Every finding on record at The Eleanor Nursing Care Center

Based on observation, staff interview and record review during an abbreviated survey (3095819) on 7/20/2026, the facility did not ensure all mechanical, electrical, and patient care equipment was in safe operating condition. Specifically, records for the preventative maintenance and maintenance of the individual air conditioning and heating units in resident rooms were missing and not provided at time of survey. This was observed on 3 of 3 resident floors. The findings are:During the Abbreviated Survey (3095819) on 7/20/26 between the hours of 10:00 AM and 5:00 PM, it was noted that there are 40 resident rooms on 3 of 3 resident floors and the air conditioning / heating units in 9 resident rooms on 3 of 3 resident floors were observed heavily soiled, and were not functioning. There were air conditioning / heating units in rooms on each floor that were not examined due to morning / afternoon care or residents on precautions.The tour on the third floor, second and first floors revealed individual air conditioning and heating units in nine resident rooms that were not working (329, 327, 318, 317, 228, 229, 226, 215 and 114). The individual air conditioning and heating units in these rooms were observed to be heavily soiled and records of units cleaned, filters cleaned, not working and units replaced were missing and not provided at time of survey. In addition, a temperature log for these resident rooms was missing and not provided at time of survey. In an interview with the Maintenance Supervisor at approximately 2:40 PM the same day, the Maintenance Supervisor stated that the facility does not have a list of rooms where the air conditioner heating units were not working or the rooms where the units were not working at optimal level. The Maintenance Supervisor further stated that every morning, the Maintenance Supervisor goes around checking which units are working and not working and cleans the filters. The Maintenance Supervisor further stated that a log is not kept. In a subsequent interview with the Maintenance Supervisor at 5:00 PM the same day, the Maintenance Supervisor stated that room temperatures are displayed on the units in resident rooms. 415.29(b)

Based on record review and interviews during a survey, the facility did not ensure the resident's legal representative upon written request was provided with a copy of the resident's medical records within 2 working days for 1 of 3 residents (Resident #117) reviewed for medical records. Specifically, on 3/10/25 Resident #117's representative requested copies of Resident #117 complete medical record. Resident #117's representative submitted an Authorization for Release of Health Information form to the facility on 3/10/25. The facility did not provide Resident #117's representative with copies of the medical records until 4/22/25. The Findings are:The facility policy titled Resident Medical Record, dated 5/2025, documented the facility will maintain records for each resident and ensure each resident's information is identified, records are secured and maintained in accordance with federal and state regulations. The facility did not have a written policy or procedure that directs staff to furnish records upon request from residents and/or their representatives. Resident #117 was admitted to the facility on [DATE] with diagnoses including but limited to Parkinson's Disease, Lewy Body Dementia and Chronic Kidney Disease.The admission Minimum Data Set, dated [DATE] documented the resident had severe cognitive impairment, required supervision for eating, moderate assistance for bathing, walked 10 feet with supervision and was frequently incontinent of bladder and bowel.Review of the Authorization for Release of Health Information form completed and dated 3/10/25 documented the resident's representative requested the resident's records from 2/14/25-present. The resident's representative signed and dated the form. Review of a letter from the facility Administrator to the resident representative dated 4/11/25 documented the cost of copies of the resident's record would be $315.00. The payment would need to be received prior to release of the records, and the check would need to be payable to the nursing facility. The package was sent on 4/22/25 by mail to the residents' representative who was the requestor after the check for payment was received by the facility. During an interview with the Finance Officer on 4/27/26 at 12:12PM they stated they were responsible for reviewing record requests and obtaining fees before releasing records. They stated they reviewed all the forms, requested payment and when that was received, they released the records. They stated they made sure the forms were properly dated. In this case the former Administrator received the request from the resident representative, provided a fee amount for the copies and sent a letter requesting payment for the records to the resident representative. Once payment was received the records were mailed to the resident representative. They stated the former Administrator took the task upon themselves and did not date the records and did not send them timely. They stated this was not their process. They reviewed the timeline of the documents requested and stated they were not aware of the two-day deadline and thought it was a 30-day window. 10 NYCRR 415.3(d)(1)(iv)

Based on observations,, interviews, and record reviews during the survey, the facility did not ensure that there was adequate staffing to provide nursing and related services to assure resident safety and attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by the facility assessment and individual plans of care. Specifically, the actual staffing was reviewed from 03/20-04/20/2026. During that time the staffing did not meet the minimal staffing numbers for nurses on 03/24/2026, 04/01/2026, 04/05/2026, 04/07/2026, and 04/13/2026 for at least one shift. Additionally, the facility had minimal staffing numbers of certified nurse aides on at least one unit and one shift on 28 of the 30 days reviewed. Staff reported working with the minimum number of certified nurse aides could be challenging and could affect the amount and timeliness of work that could be completed. The findings included:The Facility Assessment tool last updated 11/12/2025 documented a facility capacity of 120 residents but had averaged between 90 and 95 residents for the preