they completed a wheelchair evaluation on Resident #73 on 8/2/23 due to an incident report on 8/1/23. The Director of Therapy stated that at the time of the incident Resident #73's wheelchair did not have on calf board as planned. They stated the purpose of Resident #73's calf board was to prevent their feet from falling off their wheelchair pedals. The Director of Therapy stated they expected staff to read the care plan prior to the start of care. During a telephone interview on 8/26/24 at 9:47 AM, Licensed Practical Nurse #6 stated that Resident #73 was in their wheelchair wheeling themselves down the hallway and they noted a trail of blood on the carpet. Licensed Practical Nurse #6 stated that Resident #73 did not have the calf board in place and their foot fell off the wheelchair pedal. They stated the calf board lays across both foot pedals to prevent the feet from falling in-between the pedals. Licensed Practical Nurse #6 stated they were not sure why the calf board was not in place. Licensed Practical Nurse #6 stated staff were to read a resident's care plan when they are assigned to a resident. During an interview on 8/26/24 at 11:37 AM, Registered Nurse #7 Team Leader of the unit stated on 8/1/23 it appeared that Resident #73 ran over their own right foot while in the wheelchair and there was a lot of active bleeding. Registered Nurse #7 stated that Resident #73 did not have their planned foot board in place at the time of the incident and if it was, the injury would have been prevented. Registered Nurse #7 stated they would have expected Certified Nurse Aide #3 to read Resident #73 closet care plan and alert the nurse if their specialty equipment was not in their room. Registered Nurse #7 stated that Certified Nursing Assistant #3 should have not gotten Resident #73 out of bed until they had the proper equipment. During an interview on 8/26/24 at 12:25 PM, the Director of Nursing stated upon investigation of Resident #73's incident on 8/1/23, Certified Nursing Assistant #3 did not implement the residents care planned calf board. The Director of Nursing stated they did not know why the calf board was not in place but that they would expect the staff to review the closet care plan prior to care. The Director of Nursing stated it was important for staff to follow a resident care plan and ensure devices were in place to avoid any injury. 10 NYCRR 415.12(h)(2)

Based on interview, observation, and record review during a complaint investigation (#NY00329554) completed on 12/18/23, the facility did not ensure that all alleged violations involving abuse are reported immediately, but not later than 2-hours after the allegation is made, to the Administrator of the facility and to appropriate officials (including the State Survey Agency) for three (Residents #1, #2, and #3 ) of three residents reviewed. Specifically, alleged staff-to-resident verbal abuse allegations for Resident #1 and Resident #2 and staff-to-resident physical abuse allegations for Resident #3 were not reported to the Administrator and State Agency as required. The findings are: The policy and procedure (P/P) titled Abuse Prevention, Investigation and Reporting last approved date 6/2023 documented it is the policy of the facility to provide a safe, abuse free environment, educate all staff to recognize signs and symptoms of abuse, investigate all alleged abuse, mistreatment or neglect to the appropriate authorities and the New York State Department of Health. The purpose is to comply with state and federal regulations regarding abuse prevention, investigation, and reporting. Under reporting and investigation all facility employees, consultants, medical team, visitors, family members are responsible for reporting abuse, mistreatment, or neglect to Administration promptly. The Administrator or designee will report incidents of abuse, neglect, or mistreatment to the New York State Department of Health via the Health Commerce System online reporting. The report of abuse, neglect or mistreatment will be made in a timely fashion as outlined by State and Federal guidelines. The policy and procedure titled Reporting Resident Abuse, Mistreatment, Neglect or Misappropriation of Property last approved date 10/2019 documented all alleged incidents of abuse, mistreatment, neglect, exploitation, or misappropriation will be reported, consistent with Federal and State regulations. If you witness any abuse, mistreatment, neglect, exploitation, or misappropriation of resident property, and if it is safe to do so, immediately step in and stop the situation. Protect the resident from the situation. Immediately report the incident to the Nursing Supervisor, Director of Nursing, Assistant Director of Nursing, or the Administrator who begin the internal investigation. The facility will report the alleged abuse to the Department of Health. Immediate action will be taken to assure the resident receives any needed care/services and to prevent further potential abuse while the incident is under investigation. Alleged violations and injuries of unknown source must be reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury to the administrator of the facility and to other officials (i.e., State Survey Agency and adult protective services). 1. Resident #1 had diagnoses including paraplegia (paralysis of lower legs), type 2 diabetes mellitus and chronic kidney disease. The Minimum Data Set (a resident assessment tool) dated 10/13/23 documented Resident #1 was usually understood, usually understands and moderately cognitively impaired. Functional abilities indicated for toileting dependent on staff and personal hygiene substantial/ maximal assist. During an observation and interview on 12/14/23 at 1:51 PM, Resident #1 was sitting up in their bed in the high position with their lunch tray in front of them watching television. They stated everything was fine at the facility and had no issues with the staff. Resident #1 appeared to be clean with no odors in the room. They were calm and did not appear to be anxious or fearful. The document titled Incident/ Accident Form dated 12/9/23 at 11:00 AM documented allegations of verbal abuse of a staff member, Certified Nurse Aide #2 towards Resident #1. Certified Nurse Aide #1 notified Registered Nurse #1 of the allegation with an unknown date and time. 2. Resident #2 had diagnoses including schizophrenia, hypertension (high blood pressure), and chronic obstructive pulmonary disease. The Minimum Data Set, dated dated dated [DATE] documented Resident #2 was understood, usually understands and moderately cognitively impaired. Functional abilities indicated for toileting dependent on staff and personal hygiene substantial/ maximal assist. During an observation and interview on 12/14/23 at 1:49 PM, Resident #2 was sitting up in their bed with their lunch tray in front of them attempting to eat their lunch. They were in a hospital gown and their beard and hair were unkept. There was no smell or odor in the room. When asked how everything was going, they stated They treat me like a dog but would not go any further with that statement. They stated they really did not want to talk about it. Resident #2 did not appear to be anxious or fearful. The document titled Incident/ Accident Form dated 12/9/23 at 11:00 AM documented allegations of verbal abuse of a staff member, Certified Nurse Aide #2 towards Resident #2. Certified Nurse Aide #1 notified Registered Nurse #1 of the allegation with an unknown date and time. 3. Resident #3 had diagnoses including bullous pemphigoid (blistering skin condition), dementia, and Alzheimer's disease. The Minimum Data Set, dated dated dated [DATE] documented Resident #3 was sometimes understood, sometimes understands and severely cognitively impaired. Functional abilities indicated for shower/ bathe substantial/ maximal assist. During an observation and interview on 12/14/23 at 1:55 PM, Resident #3 was sitting in a chair in front of the dining table eating their lunch. Resident appeared clean and comfortable. When asked how everything was going, they stated, everything is good. When asked if they were having any issues with staff, they shook their head no. Resident appeared calm with no signs of anxiousness or fear. The document titled Incident/ Accident Form dated 12/9/23 at 11:00 AM documented allegations of physical abuse of a staff member, Certified Nurse Aide #2 towards Resident #3. Certified Nurse Aide #1 notified Registered Nurse #1 of the allegation with an unknown date and time. Review of an e-mail from Survey Builder (electronic reporting system) to the Director of Nursing subject: Webform submission from: Nursing Home Facility Incident Report revealed the three alleged abuse violations were submitted on 12/9/23 at 3:48 PM. Review of the New York State Department of Health Automated Complaint Tracking System Complaint/ Incident Investigation Report for NY00329554 received 12/10/23 at 9:20 AM revealed date/time staff first made aware of the incident was Saturday 12/9/23 at 11:00 AM and date/ time the administrator was first made aware of the incident was Saturday, 12/9/23 at 1:00 PM. During a telephone interview on 12/14/23 at 12:17 PM, Certified Nurse Aide #1 stated on multiple occasions they have heard Certified Nurse Aide #2 saying vulgar things to Resident #1. Certified Nurse Aide #2 would say you are fat or you're disgusting and nasty. Certified Nurse Aide #1 stated Certified Nurse Aide #2 would make gagging noises when caring for Resident #1. Certified Nurse Aide #1 stated Certified Nurse Aide #2 on several occasions had called Resident #2 fat and disgusting and would also make gagging noises while doing care on Resident #2. Certified Nurse Aide #1 stated they were unsure of the dates and times this occurred because it was often and when doing care. Certified Nurse Aide #1 then stated Certified Nurse Aide #2 while giving a bath to Resident #3, purposely sprayed the Resident #3 in their face several times and started laughing. Certified Nurse Aide #1 stated Certified Nurse Aide #2 said they did that because Resident #3 was annoying them. Certified Nurse Aide #1 stated Licensed Practical Nurse (LPN) #1 was in the shower room with them and witnessed the whole incident but did not say anything and just laughed about what had happened. Certified Nurse Aide #1 stated they could not recall when this incident occurred but stated they thought it was when they had just got off orientation sometime in late October/ early November 2023. When Certified Nurse Aide #1 was asked why they did not report these allegations sooner they stated they did not know why they did not speak up sooner but they should have when these incidents occurred. When asked if they had been educated on abuse, they stated they were during orientation and again this week. During an interview on 12/14/23 at 1:15 PM, Certified Nurse Aide #2 denied the verbal allegations for Resident #1 and Resident #2. They stated they did recall when Resident #3 needed to have a bath, as they had a very strong odor and normally takes a shower versus a bath. They stated they did spray the resident's hair to rinse the shampoo out of it but denied intentionally spraying Resident #3 directly in the face. They stated they have been educated on abuse. During a telephone interview on 12/14/23 at 2:13 PM, Registered Nurse #1 stated Certified Nurse Aide #1 casually mentioned to them the three allegations. Registered Nurse #1 stated they told Certified Nurse Aide #1 that they would have to report the allegations as this was considered abuse. Registered Nurse #1 stated they then filed a case call which was an anonymous reporting system in the facility. Registered Nurse #1 stated they thought this went directly to the New York State Department of Health but was later informed by Human Resources it was an inhouse reporting system only. Registered Nurse #1 then stated they reported it to the Nursing Supervisors Registered Nurse #2 and Registered Nurse #3 that morning but was unsure of the exact time. Registered Nurse #1 stated they have been educated on abuse. During an interview on 12/14/23 at 2:33 PM, Nursing Supervisor Registered Nurse #2 stated at around 10:45 AM/11:00 AM they had received a phone call from Registered Nurse #1 asking a question on how to use risk connect a program used for employee injury or concerns which goes directly to Human Resources. Registered Nurse #2 stated Registered Nurse #1 never at that time discussed with them the allegations that were made for Resident #1, Resident #2, and Resident #3. Registered Nurse #2 stated around 1:00 PM was when Registered Nurse #1 came to both Nursing Supervisor Registered Nurse #3 and them to report Certified Nurse Aide #1's allegations of abuse towards the three residents. Further interview at 3:17 PM Registered Nurse #2 stated they reported the incident to the Director of Nursing first and because the Nursing Supervisors were required to do the reporting of allegations of abuse, they reported it online to the New York State Department of Health. Registered Nurse #2 stated they have been educated on abuse and abuse reporting and was aware that allegations of abuse needed to be reported within 2 hours of the allegation. During an interview on 12/14/23 at 2:45 PM, Nursing Supervisor Registered Nurse #3 stated Registered Nurse #1 came down on 12/9/23 in the morning and told Registered Nurse #2 and them of the abuse allegations. Registered Nurse #3 stated they immediately called the Director of Nursing in the morning before noon with the information. During a further interview at 3:13 PM Registered Nurse #3 stated Registered Nurse #2 completed the report to the New York State Department of Health. Registered Nurse #3 stated they had been educated on abuse and stated they were aware of reporting any abuse allegations within 2 hours of the allegations. During an interview on 12/14/23 at 2:55 PM, the Director of Nursing stated they do not do the submissions of abuse allegations to the New York State Department of Health, the Nursing Supervisors were responsible. The Director of Nursing stated the Nursing Supervisors use my e-mail address to submit the reports. The Director of Nursing stated they did not recall the exact time they were called regarding the allegations and stated, sometime between the 7-3 shift. The Director of Nursing stated they were aware of the regulations regarding reporting any allegations of abuse. They stated Certified Nurse Aide #1 should have reported these incidents at the time of the incident and should not have waited. During a telephone interview on 12/15/23 at 9:46 AM, the Administrator stated they were notified of the allegations on 12/9/23 at 1:00 PM and were not aware of the allegations prior to that. They stated they were aware of the regulations for reporting abuse within 2 hours. 10 NYCRR 415.4(b)(4)

Based on observation, interview, and record review conducted during an Abbreviated survey (Complaint NY#00317971) completed on 6/14/23, the facility did not ensure residents had the right to be free from verbal and physical abuse for one (Resident #1) of three residents reviewed for abuse. Specifically, on 6/7/23 without provocation Resident #1 struck Licensed Practical Nurse (LPN) #1 in the head. LPN #1 reacted by becoming engaged in a verbal and physical abusive altercation with Resident #1. The finding is: The policy and procedure (P&P) titled Abuse Prevention, Investigation and Reporting dated 9/2021 documented the facility will provide a safe, abuse free environment to residents and to comply with state and federal regulations regarding abuse prevention, investigation, and reporting. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Physical abuse included but is not limited to, hitting, slapping, and kicking. Verbal abuse included oral, written, or gestured language that willfully includes disparaging or derogatory terms to residents or within ether hearing distance, regardless of their age, ability to comprehend or disability. The P&P titled Crisis Prevention Intervention dated 9/2021 documented the facility incorporated Non-Violent Crisis Prevention (CPI) skills when an emergent circumstance occurs in which there is an imminent risk of a resident harming themselves, staff, or others. The purpose will be to prepare staff to recognize and safely address residents who are displaying risk behaviors and provide education to de-escalate through non-physical interventions, such as activating an Adult Behavioral Emergency. Physical intervention should be a last resort and only used when a non-physical intervention has failed, or no safer alternative can be identified. Physical Interventions included 1.) Disengagement - a non -harmful response to a resident's risk behavior involving strikes and grabs towards others. 2.) Physical Hold- requiring a minimum of 2 assist and was used as a last resort. 3.) Opt Out Sequence- staff must plan to physically disengage as quickly and safely and not to prolong the behavioral event. The P&P titled 1:1 Supervision dated 9/2022 documented 1:1 Supervision was a measure where a staff member is assigned to monitor a resident's whereabouts for a specified time frame. The staff member must be able to visualize the resident at all times. The purpose of 1:1 Supervision was to increase safeguards for residents who are a risk to self, others, and high risk for elopement. 1. Resident #1 had diagnoses that included schizophrenia, traumatic brain injury (TBI) and alcohol abuse. The Minimum Data Set (MDS- a resident assessment tool) dated 5/16/23 documented Resident #1 was moderately cognitively impaired, understands, and was understood. Additionally, the resident exhibited verbal (yelling, cursing) behaviors towards others. Review of the untitled certified nurse aide (CNA) care guide (guide used by staff to provide care) last updated 6/13/23 documented Resident #1 was independent with activities of daily living (ADLs) and ambulation. Resident #1 had a history of making threats to staff and residents and taking items that did not belong to them. Resident #1 was easily agitated, used profanity, and had a history of name calling. Redirection, activities, and distraction techniques were planned. Aggression Interventions for Resident #1 included separation and protection, report behavior changes, report altercations, distraction, supervised activities, and 1:1 Supervision on all shifts. The Incident/Accident Form dated 6/7/23 completed Registered Nurse (RN) Supervisor #7 documented a verbal/physical altercation occurred between Resident #1 and Licensed Practical Nurse LPN #1. The time of the incident was blank. The incident form documented that Resident #1 grabbed and punched LPN #1 in the back of the head. LPN #1 responded and pushed Resident #1 into the wall and fell to the ground. LPN #1 and Resident #1 continued to fight on the floor. LPN #1 was removed from the unit post (after) the incident. Resident #1 had refused a skin assessment and had no apparent injuries that resulted from the altercation. The facility investigation (Incident Accident Follow up) dated 6/7/23 documented at 10:40 PM completed by RN #6 documented CNA #1 provided 1:1 supervision for the 3:00 PM to -11:00 PM shift. CNA #1 and CNA #2 witnessed the altercation between Resident #1 and LPN #1 and provided statements. -CNA #1 documented Resident #1 was making statements that they were going to make us lose our jobs today and swearing at us. At 10:30 PM Resident #1 came out of their room and stated they were going to hit the aide or the nurse. The statement was signed by CNA #1 and dated 6/8/23. -LPN #1 documented on 6/7/23 on the 3:00 PM to -11:00 PM shift Resident #1's behavior became more aggressive, made conversation with themselves in the third person, threatened harm to CNA #1, and loudly stated their intentions were to get someone fired. Resident #1 demanded LPN #1's watch and accused LPN #1 of taking Resident #1's watch even though the watch belonged to LPN #1. LPN#1 documented efforts made to calm Resident #1 included administering medications, offered food and snacks, offered more space between Resident #1 and CNA #1. LPN #1 documented nothing worked to calm Resident #1. LPN #1 thought Resident #1 was trying to intimidate them by walking close to LPN #1 and then Resident #1 hit me. LPN #1 attempted to use CPI tactics to prevent Resident #1 from approaching them. The water spilled and both fell on the floor. LPN #1 rushed back to get up off the floor and pulled Resident #1 away from another resident in the area and CNA #1. Once in the Recreation Room, Resident #1 approached LPN #1 closely and pressed their neck and body against LPN #1's arm and stated to LPN #1, I dare you to hit me. LPN #1 backed away and maintained position in the doorway of the Recreation room until police arrived. The statement was signed by LPN #1 and dated 6/8/23. -CNA #2 documented they heard the commotion and ran to see what was going on and saw Resident #1 and LPN #1 having an altercation. CNA #2 activated their alarm button and contacted the campus police. The statement was signed by CNA #2 and dated 6/8/23. The Police Report documented on 6/7/23 at 10:42 PM, the campus police responded to a panic alarm call for harassment with physical contact between Resident #1 and LPN #1. Resident #1 allegedly struck LPN #1 in the face at which LPN #1 threw a water pitcher and struck Resident #1 back. A scuffle then ensued between the two where both ended up on the ground. LPN #1 was able to return to their feet and Resident #1 remained grounded. The Police Report documented the following camera footage. Officers observed Resident #1 hit LPN #1 first and LPN #1 responded by throwing a water pitcher at Resident #1 before throwing a strike that brought both Resident #1 and LPN #1 to the ground. Once LPN #1 returned to their feet, LPN #1 aggressively grabbed Resident #1 by their hair/sweatshirt, then proceeded to drag Resident #1 on the floor for a few moments before releasing Resident #1. Resident #1 and LPN #1 got back on their feet and LPN #1 got into a fighting stance. Resident #1 walked away and sat down in the Recreation room. LPN #1 followed Resident #1, and the altercation continued. LPN #1 aggressively approached Resident #1. Resident #1 then walked to LPN #1 face to face. LPN #1 pushed Resident #1 away and got into a fighting stance once again. Once campus officers arrived on scene both parties split up. The twenty-four-hour Interdisciplinary Report from 6/7/23 through 6/11/23 revealed there was no documented evidence of injury or physical harm to Resident #1 related to the 6/7/23 altercation. The Nursing Behavior Progress Notes from 6/7/23 through 6/12/23 revealed Resident #1 had no documented evidence of psychological effects from the 6/7/23 resident and staff altercation. On 6/13/23 at 10:19 AM assigned staff responded to an Adult Behavioral Emergency on [NAME] Square. The staff responded appropriately and utilized verbal de-escalation techniques. During an interview on 6/13/23 at 10:27 AM, Registered Nurse (RN) #4 Nursing Supervisor stated four staff members and management were assigned every shift and responded to adult behavioral emergencies and de-escalated the situation. Staff members called with an overhead page on all shifts during the behavioral emergency with the goal of de-escalation. RN #4 stated staff were equipped with a panic button and were expected to press the panic button when an adult behavioral emergency was ineffective. The panic button alerted the facility police. In addition, the staff used CPI (crisis prevention interventions) techniques. CPI techniques were a nonphysical approach. During a telephone interview on 6/13/23 at 10:45 AM, CNA #1 stated there was no time to call an adult behavioral emergency, it happened so fast. Resident #1 hit LPN #1 on the left side of the face. They both fell to the floor. CNA #1 yelled for help, verbally intervened, and pushed their screamer button. The screamer button alerted CNA #2 on the unit they were in danger. CNA #2 then pressed their panic button alerting the campus police. LPN #1 pulled their hoodie to try to get Resident #1 up. CNA #1 stated, we were trained how to diffuse a situation with CPI techniques and told not to physically intervene. This was physical abuse. Review of the surveillance video without audio from the Kensington Unit on 6/13/23 at 11:11 AM in the presence of the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #1 revealed on 6/7/23 at 10:40 PM LPN #1 was bending over checking an oxygen tank of an unidentified resident sitting in a wheelchair at the end of a hallway against the wall. As LPN #1 stood up, Resident #1 came around the corner (1:1 aide was in visual sight) and struck LPN #1 in the left side of the head, which appeared to be unprovoked. LPN #1 reacted abruptly by turning around and threw a water pitcher they had in their hand at Resident #1. Certified Nurse Aide CNA #1 attempted to reach out at LPN #1 but was unsuccessful. LPN #1 then pushed Resident #1 against the wall. Both LPN #1 and Resident #1 fell to the ground during a scuffle. LPN #1 stood up, grabbed a hold of Resident #1's hoodie by the shoulder/arms and dragged Resident #1 approximately five feet. CNA #1 witnessed the altercation without physically intervening but can be seen speaking. CNA #2 was viewed down the adjacent hallway. CNA #2 did not physically intervene. A third unidentified staff member comes into view and picked up the water pitcher from the floor. Resident #1 stood up to their feet, walked and sat down in the Recreation room. LPN #1 followed Resident #1 into the Recreation escalating the situation and appears that a verbal altercation took place. Resident #1 stood up and approached LPN #1. LPN #1 stood in a fighting stance with closed fists, and then shook their right hand at Resident #1 during the verbal altercation. LPN #1 raised their right arm, blocked themselves from Resident #1, positioned their left arm against Resident #1's neck, and forcefully shoved Resident #1 away. The campus police then arrived on the unit, and both Resident #1 and LPN #1 walked away. Based on review of the video footage it was unable to be determined if verbal intervention occurred by CNA #1, #2 and the unidentified staff member. During an interview on 6/13/23 at 11:21 PM, ADON #1 stated LPN #1 should have defended themselves by blocking Resident #1, by holding up their arms with open hands and de-escalating the situation. LPN #1 should have stopped, walked away and not provoked Resident #1. LPN #1 should have left Resident #1 alone. Dragging someone across the floor was abuse, the whole situation was wrong. During an interview on 6/13/23 at 11:23 AM, the DON stated the video surveillance showed abuse. During a telephone interview on 6/13/23 at 12:44 PM, CNA #2 stated they heard a scuffle down the other hall between Resident #1 and LPN #1, and CNA #1 had alarmed their screamer button. CNA #2 stated when they got within eyes view and saw LPN #1 dragging Resident #1 down the hall by their shoulder and hoodie. CNA #2 stated they pressed their panic button and alerted the campus police. CNA #2 stated they were told never to physically intervene and went back to their 1:1 supervision assignment. CPI tactics were to be used de-escalated a situation. During an interview on 6/13/23 at 2:49 PM, RN #1 Team Leader stated LPN #1 had escalated the incident. LPN #1 should have pressed their panic button and stepped back. LPN #1 dragged Resident #1 on the ground and then followed Resident #1 into the Recreation Room. LPN #1 should have waited for the campus police. During an observation on 6/13/23 at 3:15 PM on the Kensington Unit, Resident #1 ambulated independently down the hallway without difficulty, where they then sat and watched television. Resident #1 refused conversation. When asked if they would answer questions, Resident #1 responded by stating, Absolutely not, get out of here! At the time of the observation Resident #1 had no visible signs of physical injuries. During an interview on 6/14/23 at 11:20 AM, ADON #2 stated LPN #1 should have stopped after the water pitcher went flying (initial interaction). LPN #1 should have not dragged Resident #1 while the resident was on the floor. LPN #1 went overboard and was physically abusive towards the resident. During an interview on 6/14/23 at 12:10 PM, the Inservice Educator RN #5 stated LPN #1 had abuse training in February 2023. CPI training was held during general orientation and as needed. CPI was a non-violent crisis prevention intervention program which included classroom lecture and hands on skilled techniques. Lecture included de-escalation techniques, being supportive which eliminated triggers. Hands-on skilled techniques were self-defense tactics when grabbed, cornered, or bit. Position, posture, and proximity were taught and being aware of surroundings. Staff were taught not to put themselves in harm's way. Blocking was done with a supportive stance, one foot forward and one foot back, arms up with open hands. Closed fists escalated the situation. When CPI failed, staff called an adult behavioral emergency or used panic buttons. CPI was geared at staff protection, not individualized for residents. Physical intervention was extreme and required 2 people. Staff were taught never to bring a resident to the floor. CNA #1 and CNA #2 were not expected to come between Resident #1 and LPN #1. CNA #1 yelled for help and CNA #2 pressed the panic button and acted appropriately. During an interview on 6/14/23 at 1:18 PM, LPN #1 stated they were in protective mode for the other resident in the area and CNA #1. When Resident #1 hit me, I shoved them away to keep them from hurting anyone else. LPN #1 stated they should have hit the panic button and ran away. Things turned into a blur, the water pitcher flew, spilled everywhere and we both fell . I just wanted them away from me, I told them to get back to their room and pulled them away. When they got up off the floor Resident #1 went and sat in the Recreation Room. LPN #1 stated they followed Resident #1 into the Recreation Room, where Resident #1 stood up in a fighting stance. My only inclination at the time was to put my hands up in a defensive motion. Resident #1 pressed up against them and said, they could go anywhere they wanted. LPN #1 stated they told Resident #1 to back off and positioned their right arm on Resident #1's neck and pushed the resident away, then the police arrived. LPN #1 stated they did drag Resident #1 and that their actions were appropriate and was not physical abuse. If I wanted to harm (Resident #1), I could have. I was more concerned for the CNA and the other resident. LPN #1 stated they had CPI training 2 years ago and it included guarding yourself, and they were taught to run away. LPN #1 stated that abuse training occurred annually. During an interview on 6/14/23 at 1:30 PM, the DON stated LPN #1 should have been mindful of Resident #1 and walked away. LPN #1 snapped and carried on. Dragging Resident #1 was physical abuse and was not tolerated. CNA #1 verbally intervened to attempt to de-escalate the situation. CNA #2 alerted the campus police. CNA #1 and CNA #2 were not expected to physically intervene. During an interview on 6/14/23 at 2:25 PM, the Administrator stated LPN #1's reflexive behavior was inappropriate, unacceptable, abusive and did not meet company standards and protocols. 10 NYCRR 415.4(b)(1)(i)

Based on observation, interview and record review conducted during a Standard survey started 10/25/22 and completed 11/1/22, the facility did not employ sufficient staff with the appropriate competencies and skill sets to carry out the necessary functions of the food and nutrition service to carry out the functions of the food and nutrition service safely and effectively. Specifically, the facility did not ensure sufficient support personnel resulting in extended meal wait times, accuracy of foods, and proper food safety with preparation and serving of foods. This included Residents #35, 230, 239 and 296. The findings are: Refer to: F 803 Menus Meet Resident Needs/ Prep in Advanced/Followed- scope and severity (S/S) = D Refer to: F 812 Food Procurement, Store/ Prepare/Serve- Sanitary- S/S = D Review of the undated Meal Times sheet provided upon entrance of facility the following mealtimes are documented to start at: 2A MLK: Breakfast- 7:45 AM, Lunch-12:00 PM 2D Delaware: Breakfast- 7:45 AM 3B [MEDICATION(S)] Gardens: Lunch- 12:30 PM 4C Niagara Square: Breakfast- 8:15 AM Observations of the following meals are as follows: -During unit 2A lunch meal on 10/25/22 tray passing started at 12:39 PM and was completed at 1:00 PM. Posted across from the servery was a sign that documented: Breakfast: 7:45 AM, Lunch: 12:00 PM, and Dinner: 4:30 PM. Please allow a 15-minute window for service. -During unit 2D breakfast meal on 10/26/22 tray passing started at 8:53 AM and was completed at 9:40 AM. -During unit 2A breakfast meal on 10/31/22 tray passing started at 8:30 AM and was completed at 8:51 AM. -During unit 4C breakfast meal on 10/31/22 tray passing started at 10:15 AM and was completed at 10:45 AM. -During unit 4D lunch meal on 10/31/22 tray passing started at 12:35 PM and was completed at 1:10 PM. -During unit 3B lunch meal on 10/31/22 tray passing started at 1:30 PM and was completed at 1:48 PM. Review of Resident Council Minutes dated 7/12/22 documented members stated that mealtimes were inconsistent, especially on weekends for lunch and dinner. Review of Resident Council Minutes dated 8/9/22 documented members stated that mealtimes were inconsistent, especially on weekends. Food Service Director (FSD) stated they are having staffing challenges and they continue to recruit new staff to fill gaps. Review of Resident Council Minutes dated 9/13/22 documented members stated that mealtimes are inconsistent, especially on weekends. Concern form sent to FSD and Assistant Food Service Director (AFSD). Review of Resident Council Minutes dated 10/11/22 documented members stated that mealtimes are inconsistent, causing residents to be late or miss special services and activities. Dinner times are close to 7 PM. Concern form sent to FSD and AFSD. Review of Resident Concern Form dated 7/18/22 documented Resident #239 on 7/17/22 stated, I was served breakfast at 10:20 AM on Sunday- cold cream of wheat. Form forwarded to dietary. FSD reviewed camera footage as unit was notified at 7:00 AM that we would need to send up meals via tray line. Food was delivered at 9:17 AM, nursing didn't start passing food until 10:00 AM. Director of Nursing (DON) notified, and staffing was educated. During an interview on 10/26/22 at 12:44 PM, the facility Ombudsman stated the residents have been complaining about the food and the times of when the food is being served. During an interview on 10/31/22 at 10:43 AM, Resident #296 stated It bothers me that the meals come late a lot. Wouldn't it bother you? During an interview on 10/31/22 at 10:43 AM, Resident #230 stated It bothers me the meals always come late. My mother always said if you are late for dinner, you will get nothing, so I am never late and have to sit and wait. It doesn't matter which meals they are all late. During an interview on 10/31/22 at 10:51 AM, Registered Nurse (RN) #11 stated trays often come late. Today they were extremely late for breakfast. It was discovered before 10:00 AM that the food cart was up here but no one from dietary had come to serve it. That is when dietary was called, and they came over about 10:15 AM and started serving up the breakfast meal. During an interview on 11/1/22 at 10:24 AM, Resident #239 stated that they did file a grievance back in July 2022 regarding breakfast being late. They stated meals come late all the time. They stated what resident wouldn't be upset if their meals come late. They have schedules for a reason. There are times because the meal was late causing other things not to get done, like treatments or appointments. Yes, I am upset that the meals do not come on time. During an interview on 10/31/22 at 12:01 PM, the FSD stated they have been having staffing issues as they have been 40 staff members down since 7/2021 and currently were short 14-16 staff either full time or part time positions, especially the servers. They were not able to get the meals out in timely manner. When they are short servers there will only be two servers assigned to 4 units. Optimal number of servers would be 3 per floor or 4 units and we would need a total of 12 servers per meal. There are times when the facility only has 1-2 servers per floor which causes meal service to take longer as they would not serve upstairs in the unit serveries, but from down in the kitchen. When they do this, disposable containers are used as the plates and utensils are all up on the servery. This was usually done on the weekends as that was when they are really short staffed. There have been multiple discussions with the Administrator, DON and Acting DON and they have implemented meal audits. It has to be a team effort for this serving style. During an interview on 11/1/22 at 10:20 AM, FSD stated they did not have any policies regarding staffing or meal serving times. 415.14(b)(1)(2)

Based on observation, interview, and record review conducted during a Standard survey started on 10/25/2022 and completed on 11/1/22, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living (ADL's) received the necessary services to maintain grooming and personal hygiene for three (Residents #58, #150 and #279) of seven residents reviewed for ADLs. Specifically, there was lack of hand hygiene and glove changes during morning (AM) care and staff did not wash the residents face, hands, and underarms (Resident #58), Resident #150 had greasy, long, and unkempt hair, with no access to a barber, and Resident #279 had long fingernails with brown debris under their thumb nails. Additionally, Resident #279 did not have rolled washcloths to both hands as ordered. The findings are: Review of the facility Policy and Procedure (P&P) titled Grooming, AM & PM Care, revised 9/2022 includes grooming, hair combed, daily shave for men/PRN (as needed) for women, oral care, application of deodorant after washing under torso, and nail care. The Certified Nurse's Aide (CNA) is to document completion of ADLs or if unable to complete ADLs. Review of the facility's undated The Resident Handbook (part of the admission packet) documented there was a beauty shop located on the ground floor. Services available included haircuts, styling, and perms. Charges can be deducted from the resident's account. Residents should see the Administrative Control Clerk (ACC) to make an appointment or call the beauty shop directly. The facility P&P titled Nail Care last revised 8/2021, documented to provide nail care weekly on bath days and as needed. Assure resident's nails are kept clean without jagged edges which could lead to injury. 1.Resident #150 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 8/26/22 documented the resident was cognitively intact and required extensive assistance of one staff member for personal hygiene. The closet care plan dated 10/20/22 documented Resident #150 needed assistance for grooming and was to be offered shaving and grooming daily. During an observation and interview on 10/26/22 at 8:59 AM, Resident #150 had greasy, long and unkempt hair. Resident #150 stated that they had been trying to get a haircut for about two months but haven't been able to because the hairdresser left. Further observations on 10/27/22 at 12:52 PM and 10/28/22 at 8:11 AM, revealed Resident #150's hair was long and unkempt. During an interview on 10/28/22 10:59 AM, Certified Nurse Aide (CNA) #2 stated the facility used to have a hairdresser but they left a while ago and they didn't have one now. During an interview on 11/1/22 9:54 AM, Resident # 150 stated that their family would take them out for a haircut the next day, although they would have preferred to have one at the facility, if a hairdresser was available. During an interview on 11/1/22 9:57 AM, the Administrative Control Clerk stated that the facility did not have a hairdresser and hasn't had one since July. The Administrative Control Clerk stated if a resident wanted a haircut, the family could arrange for a hairdresser and that it was a problem for some residents. During an interview on 11/1/22 at 10:00 AM, Registered Nurse (RN) #1 stated that the facility used to have a beautician but has not had one for many months now. RN #1 stated that to get appointments for the residents, the family would have to come in and do it or do the hair themselves since the nursing staff cannot cut the hair. During an observation and interview together with RN #1 on 11/1/22 10:04 AM, RN#1 stated that Resident #150's hair was long, and that the resident should have a haircut as they wanted to. During an interview on 11/1/22 10:51 AM, Acting Director of Nursing (DON), stated that they usually provided hairdresser services but the last hairdresser had resigned, and there is none now. The Acting DON stated residents and staff were aware the facility did not have one now, and the position had been posted, and they were trying to hire one. The Acting DON stated if a resident wanted a haircut, they would have to reach out to families to arrange it. 2. Resident #58 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 8/11/22 documented resident # 58 had moderately impaired cognition, required extensive to total assistance of one person for ADLs. Review of the closet care plan dated 10/20/22 documented Resident #58 needed total assistance of one staff for bathing and oral care. During an observation of morning care on 10/31/22 at 10:37 AM, CNA #3 provided perineal-care (area between the genitalia and anus) and did not change their gloves, wash hands, and replace the water in the basin, before they wet a washcloth and cleaned brown debris off, in and around the resident's mouth. CNA #3 did not provide oral care, clean the resident's back, armpits, or brush the resident's hair. CNA #3 disposed of the used water from the basin in the single sink of the bathroom the resident shared with another resident. During an interview on 10/31/22 at 10:49 AM, CNA #3 stated Resident #58 needed total assistance with all morning care and that the resident's back, feet, armpits should have been cleaned, the resident's hair combed and brushed, and oral care should have been done during morning care. CNA #3 stated they should have changed their gloves and washed hands, before they cleaned the chocolate pudding off, in and around the resident's mouth and should have disposed of the used water from the basin into the toilet and not the single sink of the bathroom the resident shared with another resident to avoid cross contamination. During an interview on 10/31/22 at 1:23 PM, Licensed Practical Nurse (LPN) #1 stated that morning care for Resident #58 included, brushing hair, washing upper and lower body, peri-care and oral care. LPN #1 stated that CNA #3 was made aware of these guidelines this morning. LPN #1 stated CNA #3 should have washed their hands and changed gloves before cleaning the resident's mouth and should have dumped the used water into the toilet. During an interview on 11/1/22 at 11:08 AM, the Acting DON, stated that morning care included oral care, washing face, combing hair and staff should complete care as outlined by the resident's care plan. The Acting DON stated that nurses were responsible for ensuring that staff follow the care plan. The Acting DON stated that it was not acceptable that the CNA breached infection control protocols by not changing the gloves after peri-care, prior to cleaning the resident's mouth and did not carry out complete morning care for the resident as per resident's care plan. The Acting DON stated that they would have expected CNA #3 to have changed her gloves and dump the dirty water into the toilet and not the sink. During an interview on 11/1/22 at 12:06 PM, In -Service Coordinator #1 stated CNAs were taught to check the care plans and follow them and were provided infection control and other competency during orientation, and trainings before they hit the floors. In-Service Coordinator #1 stated they would have expected staff to wash hands and change gloves between dirty and clean sites of the body during care, and to dispose of the water after care in the toilet and not the sink. During an interview on 11/1/22 at 12:10 PM, In -Service Coordinator #2 stated CNA #3 should have worked from clean to dirty sites and changed gloves while moving from one task area to the other, when providing morning care to the resident. The In-Service Coordinator #2 stated that morning care included washing the resident's hands, face, underarms, peri area, and providing oral care. 3. Resident #279 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-a resident assessment tool) dated 10/18/22 documented Resident #279 had severe cognitive impairment, was rarely/never understood, and sometimes understands. In addition, Resident #279 had functional limitation in ROM (range of Motion-normal range of motion for a joint) on both sides UE (upper extremities) and LE (lower extremities). Also, required extensive to total assistance for ADL's. Review of the closet care plan dated 10/20/22 revealed Resident #279 required total assistance with grooming and required rolled washcloths to left (L) and right (R) hand(s) on as tolerated, at all times except care. Review of physician's orders printed 11/1/22, revealed an order dated 4/5/22 to cleanse Resident #279's left and right hand with soap and water, dry thoroughly and place a rolled washcloth daily and PRN (as needed) for contracture care. Another physician's order dated 4/5/22 documented to check for placement of hand rolls to bilateral hands, if not present complete PRN. Review of Medication, Treatment, and Task Administration Record Report for October 2022 documented no refusals of treatment orders for rolled washcloth and handrolls to bilateral hands. Review of nurse's notes dated from 9/13/22-10/26/22, documented no refusal of nail care or placement of bilateral hand rolls. Observations of Resident #279 revealed: -On 10/25/22 at 9:46 AM and 10:00 AM, visible fingernails on both hands were long (over the tips of the fingers), thumb fingernail on the left hand was dirty with dark debris, and jagged. Fingers on the left hand were curled into the palm of their left hand with their left index fingernail visibly pressing into the palm of their left hand. No rolled washcloth was present in their left hand. -On 10/31/22 at 10:33 AM, bilateral fingers/hands curled into fist position with no rolled washcloths present. At 1:29 PM, bilateral hands were clenched in fist position with fingernails curled into palm of hands. Bilateral thumb nails visible and were noted to be long, jagged with dark debris present. No rolled washcloth present to bilateral hands as ordered. -On 11/1/22 at 7:37 AM, a rolled washcloth was in their left hand only. During an interview on 10/31/22 at 11:45 AM, CNA #6 stated they were responsible for applying splints per the care plan so residents do not lose their ability to move. At 1:29 PM, CNA #6 stated they should have noticed Resident #279 did not have rolled washcloths to bilateral hands and they should have had them in place. Additionally, CNA #6 stated rolled washcloths were needed so Resident #279 contractures didn't get worse. During an interview on 10/31/22 at 11:59 AM, LPN #8 stated all nursing staff were responsible to ensure residents are wearing adaptive equipment as care planned. During further interview and upon observation at 1:36 PM, LPN #8 stated Resident #279 nails needed to be cut and cleaned because they were long and had dried debris under the nails. Additionally, dried skin were noted to palm of hands with nail indentation noted to palm of left hand. During an interview on 11/1/22 at 7:37 AM, RN #5 stated every shift was to make sure rolled washcloths were in place to bilateral hands. During observation at this time RN #5 confirmed that Resident #279, only had a rolled washcloth in their left hand and should have had one present in their right hand as well so their hand doesn't contract anymore. During an interview on 11/1/22 at 11:36 AM, Certified Occupational Therapy Assistant (COTA) #2 stated Resident #279 was care planned for a rolled washcloth to both hands for skin integrity and to maintain what movement they had. During an interview on 11/1/22 at 11:11 AM, the Acting DON stated they expected CNAs to perform nail care on residents unless they were diabetic then the nurse would be expected to complete. Nail care was expected to be completed on shower/bath day or anytime it was needed to prevent scratching, skin tears and infection. Additionally, the Acting DON stated rolled washcloths to hands were utilized for hand hygiene, and for contractures to help with joint mobility. Refusals of care should be reflected in the resident's plan of care. 415.12 (a) (3) (e) (2)

Based on interview and record review conducted during the Standard survey started 10/25/2022 and completed on 11/1/2022, the facility did not ensure they immediately consulted with the resident's physician when there was a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for one (Resident #343) of two residents reviewed. Specifically, there was a delay in notification to the medical provider when a peripheral intravenous line (PIV-a tiny flexible tube that is inserted into a vein for the delivery of fluids/medications) access was unable to be obtained for antibiotic (ABT) administration. The finding is: The facility policy and procedure (P&P) titled Physician/Provider Notification for Change in Patient Condition, dated 2/2022, documented that the registered nurse (RN) assigned to the patient or supervising the care of the patient was responsible for notification of and communication to the Physician/Provider regarding significant changes or significant deterioration in the patient's condition, and for assuring that there was a physician/provider response/intervention. The P&P documented that the changes in the condition of the patient are determined by assessments utilizing parameters defined in standards of care, physician/provider orders, and the patient's previous condition. The P&P documented that the physician/provider notification was to be documented in the medical record with pertinent information, which includes date, time, need, name of each physician/provider notified, actions taken, and/or patient's response to treatment. The facility P&P titled Intravenous Therapy, dated 9/2021 documented the purpose of intravenous (IV) therapy was to provide intravenous access for the administration of specified medications. If the nurse cannot restart the IV line, the medical team was to be notified. 1. Resident #343 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- a resident assessment tool) dated 10/11/22 documented that the resident was sometimes understood and rarely/never understands and had severely impaired cognitive skills. The MDS documented that Resident #343 had received IV therapy in the last 14 days. Review of Resident #343's physician telephone orders revealed RN #9 received the following orders: -On 10/13/22 at 12:30 PM, the Physician Assistant (PA) ordered to send the resident to the [MEDICATION(S)] radiology catheter lab to replace a PICC line (peripherally inserted central catheter-a catheter that is inserted through a vein and advanced until the tip enters the central venous system) to the left arm and to hold intravenous (IV) [MEDICATION(S)] (an antibiotic medication) until the PICC was replaced. -On 10/15/22 at 12:00 PM, Physician #1 ordered to attempt PIV insertion and if able to gain access continue [MEDICATION(S)] IV order as scheduled. -On 10/19/22 at 9:50 AM, the PA ordered to send the resident to the emergency department for PICC placement. Review of the Medication, Treatment and Task Administration Record Report dated October 2022 revealed Resident #343 received [MEDICATION(S)] 2 grams via PICC every 8 hours (at 5:00 AM, 1:00 PM and 9:00 PM). The report documented from 10/13/22 at 9:00 PM thru 10/15/22 at 5:00 AM that the [MEDICATION(S)] was on hold. The report further documented from 10/15/22 at 1:00 PM thru 10/19/22 at 9:00 PM [MEDICATION(S)] was not administered. Review of the LTC Acute Visit written by the PA on 10/17/22, documented that Resident #343 incidentally pulled out the PICC line from their right arm on 10/13/22 and orders were given to have [MEDICATION(S)] radiology place a new PICC. The PA documented the [MEDICATION(S)] was placed on hold and over the weekend the PICC was still unable to be placed, therefore new recommendations were given to administer the [MEDICATION(S)] via PIV until a PICC could be placed. The PA further documented that it was okay to give the [MEDICATION(S)] via PIV in the interim. There was no documentation that the PA was notified the resident didn't have PIV access for the ABT administration. Review of a LTC Acute Visit note dated 10/19/22, the PA documented that Resident #343 was sent to the emergency room for new PICC placement. Review of the nursing notes, behavioral notes and 24 Hour Interdisciplinary Report from 10/15/22-10/19/22 revealed no documented evidence that a medical provider was notified of the inability to gain PIV access or to obtain further orders. During an interview on 10/31/22 at 11:06 AM, RN #9 (Team Leader (unit manager)) stated that Resident #343 self-removed their PICC on 10/13/22. RN #9 stated they received an order to hold the [MEDICATION(S)] and to have the PICC reinserted by [MEDICATION(S)] radiology. RN #9 stated that they contacted Physician #1 on 10/15/22 and received an order to attempt to access of a PIV to administer the IV antibiotic due to [MEDICATION(S)] radiology needing a prior authorization from the insurance company for insertion of a PICC line. RN #9 stated on 10/15/22 they attempted twice to access a PIV, but it was unsuccessful. RN #9 stated they wrote on the unit report sheet to attempt PIV access the next shift. During a further interview on 11/1/22 at 9:11 AM, RN #9 stated when they worked 10/16/22, Resident #343 still did not have PIV access. RN #9 stated they did not contact a medical provider on 10/15/22 or 10/16/22 that the PIV access was unsuccessful and that they should have. RN #9 stated that Resident #343 was sent to the emergency roiagnom on [DATE] for PICC line placement. RN #9 stated they did not document a nursing note regarding communication that they had with any medical provider and that they should have. During an interview on 10/31/22 at 11:12 AM, the PA stated that Resident #343 originally pulled out their PICC line and they ordered a new PICC line to be place through radiology. The PA stated radiology needed a prior authorization and the on-call physician (Physician #1) was contacted by the facility on 10/15/22. The PA stated Physician #1 ordered a PIV to be placed. The PA stated their expectation would be that a provider be notified that the PIV placement was unsuccessful so the resident could have been sent to the emergency room earlier. During a telephone interview on 11/1/22 at 12:28 PM, Physician #1 stated they ordered a PIV to be placed for Resident #343. Physician #1 stated they do not recall being notified that the PIV was not obtainable, and their expectation would be a return phone call for further orders. During a telephone interview on 11/1/22 at 1:24 PM, RN #18 (3-11 nursing supervisor) stated that on 10/15/22 Resident #343 had an unsuccessful attempt at PIV access on the day shift by RN #9. RN #18 stated that it was not reported to them that another attempt needed to be completed and that they did not contact a medical provider that the PIV was not obtainable. During an interview on 11/1/22 at 2:17 PM, the Acting Director of Nursing (DON) stated their expectation would be for a medical provider to be notified if a PIV was ordered and the nurse could not access the line as soon as possible for further orders. The Acting DON stated they expected all MD notifications to be documented in the resident's medical record. 415.3 (f)(2)(ii)(b)(c)

Based on interview and record review conducted during the Standard survey started on 10/25/22 and completed on 11/1/22, the facility did not ensure that grievances were resolved in a timely manner for one (Resident #240) of four residents reviewed for personal property. Specifically, there was lack of a thorough investigation and resolution into a resident's report of missing property. The finding is: Review of the facility policy and procedure (P&P) titled Prevention of Resident Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property dated 10/19, revealed all staff were trained annually and on orientation regarding misappropriation of resident property. Complaints regarding resident property required an investigation. Review of the facility P&P titled Resident/Family Concerns revised 10/19, revealed it was the policy of the facility to assure timely investigation and resolution of all resident concerns. When a complaint is received, the Grievance Officer will write the complaint into the log, assign complaint to applicable department director and or management staff. The individual assigned will investigate the complaint and provide a summary to applicable Grievance Officer. All complaints will be monitored by the Facility QAPI Committee and concerns will be responded to in writing. The Grievance Officer will forward the letter to the resident/designated representative and the letter would be maintained for three years. 1. Resident #240 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - a resident assessment tool) dated 9/17/22 documented the resident was cognitively intact, was understood and understands. During an interview on 10/26/22 at 10:36AM, Resident #240 stated they were missing two blue totes full of miscellaneous personal items. The items included a $20.00 gift card, multiple bottles of body spray, multiple sticks of deodorant, and three shirts. Resident #240 stated the missing items were reported to the Operations Manager. The Operations Manager helped pack the totes prior to a room change, then they went missing. There was no resolution reported back to the resident. Review of facility grievances from 2/12/20 to 10/31/22 revealed no concern forms for Resident #240's missing totes that contained personal items. During an interview on 10/31/22 at 11:13AM, the Operations Manager stated they packed Resident #240's personal items into two blue totes which contained multiple body sprays, multiple deodorant, some clothing, soda, bottled water, and multiple personal care items. The Operations Manager stated they were not aware of the $20.00 gift card. Resident #240 had changed rooms from 1/19/21 to 2/14/21 and the totes went missing. The Operations Manager stated a concern form was filed and logged on 3/8/21 for the missing totes. A letter of acknowledgment should have been sent to the resident. The letter informed the resident when an investigation was started. At the end of the investigation an additional letter was sent to the resident informing them of the resolution if there was one. The Operations Manager stated I don't believe the totes with the missing items were found, there were no letters sent to the resident, and no resolution occurred. The Operations Manager stated the investigation was incomplete. Review of the facility's untitled concern form log revealed a missing tote for Resident #240 was logged and referred to the team leader on 3/8/21. There was no documented evidence the missing totes were investigated. During an interview on 11/1/22 at 9:24AM, the Secretary to the Administrator stated complaints or grievances were logged into a binder. A letter of acknowledgment was sent to the resident. The appropriate department head would be notified and was responsible in conducting the investigation. Resolution letters stating the outcome were sent to the resident. In this case, the Team Leader would be responsible for the investigation. I'm not sure what happened, the concern was logged in on 3/8/21. The Team Leader never sent a response and should have. There was no follow up. During a telephone interview on 11/1/22 at 10:10 AM, Registered Nurse, (RN) #7 Team Leader (TL) stated the missing totes were reported to the Operations Manager and the Social Worker. The Social Worker was responsible and filed the concern form. The totes contained personal care items purchased by Resident #240's family member and were labeled with the resident name. The RN #7 TL stated the items were never found. During a telephone interview on 11/1/22 at 11:02 AM, RN #15 stated Resident #240 had transferred to their unit during COVID-19 and then returned to their original room. RN #15 stated the blue totes were never located and they didn't know what happened to them. RN #15 stated they just kept telling the resident, they were looking for them. During an interview on 11/1/22 at 11:44 AM, the Social Work Assistant stated a concern form was filed, the team leader should have followed up on the missing items. Typically, residents received a letter before and were notified after of the outcome of the investigation. Resident #240 never received a follow up letter and should have. The Social Work Assistant stated the missing totes with the missing items were never found. The resident was not notified. During an interview on 11/1/22 at 2:13 PM, the Administrator stated internal investigations were completed to determine if the facility was at fault. The team leader should have completed follow through on the missing totes with personal items on the log form. A conclusion should have been determined and reported to the resident. The resident should have been reimbursed for the missing items or arrangements made to the satisfaction to the resident. 415.3(c)(1)(ii)

Based on observation, interview, and record review completed during a Standard survey started 10/25/22 and completed on 11/1/22, the facility did not ensure that the resident is free from physical restraints imposed for purposes of convenience, that are not required to treat the resident's medical symptoms, and when the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints for one (Resident #51) of one resident reviewed. Specifically, the resident had a merry walker (a seated rolling walker used to assist ambulation) with no doctor's order in place and no re-evaluation of the need for continued use of the restraint. In addition, Resident #51 had chair and bed alarms with no on-going re-evaluation of the need for the restraint and supporting clinical documentation to warrant the use of the restraint. The finding is: Review of the policy and procedure titled Physical Restraint Use last reviewed 9/2022 documented it is the policy of the facility to respect the resident's right to be free from physical restraints. Utilize restraints in accordance with the medical order, only when other options to enable the resident to reach their highest practicable level of function have failed. Purpose to provide resident centered care and services to ensure that the resident's right to freedom from physical restraint is respected by all staff, if a resident must have a restraint that the least restrictive restraint is utilized and that all restraint use is appropriately assessed prior to applying a restraint, and that all staff in the facility are oriented to the policy and procedure for physical restraint use. Restraints will only be used when all reasonable less restrictive alternatives have been considered and rejected based on the resident's well-being. Recommendations will be reviewed with the medical team and if restraints are ordered, they will be applied per order until the Comprehensive Care Plan Team (CCP) completes a full assessment within 14 days. Orders will contain the type of restraint, reason for the restraint, and frequency of removal. The Director of Nursing (DON)/ designee will monitor the use of restraints to assure compliance with facility policy and report to the Quality Assurance Committee. The State Operational Manual issued 10/21/22 defines position change alarms are alerting devices intended to monitor a resident's movement. The devices emit an audible signal when a resident moves in certain ways. Physical restraint is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: attached or adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement or normal access to their body. Examples of facility practices that meet the definition of a physical restraint include but not limited to: placing a resident in an enclosed framed wheeled walker, in which the resident cannot open the front gate or if the device has been altered to prevent the resident from exiting the device and using a position change alarm to monitor resident movement, and the resident is afraid to move to avoid setting off the alarm. 1. Resident #51 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- a resident assessment tool) dated 8/10/22 documented Resident #51 was sometimes understood, sometimes understands and was moderately cognitively impaired. The resident had bed and chair alarms that were used daily indicated under restraints. There was no indication of the use of a merry walker. Review of the General Care Plan dated 5/17/22 revealed in the physical restraint section, the resident was to be out of bed (OOB) to the merry walker. The resident was to sit in a stationary chair with an alarm for meals, and the merry walker was to be released every (q) 2 hours (h) and reapplied. Review of untitled certified nurse aide (CNA) care guide dated 10/24/22 documented under safety/ restraints high fall risk- yes, no clutter around bed alarm, box out of reach. Low bed, bed wedges, landing mat, and bed alarm. Restraint location: merry walker, every 2 hours removed and reapplied. Under ambulation assistive devices: merry walker. Supervision in merry walker. Encourage to sit in merry walker when tired. Under transfer: remove from merry walker for meals (chair with chair alarm at table) hand held assist for transfers. Must be in sight at all times in merry walker. Dycem (non-slip, self-adhesive mat) to top of merry walker seat to prevent sliding out. The following observations were made: On 10/25/22 at 10:20 AM, Resident #51 was noted to be in a merry walker with a seatbelt wandering around the unit going up and down the halls. When the resident was asked if they could unlock the device they stated, I think so, but then was unable to complete the task and then said, I guess I can't do it. On 10/25/22 at 12:20 PM, during the lunch meal, Resident #51 was in a straight back chair with a chair alarm and Dycem on the seat under them. The resident stood up several times during the meal and was setting the alarm off which was making a high pitch alarming sound. Staff would then turn towards the resident and tell the resident to sit down. On 10/27/22 at 1:53 PM, Resident #51 was in their merry walker walking/rolling around the unit and approached the nursing station. At that time with Registered Nurse (RN) #16, the resident was asked to unlock the seatbelt and was unable to release it. RN #16 then demonstrated that the resident would need to unlock the seatbelt and then have to unlock the arm to the merry walker and lift it to get out. On 10/31/22 at 11:09 AM, Resident #51 was in the merry walker wandering around the unit going up and down the hallways. Resident was asked to release the seat belt and they stated, I am not able to unlock it. Resident did not even try to release the seat belt. On 10/31/22 at 1:09 PM, Resident #51 was seated in a straight back chair with the chair alarm under them in the dining room during the lunch meal. The resident stood up multiple times during the meal and the alarm kept sounding. Resident #51 stated, The alarm does scare me sometimes or startles me at times as I forget it is there. a. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No documented diagnosis. Initiated date of 11/3/21. Review of the Medication and Treatment Administration Record Report (MAR/ TAR) dated September 2022 and October 2022 documented nothing regarding the use of the merry walker. Review of the Acute Visit for interval visit dated 9/28/22 and completed by the Medical Director documented Resident #51 used a merry walker, had frequent falls, and was able to ambulate independently with the merry walker. Review of Annual Visit dated 8/9/22 documented reason for visit annual history and physical. Resident uses a walker when OOB. No indication for the use of the merry walker. Review of Nurse Notes dated 11/1/21 documented at 3:56 PM, the resident was sitting in their merry walker in front of the nurses' station. They slid off the seat of the merry walker to the floor sitting on their buttocks. They remained inside the walker. The resident did not hit their head and said they were not hurt with no complaints of discomfort offered when asked. The strap to the walker was noted to be very slack and it was tightened and Dycem would be applied to the merry walker seat to prevent sliding. Review of Nursing Comprehensive Care Plan Assessments dated 7/7/21, 9/27/21, 11/24/21, and 2/23/22 documented the resident did not use a physical restraint and the restraint decision tree completed was marked N/A (not applicable). Assessments dated 9/27/21, 11/24/21, and 2/23/22 documented the resident utilized a merry walker to enhance mobility and prevent falls. The 5/19/22 and 8/10/22 Assessments documented the resident utilized a merry walker to enhance mobility and prevent falls. Resident was unable to demonstrate self-removal of merry walker. Restraint decision tree and quarterly done. b. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Ensure the bed alarm was in place and functioning Q shift for Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Check chair alarm (uses in dining room, while at table) with no documented diagnoses. Initiated date of 9/22/21. Review of the MAR and TAR dated August 2022, September 2022 and October 2022 documented the bed and chair alarm were being checked per the order. Review of the Acute Visit for interval visit dated 9/28/22 and completed by the Medical Director documented Resident #51 had a bed and chair alarms with no documented indication for the use. Review of Annual Visit for annual history and physical dated 8/9/22 and completed by the Physician Assistant revealed no documentation regarding the use of the bed and chair alarm. Review of the Nursing Comprehensive Care Plan assessment dated [DATE], 9/27/21, 11/24/21, and 2/23/22 documented the resident did not use a physical restraint and that chair and bed alarms were used. The Assessments dated 5/19/22 and 8/10/22 documented the resident had chair and bed alarms but were not indicated as restraints. Review of the nurses notes, provider notes, and therapy notes between 9/2021 through 10/29/22 documented no on-going re-evaluation of the need for the bed and chair alarm and supporting clinical documentation to warrant the use of the chair and bed alarm. During an interview on 10/31/22 at 11:14 AM, RN #16 stated Resident #51 was falling a lot when they were first admitted and has had the merry walker since 2/11/21 for status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The order for the merry walker was discontinued on 8/25/22 because the resident had not been able to release the seatbelt themselves. There was no order for the merry walker for September 2022 and October 2022. RN #16 stated Resident #51 had a chair and bed alarm and they were also considered restraints. They have the bed and chair alarm to alert the staff when the resident was either standing up or was trying to get out of their bed. RN #16 stated they really do not want us to be using them because they are considered restraints. At 2:03 PM, RN #16 stated the unit secretary was unable to locate the original order for the merry walker from February 2021. During an interview on 10/31/22 at 12:42 PM, RN #11 stated a merry walker was considered a restraint if the resident was unable to release it. An order was needed for restraints like the merry walker. When Resident #51 came to their unit in May 2022, the resident was unable to release the merry walker and that was when it was considered to be a restraint. The merry walker was discontinued on 8/25/22 because the resident was no longer able to release the seatbelt and there wasn't a need to check if they could release it. A new order for the use of the merry walker should have been written at that time as the resident continued to use the merry walker. Resident #51 has the merry walker because of their poor safety awareness and was at high risk for falls and it helped them to be able to ambulate by themselves. RN #11 stated the bed and chair alarms were not considered restraints. The reason Resident #51 had them was for their safety as they were at risk for falls. The alarms alerted the staff that the resident may be attempting to ambulate or get out of their bed. Resident #51 sometimes stands up abruptly and if they do not have a staff member right there, the resident would get up and walk. The bed alarm was used so that staff heard the resident trying to get up while they were in bed. If the resident had a restraint, they reassessed the need for the restraints quarterly and as needed. During an interview with the Director of Therapy, Physical Therapist (PT) #1 and PT #2 on 11/1/22 at 8:58 AM, it was stated Resident #51 was first assessed for the use of the merry walker between 2/1/21- 2/15/22 because of prior falls that the resident had due to self-transferring. The resident would be re-assessed quarterly or on an as needed basis for their physical ability of walking in the device, not for the assessment of being able to release the device. Resident #51 needed assistance to get in and out of the walker but could negotiate the merry walker themselves. It was stated that the merry walker was not a restraint if the resident can unhook it themselves. If they cannot, at that point someone should walk with them or be 1:1 (one on one). They stated the resident was recently added to therapy on 10/24/22 and were working with Resident #51 regarding the merry walker. During an interview on 11/1/22 at 10:26 AM, the Medical Director stated they would consider the merry walker a restraint if the resident was unable to get out of it or if they were locked in it. The Medical Director stated, I guess a restraint would need a doctor's order. The Medical Director stated they do not consider chair or bed alarms restraints as they do not stop residents in any way from moving. Chair and bed alarms alerted the staff that a resident might be getting up and moving and would help prevent residents from falling. During an interview on 11/1/22 at 10:41 AM the Acting DON stated a merry walker was considered a restraint if the resident was not able to self-release the merry walker on demand. The Acting DON stated that if the merry walker was considered a restraint they would expect a doctor's order for it. They stated they did not know why Resident #51 was in the merry walker but expected the nursing staff to be releasing the resident from the merry walker q2h and to be continually assessing the need for the merry walker. The Acting DON stated that they would not consider a chair or bed alarm a restraint. 415.4(a)(2-7)

Based on observation, interview and record review conducted during an Abbreviated survey (Complaint #s NY 586 and NY 377) completed on 4/12/21, the facility did not ensure the resident's right to be free from sexual abuse for two (Residents #1 and #3) of seven residents reviewed. Specifically, Resident #3 was touched inappropriately by Resident #4, and Resident #1 with a history of wandering into other resident's rooms, was found partially clothed in Resident #2's bed. A physical assessment revealed possible trauma. Resident #1 was transferred to the hospital for a sexual assault assessment, which revealed Resident #1 had a genital wall tear and was treated prophylactically for sexually transmitted diseases (STD). This resulted in actual harm to Resident #1 that is not immediate jeopardy. The findings are: A facility policy and procedure (P&P) titled Abuse Prevention, Investigation and Reporting dated 10/2015 defined sexual abuse as sexual harassment, sexual coercion, or sexual assault. Signs of sexual abuse include but are not limited to: bruising around genital area, bruising on inner thighs, unexplained vaginal bleeding, and torn stained undergarments. A facility P&P titled, Prevention of Resident Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, revised 10/2019, documented the facility is to provide residents with an environment that is free from abuse. Methods for prevention of abuse are to assess, care plan, and monitor residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors. A facility P&P titled, 1:1 Supervision, revised 10/2019, documented 1:1 supervision requires assigned staff members to visualize the resident at all times and additional staff must be assigned by the nurse to cover for the primary assigned staff member's breaks. The purpose of 1:1 supervision is to increase safeguards for residents who are a risk to self and others. 1. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - a resident assessment tool) dated 1/18/21 documented the resident had severe cognitive impairment. A Physician History and Physical dated 10/16/20 documented Resident #1 had advanced dementia, significant lack of insight and understanding, lacked capacity (for medical decision making). Staff should provide a safe and caring environment. The current Closet Care Plan (guide used by staff to provide care) dated 3/19/21 documented Resident #1 was independent with ambulation and wandered without purpose. Resident #1's Comprehensive Care Plan (CCP) with dated of 3/22/21 documented the resident had dementia and was unable to be educated. The CCP did not address Resident #1 wandering into other resident's rooms. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented the resident had moderate cognitive impairment. The current Closet Care Plan dated 3/19/21 documented Resident #2 was independent for bed mobility and to remind resident to call staff if other residents upset him. Resident #2's Comprehensive Care Plan dated 1/8/21 documented behavioral symptoms. Interventions included to identify negative behaviors; set expectations; document behavior and monitor impending violent behavior. The facility's Resident Incident Report initiated on 3/20/21 at 1:35 AM, documented Licensed Practical Nurse (LPN) #2 found Resident #1 in Resident #2's bed not wearing pants or undergarments on 3/20/21 at 1:35 AM. Resident #2 wore no shirt, no pants or underwear. Registered Nurse (RN) #6 Supervisor was notified. Resident #1 was immediately removed from the bed and provided a brief and pants. LPN #2 assisted Resident #1 to the nurse's station with 1:1 supervision. Resident #1 had a linear (straight line) spot of blood in brief upon RN assessment. Resident #1 was unable to comment due to impaired cognition. The Nurse Practitioner (NP) #1 was notified at 3:00 AM. Resident #1 was transferred to the emergency room (ER) for evaluation at 4:05 AM. Emergency Department ED-Provider Report dated 3/20/21 at 4:42 AM documented Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Blood was noted in Resident #1's brief and caused concern for sexual assault. Resident #1 didn't remember the incident and was referred to the Sexual Assault Nurse Examiner (SANE). The Legal Guardian was notified and a 2-person consent received for SANE evaluation. The Legal Guardian agreed to a sexual assault collection kit, prophylaxis treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . SANE evaluation revealed 0.5 cm (centimeter) tear in the right lateral genital wall with some microscopic (small) bleeding and petechiae (brown-purple spots due to bleeding under the skin- caused by trauma). Resident #1 was discharged back to the facility on [DATE] at 7:15 AM. Review of the facility's surveillance video footage on 4/9/21 at 9:21 AM, revealed on 3/19/21 at 10:15 PM Resident #1 was ambulating in the hallway wearing shoes, pants, and a shirt, and entered Resident #2's room. At 1:30 AM (3/20/21) LPN #2 entered Resident #2's room. At 1:31 AM, LPN #2 was seen exiting the room to gather a brief and re-entered the room at 1:31 AM. At 1:34 AM, LPN #2 escorted Resident #1 out of Resident #2 room. Resident #1 had remained in Resident #2's room for 3 hours and 15 minutes. The video footage also revealed CNA #4 was sitting at the nurses' station from 11:00 PM to 1:30 AM (3/20/21). During an interview on 4/9/21 at 8:43 AM, RN #6 Nursing Supervisor, stated per the surveillance video on 3/20/21, Resident #1 was discovered in #2's bed partially clothed. RN #6 stated he performed a visual skin check with assistance of a female nurse and a two-inch linear line of fresh blood was noted in Resident #1's brief. RN #6 reported the incident to the Operations Manager (the Administrator on call) at 1:45 AM and notified the facility police at 2:30 AM and a report was filed. RN #6 stated they were concerned of possible trauma, after observing fresh blood in the brief. They notified NP #1 on 3/20/21 at 3:30 AM and NP #1 agreed to send Resident #1 to the ER for evaluation for possible sexual assault. During an interview on 4/9/21 at 9:58 AM, LPN #2 stated she entered Resident #2's room at 1:30 AM and found Resident #1 in Resident #2's bed. LPN #2 pulled the sheet down; Resident #1 had no pants or brief on, and Resident #2 was covered with a sheet from the waist down. LPN #2 called the RN Nursing Supervisor. LPN #2 asked Resident #2 what had happened, Resident #2 stated, What do you think happened between two adults?. LPN #2 stated it was not unusual to find Resident #1 in other resident's beds but never without any clothes on. LPN #2 stated they were concerned that a sexual assault may have taken place. LPN #2 stated Certified Nurse Aide (CNA) #4 was responsible for walking rounds at the beginning of the shift on 3/19/21 to account for all residents but did not conduct rounds according to the surveillance video. If rounds were completed, Resident #1 would have been found sooner. During an interview on 4/9/21 at 10:01 AM, the Operations Manager stated the RN Nursing Supervisor called to report the incident at 1:45 AM. The Operations Manager stated CNA #4 should have conducted rounds at the beginning of the 11:00 PM -7:00 AM shift to account for all residents. The surveillance video revealed CNA #4 did not do rounds, and falsely claimed she had done so by her written statement. During a telephone interview on 4/9/21 at 11:10 AM, the hospital ER SANE (RN) #7 stated she examined Resident #1 using the rape kit after consent from Resident #1's Legal Guardian on 3/20/21. The findings of the sexual assault exam revealed a 0.5 cm tear on the inside genitalia, which indicated penetration. The SANE RN #7 stated the report was released to the local police department and Resident #1 had no additional physical injuries and was unable to recall the event. During an interview on 4/9/21 at 1:24 PM, Resident #1 was pleasantly confused, made non-sensical statements, and was unable to participate in an interview. During interview on 4/9/21 at 4:04 PM, Resident #2 stated they recently had their room changed due to an incident that occurred. Resident #2 stated they told LPN #2 they would not have had sexual contact with Resident #1 if they knew Resident #1 had dementia. Resident #2 wouldn't specify what sexual contact occurred with Resident #1 and became resistant to further interview. During an interview on 4/9/21 at 1:41 PM, CNA #2 stated Resident #1 had dementia, wandered into rooms daily and was redirected by staff. During an interview on 4/9/21 at 1:54 PM, CNA #3 stated Resident #1 wandered daily and often found Resident #1 in other resident's beds. During an interview on 4/9/21 at 2:10 PM, RN Team Leader #3 stated Resident #1 had dementia, was affectionate towards other residents and staff. Resident #1 previously shared a room with their spouse and often slept in the same bed. The wandering behaviors had increased after their spouse passed away. RN #3 stated when Resident #1 was found in another bed, redirection was provided. An attempt to contact CNA #4 on 4/12/21 at 9:16 AM was unsuccessful. During a telephone interview on 4/12/21 at 11:00 AM, Social Worker (SW) #1 stated Resident #2 occasionally showed aggressive behaviors towards staff and other residents. SW #1 stated the injury Resident #1 sustained caused concern that Resident #1 and #2 had a sexual encounter. SW #1 stated Resident #1 didn't understand and wasn't aware of what happened. During a telephone interview on 4/12/21 at 1:46 PM, NP #1 stated she was notified by the RN Nursing Supervisor on 3/20/21 at 3:30 AM they were concerned that a sexual assault may have taken place between Resident #1 and Resident #2. NP #1 stated the blood in the brief indicated recent trauma and staff were concerned. NP #1 stated forceful intercourse would lead to a tear in the genital wall and given Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview on 4/12/21 at 2:45 PM, the Director of Nurses, (DON) stated CNA #4 was responsible to do rounding at the beginning of her shift at 11:00 PM to account for all residents. The DON stated per surveillance video, CNA #4 never conducted rounds. During an interview on 4/12/21 at 3:23 PM, the Administrator stated she was informed of the incident at 7:00 AM on 3/20/21. The RN Supervisor noted blood in Resident #1's brief, which warranted some concern of injury and the resident was sent to the ER. The Nursing Supervisor reviewed the surveillance video that showed Resident #1 entered Resident #2's room at 10:15 PM. The Administrator stated CNA #4 never conducted rounds at the beginning of the shift and provided a false statement. The Administrator stated it was unfortunate the incident occurred and any tear in the skin was considered an injury, but the cause was unknown. 2. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Determination of Capacity for Resident #3 signed and dated by a physician on 9/6/17 documented Resident #3 had no capacity to make healthcare decisions. Review of the Closet Care Plan (guide for staff to provide care) for Resident #3, last updated 2/12/21, documented Resident #3 required total assistance with personal care, bathing, feeding, and toileting. Resident #3 ambulates independently and wanders without purpose. Observation of Resident #3 on 3/18/21 at 12:50 PM revealed the resident was awake in their room, sitting on their bed. Resident #3 did not respond to this Surveyor's greeting and was unable to be interviewed. Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented the resident understands and was understood. Review of the Comprehensive Care Plan for Resident #4, updated and reviewed by the facility 8/17/20, documented the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Closet Care Plan for Resident #4, updated and reviewed by the facility 12/9/20, documented behavioral interventions included report behavior changes, report altercations, redirect if disrobing or agitated, distract if inappropriate, supervised activities and 1:1 day shift, 1:1 evening shift and 1:1 night shift. Additionally, the Closet Care Plan included the following aggression intervention comments: 1:1, no physical contact with female caregivers, may have a Certified Nurse Aide (CNA) outside closed bedroom door for 1:1, no physical barriers are to be between resident and supervising staff, other than bedroom door. Review of the Social Work Behavioral Care Plan for Resident #4, dated 2/3/21, documented Resident #4 exhibited resistive behaviors directed at staff, other residents, family members, self, and visitors. This was evidenced by history of threats, history of violence, bullying, pacing, clenching fists, taking a threatening stance, using foul language, name calling, throwing objects, verbal outbursts, inappropriate sexual gestures, and scratching/biting/spitting. The document also indicates Resident #4 is unpredictable and a level one sex offender. Review of the Resident Incident Report for Resident #4, dated 3/5/21, documented on that date at 1:40 PM, Resident #4 was found to grab the privates of another resident while standing in the main dining room. Resident #4's comment after the incident was, I was just kidding around. Review of the Resident Incident Report for Resident #3, dated 3/5/21, documented on that date at 1:40 PM, Resident #3 was wandering the unit and LPN (Licensed Practical Nurse) #1 witnessed and interrupted the inappropriate touching of Resident #4 touching the genitalia area of Resident #3, all clothing intact. According to the Resident Incident Report, Resident #3 was unable to comment after the incident due to dementia and traumatic brain injury. Review of a Witness Statement Form, signed by CNA #1 on 3/5/21, documented CNA #1 was assigned to Resident #4. CNA #1 went to use the bathroom, and that was when the incident occurred. Review of Nursing Unit Work/Break Schedule dated 3/5/21 documented CNA #1 was assigned to 1:1 supervision for Resident #4 during the 7:00 AM to 3:00 PM shift. During a telephone interview on 4/6/21 at 10:18 AM, CNA #1 stated she was assigned to 1:1 with Resident #4 the day of the incident. CNA #1 stated Resident #4 was 1:1 because of their behavior, they are sexual to employees, aggressive, have mood swings, and sometimes can get into problems with other residents. CNA #1 stated she had an extreme bathroom emergency and ran to the bathroom. She further stated she thought she told the nurse that she was going to the bathroom but was not 100% sure. She ran into the bathroom and was not gone more than five minutes. CNA #1 stated when she works on that unit, staff make sure they cover their resident when someone needed to walk away. CNA #1 stated she knew she should not have left the resident alone and normally she would tell another staff member before leaving for the bathroom. During an interview on 3/18/21 at 12:12 PM, LPN #1 stated she was coming back down the hall, when she saw Resident #4 touching Resident #3 in the private area over clothes. She stated she intervened and told Resident #4 to stop and redirected Resident #3 out of the area. LPN #1 further stated Resident #4 told her, I'm not even doing nothing, and this is what teenage boys do. Additionally, LPN #1 stated Resident #4 is 1:1 24 hours per day, and CNA #1 was assigned to be their 1:1 that day. CNA #1 was not present when the incident occurred. During an interview on 3/18/21 at 11:55 AM, the (Registered Nurse) RN Team Leader #1 stated Resident #4 has impulse control problems and a history of sexual contact with other residents and staff. The RN #1 added that after the incident, Resident #4 stated, It's locker room stuff, it's what guys do. RN #1 stated that Resident #3 has early onset dementia and is non-verbal and did not appear to have understood what occurred. RN #1 added that Resident #4 has been 1:1 for more than two years straight and at the time of the incident, CNA #1 was assigned to them. After the incident, CNA #1 told him that she stepped away to go to the bathroom. CNA #1 should have found someone to sit with Resident #4 for a few minutes. RN #1 stated to his knowledge, CNA #1 did not do that. For the 1:1 supervision assignment, they don't schedule breaks, they just step in for each other. During an interview on 3/18/21 at 1:41 PM, the Director of Nurses (DON) stated CNA #1 should have called someone to relieve her to cover the 1:1 while she was gone and she does not know if CNA #1 asked to leave on a break before she left. The DON further stated there was not an official schedule for breaks of staff who were doing 1:1 supervision, and it had to be an open situation due to the nature of the unit. During an interview on 3/18/21 at 1:45 PM, the Assistant Director of Nursing (ADON) stated CNA #1 said she had yelled out, I'm going to the bathroom and she went to the bathroom. The ADON further stated she asked CNA #1 if she made sure if the nurse heard her, and she replied, I don't know if they did or not. During an interview on 4/5/21 at 2:15 PM, the Operations Manager stated Resident #4 is on 1:1 supervision for numerous reasons, including physical and sexual inappropriateness. The Operations Manager also stated 1:1 supervision means watching a resident 24 hours per day. 415.4(b)(1)(i)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY 357) completed on 9/26/19, the facility did not ensure the resident's right to be free from abuse for one (Resident #1) of four residents reviewed for sexual abuse. Specifically, Resident #2 was assessed on 7/10/19 as being a sexually dangerous person and required constant supervision. On 8/30/19, Resident #2 was found in Resident #1's room having non-consensual oral sex with Resident #1. Resident #1 informed the police about the incident and stated he wanted to press charges. Resident #2 was arrested and remains incarcerated. Resident #1 also reported he feels safer now that Resident #2 is no longer at the facility. This resulted in actual harm that is not immediate jeopardy to Resident #2. The finding is: Review of the facility policy and procedure (P&P) titled Abuse dated as reviewed on 7/20/18 documented the facility is to provide a safe, abuse free environment to residents and to comply with state and federal regulations regarding abuse prevention, recognition, investigating and reporting. Sexual abuse is defined as any non-consensual sexual contact of any type with a resident. Review of the facility P&P titled Special Observation revised 2/2019 documented Constant Supervision is a temporary measure where a staff member is assigned by the nursing supervisor on duty to monitor a resident's whereabouts for a specified time frame. The staff member must be able to visualize the resident at all times. These residents may not leave the neighborhood unattended. More than one resident on constant supervision may be monitored by one staff member on the same neighborhood. Additional staff must be assigned by the nurse to cover for the primary assigned staff member's breaks. 1. Resident #1 is a [AGE] year-old male admitted to the facility on [DATE] on the locked male unit with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated 8/12/19 documented the resident was cognitively intact. Review of a physician note dated 8/9/19 documented the resident is verbally and physically aggressive and at times difficult to redirect. The resident continues to have behavioral issues and lacked capacity to make any significant decisions. The resident's Care Plan last updated on 8/30/19 at 5:01 PM documented the resident used a rolling walker for ambulation and transfers and is kept in supervised areas when out of bed. 2. Resident #2 is a [AGE] year-old male admitted to the facility on [DATE] and on the locked male unit with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was cognitively intact. Review of a physician note dated 2/28/19 documented the resident had a history of [REDACTED]. Review of a physician note dated 4/12/19 documented the resident did not have capacity and is not competent. Review of a Behavioral Health Services Note dated 7/10/19 written by a LCSW-Licensed Clinical Social Worker documented Resident #2 had limited insights that impacted behavior and he was being assessed as a sexually dangerous person. The resident's Care Plan last updated on 4/23/19 at 10:34 AM documented the resident was independent with ambulation and transfer and he required constant supervision. The resident was not to have female care givers. He may have a certified nurse aide (CNA) outside his closed door for constant supervision and staff is to insure no residents are in the room. The facility's Format for Offsite Investigation Summary initiated on 8/30/19 at 11:40 PM by the Registered Nurse (RN) Supervisor at 11:40 PM documented Resident #2 was found by CNA #1 in Resident #1's room kneeling on the floor by Resident #1's bed with his face between Resident #1's legs. Resident #1 was on the bed with his pants pulled down. Review of the Nursing Post Occurrence assessment dated [DATE] at 3:42 AM documented Resident #2 was able to describe the event clearly. He was escorted out of the building by the police for possible criminal charges on 8/31/19 at 3:20 AM. Review of the statement from night shift CNA #1 that witnessed the incident documented at approximately 11:40 PM on 8/30/19, she was performing her walking rounds and entered the room of Resident #1. She observed Resident #2 kneeling on the floor by Resident #1's bed. Resident #2's face was between Resident #1's legs at the groin area. The residents stopped when she came in to the room. Resident #2 left the room. Resident #1 had his pants pulled down and was lying on his back on the bed. Review of the statement from night shift CNA #2 documented on 8/30/19 he was assigned to Resident #2 and another resident for constant supervision and there were only two CNA's on duty. CNA #2 saw the other resident go into another resident room on the opposite hallway and went to intervene. As a result, he did not watch Resident #2. When he returned to the Nurse's Station, CNA#1 told him that Resident #2 was in Resident #1's room. Review of a Medical Center Police Report Sex Offense dated 8/31/19 at 12:38 AM documented Resident #1 informed the police officer about the incident and stated he wanted to press charges against Resident #2. The Deposition of Witness filed by Resident #1 documented at approximately 11:39 PM on 8/30/19, Resident #2 entered the room of Resident #1 and requested oral sex. Resident #1 asked Resident #2 if he had money to pay for the act. Resident #2 stated he did not have money and Resident #1 declined having sex. Resident #2 approached Resident #1, physically pushed him on the bed, pulled his pants down and forcibly conducted oral sex several times for three minutes. Staff entered his room and disrupted the incident and Resident #2 left the room at approximately 11:41 PM. The victim claimed no physical injuries as a result of this incident and declined to be seen by a doctor. Review of the video camera footage dated 8/30/19 at 11:39:36 PM revealed Resident #2 entered Resident #1's closed door to his room and closed the door behind him. At 11:41:08, PM CNA #1 was observed entering the room and exited calling for help. Resident #2 was observed leaving the room at 11:41:24 PM. During an interview on 9/9/19 at 11:56 AM, Resident #1 stated that Resident #2 came into his room and asked for oral sex. Resident #1 asked for money and Resident #2 stated he did not have any money. Resident #1 stated, I was standing when he pushed me down on the bed and pulled my pants down and I said, no, no. He said whether you want it or not we're having it. I told him he'd get caught but he kept it up. An aide came in and it stopped. During an interview on 9/9/19 at 2:15 PM, RN #1 stated when a resident is on constant supervision it means the resident must be in line of sight to staff when out of their rooms. The staff member must be close enough to intervene if behaviors occur. Resident #2 becomes very agitated when staff are right on top of him so having staff as one on one is not effective. During telephone interview on 9/9/19 at 3:45 PM, CNA #1 stated she worked the night shift on 8/30/19 starting at 11:00 PM. There were two CNA's and one Licensed Practical Nurse (LPN) at the beginning of the shift. CNA #2 had constant supervision duty for Resident #2 and another resident. The unit was very active that night. CNA #1 started her rounds and was checking on residents when she walked into Resident #1's room and found Resident #2 which was not permitted. She left the room and called for help. During a telephone interview on 9/10/19 at 11:20 AM, CNA #2 stated on 8/30/19 he stayed over from the evening shift to work the night shift and was floated on to the locked male unit. His assignment was constant supervision for Residents #2 and another resident. He was familiar with Resident #2 and knew that the other resident liked to go into other resident's rooms when he wandered and needed to be watched. There were two CNA's and one LPN at the beginning of the shift. A third CNA came in after midnight. The other resident wandered down the hallway and attempted to enter another resident's room. CNA #2 was aware that constant supervision meant always in sight. He was worried the other resident would enter a resident's room, so he intervened. Resident #2 was sitting in the opposite hallway. During this time CNA #1 found Resident #1 and Resident #2 together and called for help. During an interview on 9/10/19 at 12:20 PM, the Medical Director stated he became aware of the incident after it occurred. Resident #2 was on constant supervision for behaviors. He did not get to formally assess Resident #2 because he is no longer at the facility. During an interview on 9/12/19 at 9:00 AM, the Administrator stated he was notified of the incident and was on site that night. The facility police watching surveillance video observed an altercation outside of the resident's room and came to the unit. No physical injury occurred during the 8/30/19 incident. Resident #2 was picked up by the city police that night and had not returned to the facility. During an interview on 9/12/19 at 9:46 AM, the Director of Nursing stated Resident #2 had been on constant supervision because of his history of behaviors. He was not interviewed because he was taken away by the police that night, but he historically did not deny his behaviors. The investigation was inconclusive in terms of abuse given that Resident #2 could not be interviewed. In addition, CNA #2 was only assigned to Resident #2 that night; not two residents. CNA #2 should have been paying close attention to Resident #2. During an interview on 9/26/19 at 10:10 AM, Resident #1 stated, I told him (Resident #2) I didn't want to do it (oral sex). He's a big dude. I feel safer now that he's no longer here. 415.4(b)(1)(i)

Based on observation, interview and record review conducted during a Partial Extended survey (Complaint #NY 355) completed on 8/27/19, the facility did not ensure that each resident received adequate supervision and assistive devices to prevent accidents for one (Resident #1) of four residents reviewed for accidents. Specifically, the facility failed to ensure that a severely cognitively impaired resident who frequently wandered and was identified at high risk for elopement with multiple, recent attempts to leave the unit, was adequately supervised to prevent elopement. Maintenance staff identified that stairwell door 2b egress alarm was not functioning on 5/24/19 and did not notify the nursing staff. The resident entered the stairwell on the second floor at 6:02 AM and was found at 7:42 AM seated on the ground floor steps with a blood sugar of 34 (normal range 60-110). This resulted in Immediate Jeopardy and Substandard Quality of Care to resident health and safety for Resident #1. The finding is: Review of the facility policy and procedure titled Elopement: Wandering Resident/Missing Resident with a revised date of 5/19 revealed it was policy for the facility to implement the measures to ensure the safety of all residents; Assess all residents for their risk of elopement/wandering on admission, readmission and with significant change in condition; utilize specific measures as outlined in the plan of care and the missing resident protocol; utilize and maintain electronic safety devices to assist staff in monitoring the resident who wanders and supervise residents at risk for elopement/wandering when leaving the neighborhood. Residents identified at risk for eloping/wandering behaviors will be considered for admission or transfer to one of the secured neighborhoods when other interventions are deemed ineffective. 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated 5/4/19 documented the resident was severely cognitively impaired, usually understands and is usually understood. Section [NAME] Wandering revealed this behavior occurred 1-3 days per week. Review of the Resident's Plan of Care - General Care Plan dated initiated on 4/27/19 documented under Problems: Behavioral symptoms. Intervention: Elopement/ Wandering Risk Evaluation. The Admission Elopement Assessment completed on 4/27/19 documented the resident was a low risk for elopement with a Total Elopement Score of five (If score is 3-5 there is low risk for elopement at present time). Review of a Nursing Elopement/ Wandering Risk Evaluation by Registered Nurse (RN) #1 dated 5/7/19 at 2:00 PM documented the resident wandered without purpose and had an Elopement Total score of nine (If score is 6-9, there is medium risk for elopement at present time). A Nursing Behavior Note dated 5/10/19 by RN #1 at 3:00 PM documented the resident wanders the unit in her wheelchair self -propelling into other rooms. She has been redirected away from elevator areas as well. Review of a Nursing Elopement/ Wandering Risk Evaluation dated 5/10/19 by RN #1 at 4:19 PM documented the resident occasionally expressed desire to leave or behaviors linked to elopement and unsuccessful attempts at elopement. The Elopement Total score was 24 (If score is 10 or more, the risk is high for elopement at present time). A Nursing Progress note titled Comprehensive Care Plan assessment dated [DATE] at 6:27 AM by RN #1 documented the resident wanders the unit in her wheelchair, in and out of other resident's rooms. She has also left the unit unable to find her way back. Staff attempt to keep unit doors closed. Nursing Behavior Note dated 5/19/19 at 7:00 AM by RN #1 documented Per evening shift resident wandered off unit to another neighborhood. Staff on another unit called to come get her. Redirected with some agitation. Nursing Behavior Note dated 5/19/19 at 1:32 PM by Licensed Practical Nurse (LPN) #2 documented resident wandering all shift. She was found off unit one time and redirected back to unit. Review of the 24 Hour Interdisciplinary Report dated 5/21/19 by LPN #5 for the night shift documented multiple attempts to go out fire doors. Nursing Behavior Note dated 5/21/19 at 2:30 PM by LPN #4 documented the resident escaped the unit three times however, did not make it far and staff was able to bring resident back almost immediately after leaving. Review of the Offsite Investigation completed by Assistant Director of Nursing (ADON) #1 revealed on 5/25/19 at 7:30 AM, the RN Team Leader was conducting unit rounds and noted Resident #1's bed was empty. At 7:42 AM, the resident was found by staff on the ground floor of the stairwell near her room. She was seated on the floor and stated she walked down the stairs. The resident's wheelchair was out in the stairwell. Review of a Nursing Occurrence Assessment 5/25/19 at 1:44 PM written by LPN #1 documented the resident was unable to be located for the 7:30 AM finger stick to check blood sugars. The resident was found on the back stairwell all the way to the ground floor with no apparent injuries. Her wheelchair was on the second floor. The resident did not know how she got there and stated she was lost. During an interview on 8/22/19 at 2:47 PM, Plant Operations staff #1 stated that on 5/24/19 stairwell door 2b had failed the inspection and he told his Supervisor. He did not notify anyone else on the floor including the nursing staff because it's not my job to notify anyone else. During an interview on 8/22/19 at 3:10 PM, the Plant Operations Supervisor revealed the process for checking the egress doors are completed once a month by Plant Operations staff and stated, I check the doors randomly a few times a week, just to make sure they are working. After checking the doors, it is documented by the Plant Operations staff on the Delayed Egress Door Inspection sheet. In addition, he did not recall being notified on 5/24/19 by Plant Operations staff #1 that the door was broken. During an interview on 8/22/19 at 3:17 PM, the night Nursing Supervisor that worked on 5/25/19 stated that she did not receive any report that the stairwell door was broken and did not believe any of the nursing staff on the unit were aware. When she found Resident #1's wheelchair it was upright on the second landing and the resident had history of turning off her chair alarm. During a phone interview on 8/22/19 at 4:07 PM, Biomed-staff (hospital-based technicians) member #1 stated that he was called on 5/25/19 in the morning by a nurse explaining that something was wrong with a stairwell magnet alarm and a resident had been found in the stairwell. I remembered because it was Memorial Day and I was the only one working in Bio-Med. He immediately went to the unit and stated I was able to just push on the door (stairwell door 2b) and open it. I just took the stop sign and alarm box off and threw the alarm box in the garbage because it was broken. I installed a new stop sign with alarm boxes. He stated Saturday (5/25/19) late in the morning was the first time he had heard that there was a problem with the door. Review of a report titled Quality of Care /Treatment, Elopement dated 5/24/19 and untimed documented that the delayed egress door inspection failed and was repaired on 5/28/19. The report documented the 5/25/19 camera footage as follows; -6:00 AM - (Resident #1) propelled herself to the door. -6:01 AM - Opened door (alarm did not sound) then immediately closed the door. -6:02 AM - Reopened exit door, wheeled herself in her wheelchair forward into the stairwell with door closing behind her. -6:04 AM - Walked back into the hall then out door again at 6:11 AM. Further review revealed the stop sign and alarm box were not noted in the report. During an observation on 8/22/19 at 1:37 PM of the 5/25/19 camera footage revealed there was a stop sign stretched across stairwell door 2b with a blue box alarm attached and sitting on the handrail next to the door. The resident was observed at 6:00:47 (seconds) to come to the door, attempted to open the door despite the stop sign and picked up and handled the blue box (alarm). At 6:01:53 she took the stop sign down, folded it and placed it on the handrail. At 6:02:51, she pushed herself in her wheelchair out the door. At 6:09:04 she came back onto the unit through the door and ambulated unaided down the hall. At 6:10:57 she pushed the door open and went into the stairwell. Review of a Biomed Order entered by RN #1 dated 5/25/19 at 10:52 AM documented a request for a blue magnetic box alarm for Stop Sign on fire door not functioning. A hand-written note on the request documented the box was already checked by plant operations and the box was broken and not a battery issue. It was replaced with two alarms/ stop signs on the door on 5/25/19 at 11:30 AM. A written statement from LPN #3 documented that on 5/25/19 she stayed the night shift to work as an aide. Last rounds were around 4:00 AM and finished around 5:00 AM. Resident #1 was in bed and clean when last checked with her bed alarm on in place. LPN #3 left the unit around 5:15 AM. During an interview on 8/26/19 at 11:36 AM, LPN #3 stated Resident #1 had a history of [REDACTED]. She had a bed and chair alarm for safety. LPN #3 was not informed that the stairwell door was broken and recalled there was a strip across the door. She did not know the date or time she observed the strip or know when it was placed. A written statement from Certified Nurse Aide (CNA) #3 documented that on 5/25/19 she checked Resident #1 around 6:40 AM and she was in her bed. During an interview on 8/26/19 at 3:13 PM, CNA #3 stated she was not aware that the stairwell door was broken or that the alarm on the door was not working. She stated that Resident #1 was in bed when she did her last rounds. A written statement from LPN #5 documented that on 5/25/19 between 6:15 AM and 6:45 AM she saw Resident #1 strolling up and down the hallway in her wheelchair. During an interview on 8/27/19 at 8:10 AM, LPN #5 stated that Resident #1 on 5/25/19 was puttering on the unit in her wheelchair but did not remember the exact time. The resident had attempted to leave the unit in the past on her night shift, but she never actually got off the unit. The resident was known to get herself out of bed and was able to turn her bed and chair alarms off or disable them. LPN #5 was not aware that the stairwell door was broken and that the alarm was non-functioning. During an interview on 8/26/19 at 1:53 PM, RN #1 stated Resident #1 had wandered off the unit a few times and was going to other units across the hall. Staff would attempt to keep the unit doors closed with a stop sign. Staff were aware of the resident's wandering and heightened elopement risk. She did not know the door was not functioning or that the alarm did not work. Maintenance is responsible for checking the doors and then informing nursing if the door does not work. Nursing puts that information on the 24-Hour Report and informs the next shift. The resident was able to transfer herself into the wheelchair and was known to turn off her alarms. RN #1 stated she worked on 5/25/19 and during her room to room rounds at the start of the 7:00 AM-3:00 PM shift discovered the resident was not in her room. After the resident was found, she called the Biomed department. They put two stop signs and two alarms on the stairwell door for safety. During an interview on 8/27/19 at 12:24 PM, the Administrator revealed he probably was notified on 5/24/19 in the evening that the door was broken. Maintenance conduct monthly checks on the stairwell doors and the maintenance worker discovered during checks that the door did not work. The maintenance staff should have informed nursing of his finding. An unidentified staff member put a functioning alarm and stop sign on the door on 5/24/19, but the resident may have tampered with the alarm making it non-functioning. He stated both nursing staff and the maintenance supervisor should have been notified of the broken door. The Administrator stated that they did not have a policy & procedure regarding this issue. During an interview on 8/27/19 at 1:00 PM, ADON #1 revealed she was not aware of the broken stairwell door and stated that the alarming stop sign was probably not the right intervention. If I had known the door was not functioning, there would have been a staff member sitting at the door until it was fixed. Nursing staff should have been informed by maintenance that the door was not working. Observation on 8/27/19 at 11:30 AM of stairwell door 2b where the resident eloped revealed it had a push bar that would alarm when pushed for 30 seconds before it releases and can be opened. The facility was notified on 8/27/19 that immediate jeopardy began on 5/25/19. The immediacy was removed on 5/28/19 and the facility implemented sufficient corrective actions as of 5/28/19. Review of the facility implemented corrective actions revealed the following: -5/25/19, Two stop-sign banners with two functioning audible alarms were attached to the stairwell door 2b by Biomed staff. The door was then monitored by staff. -5/28/19, Stairwell door 2b was repaired by maintenance staff. -5/30/19, All Plant Operations (maintenance) staff were in-serviced regarding measures to take when a malfunctioning door alarm is identified. -6/6/19, Resident #1 was transferred to the Fourth-Floor secure memory care unit. 415.12(h)(1)

Based on record review and staff interview conducted during an Abbreviated survey (complaint #NY 725) completed on 9/19/11, the facility did not ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical well being. One (Resident #1) of three residents reviewed for quality of care had an issue involving a two day delay in the performance of a Doppler study (a diagnostic test to evaluate blood circulation) of the resident's arm to evaluate a change in condition. Resident #1 complained of right arm numbness and tingling on 8/27/11 and a "stat" (immediate) Venous Doppler ordered on [DATE] was not done until 8/29/11. The resident was transferred to the emergency room and subsequently underwent surgical removal of a blood clot from the right brachial (inside the elbow) and radial (inner wrist) arteries on 8/29/11. This resulted in actual harm that is not immediate jeopardy. The finding is: 1. Resident #1 has [DIAGNOSES REDACTED]. Review of the hospital Discharge Summary Report dated 8/17/11 revealed that the resident was admitted to the facility for sub-acute rehabilitation. The Discharge Summary Report documented that the resident is "alert and oriented x3" (to person, place and time) with normal mentation. Review of a Nursing Progress Note, written by a Licensed Practical Nurse (LPN #1), dated 8/27/11 at 6:00 AM revealed that the resident complained of shortness of breath and a [MEDICATION NAME] treatment (medicated aerosol breathing treatment) was given. The note also documented that the resident complained of right arm numbness and tingling and "[MEDICATION NAME]" (narcotic pain medication) was given. Further review revealed the Nursing Supervisor was called to assess, and the Nurse Practitioner was called regarding the resident's signs and symptoms. Review of a "Physician order [REDACTED]. - a portable chest x-ray "now due to increased shortness of breath and congestion" - a complete blood count (blood work) and a basic metabolic profile (blood work) - cardiac enzymes (blood work to evaluate heart damage) - a Doppler study of the right upper extremity due to increased swelling and pain Review of a computerized order form entitled "Venous Scan-Unilateral" dated 8/27/11 revealed that a request for a Venous Scan of the right upper extremity was entered into the computer by LPN #1 at 8:00 AM on 8/27/11. The priority level was indicated as "S". During an interview on 9/8/11 at approximately 12:00 PM, NP #1 explained that the "S" on the order form stands for "Stat" (immediate). NP #1 further stated that she ordered a Venous Doppler of the resident's right arm due to the resident's complaints of pain, [MEDICAL CONDITION] (swelling caused by excess fluid accumulation) and [MEDICAL CONDITION] (disorder affecting nervous system) of the right arm. NP #1 stated that she verbally gave the order to the nurse as "stat" because it was a weekend and sometimes it takes time to get tests done. NP #1 further stated that she left the SNF (Skilled Nursing Facility) for the weekend shortly after ordering the test and another NP (NP #2) was on-call for the weekend. NP #1 stated that when she left the facility, she expected the Doppler to be done in a timely manner. During an interview on 9/8/11 at approximately 10:30 AM, the weekend Registered Nurse (RN) Supervisor stated that she worked as the Nursing Supervisor on 8/27/11 during the day shift. The RN Supervisor stated that the Staff Nurse (LPN #1) entered the order for the Doppler study into the computer on a timely basis. The RN Supervisor stated that the procedure for getting Doppler studies done on the weekend is for the medical provider, either the Physician or the Nurse Practitioner, to call the Vascular Lab and speaks to the Vascular Physician who will call a Vascular Technician in to perform the test. The RN Supervisor stated that she informed the covering NP #2 that he would have to call the Vascular Physician to get the Doppler study done. She further stated that she does not know if NP #2 called the Vascular Lab. The RN Supervisor stated that she worked on 8/28/11 during the day. She stated that she assessed the resident's right arm and it was not as [MEDICAL CONDITION] as on 8/27/11 and the resident's digits felt the same as they did on 8/27/11. She further stated that the resident had no complaints about his right arm. The RN Supervisor stated that she did not make any phone calls on 8/28/11 regarding the Doppler study. Review of a Nursing Progress Note written by LPN #2 dated 8/27/11 for the 7:00 AM to 3:00 PM shift revealed that NP #1 was "made aware of labs (laboratory results), CXR (chest x-ray)". The LPN documented that the Doppler study still needed to be done. LPN #3 stated during a telephone interview on 9/8/11 at approximately 12:00 PM that she worked the day shift on 8/28/11. She stated that during the shift she called the Vascular Surgeon's office to inquire about the resident's Doppler study. LPN #3 stated that she spoke with the Vascular Surgeon's answering service and was told that the Doppler study would be done on Monday (8/29/11). The LPN stated that she assessed the resident's right arm and it did not appear to be worse over the weekend. Review of a a Nursing Progress Note written by RN #1 dated 8/28/11 for the 3:00 PM to 11:00 PM shift, revealed that Resident #1 was medicated once for pain with [MEDICATION NAME] with some effect. The RN documented that the resident complained of some [MEDICAL CONDITION] in the right arm and "numbness in fingers. To have Doppler in the AM". Review of the "24 hour Nursing Report" for the day shift dated 8/28/11 revealed that [MEDICAL CONDITION] persisted in the right upper extremity. The 24 Hour Nursing Report documented that on the evening shift, the resident complained of "some numbness" in the right hand with "slight [MEDICAL CONDITION] noted". Review of a Nursing Progress Note written by RN #2 dated 8/29/11 at 9:50 AM revealed the resident complained of numbness in the right upper extremity and right sided jaw pain when chewing. RN #2 documented that the resident was able to raise both arms equally, grip was equal, and there was no complaint of chest pain however there was some shortness of breath with conversation. Review of a "Vascular Lab Preliminary Report" dated 8/29/11 at 10:45 AM revealed that the venous study of the upper extremity was done with no evidence of [MEDICAL CONDITION] ([MEDICAL CONDITION] - the formation of a blood clot in a deep vein). The report documented that there was an "Incidentally noted acute thrombus in the brachial artery. PPG (photoplethysmography - noninvasive measurement of blood circulation) of the right hand reveals critical flow reduction". Review of an undated ER (emergency room ) Transfer Form and a Notice of Transfer dated 8/29/11 revealed the resident was transferred to the ER because a "Doppler of the RUE (right upper extremity) done today showed a complete obstruction, no blood flow to fingers per Vascular". Review of a hospital "history and physical examination [REDACTED]. The Physician documented that the right hand had decreased sensation and a weak radial and a palpable (felt or touched) brachial pulse. The Physician documented there was "acute critical limb ischemia (restricted blood flow to an area)" with a plan to take the resident to surgery for [REDACTED]. The Physician also documented that there was a high risk of limb loss. Review of an Operative Report dated 8/29/11 revealed that the resident had a "2 day history of worsening hand tingling, numbness, pain, cold, nonviable, and with no capillary refill. No hand signals. The patient was urgently started on a [MEDICATION NAME] (blood thinning medication) drip (intravenous infusion) and taken to the OR (operating room) for exploration". The Report documented the preoperative [DIAGNOSES REDACTED]. The report further documented that the operation performed was a right brachial artery embolectomy and a right radial artery embolectomy. The report documented that at the conclusion of the procedure the resident has a palpable radial pulse. The Director of Nursing (DON) stated during a telephone interview on 9/14/11 at approximately 3:30 PM that the facility did not have a specific written policy on how to order vascular tests (Doppler studies) on the weekends. The DON stated during a telephone interview on 9/19/11 at approximately 11:00 AM that she was not aware of any memo from the Vascular Laboratory regarding a procedure for getting vascular lab tests done on the weekends. The DON stated that on weekends, nursing staff are to follow the "Protocol for Dealing with Urgent Medical Issues for the Entire SNF (skilled nursing facility) after Hours" (undated) which was faxed to the Department of Health on 9/15/11. During a telephone interview on 9/14/11 at approximately 12:30 PM, the Vascular Laboratory Supervisor stated there are no Vascular Lab Technicians in the facility on Saturdays and Sundays, however the Technicians are on call from 8:00 AM to 10:00 PM on both days. The Supervisor further explained that the procedure for getting vascular lab tests done on the weekends is for the nursing staff to call the Vascular Lab and the lab's answering service will receive the call. Nursing staff are to explain the test needed, the answering service will clear it with the Vascular Physician and a Vascular Lab Technician will be sent to perform the test, usually within an hour. The Vascular Lab Supervisor stated that this has been a long standing laboratory procedure for weekend tests. She further stated that review of the Vascular Lab's telephone logs for 8/27/11 and 8/28/11 revealed there was no evidence of any calls from the skilled nursing unit staff or a Nurse Practitioner regarding a Doppler study for Resident #1. During a telephone interview on 9/15/11 at approximately 9:45 AM, the facility Medical Director stated per her conversation with NP #1, the NP evaluated the resident's arm on the morning of 8/27/11. NP #1 noted that a radial pulse was present and there was no evidence of an arterial occlusion (blockage of an artery). NP #1 was concerned about a [MEDICAL CONDITION], so she ordered a Doppler study of the right arm. The Medical Director explained that if the resident had shown signs of vascular compromise in the right arm over the weekend, the staff would have sent him to the emergency room . The Medical Director stated that NP #2 called the Radiologist four times on 8/27/11 to get the Doppler study done and the Radiologist did not return the calls. The Medical Director stated that NP #2 assumed the issue had been resolved when he did not hear anything more. In summary, there was a two day delay in the performance of a Doppler study on Resident #1's right arm. This delay led to a worsening of the resident's symptoms and resulted in limb ischemia. 415.12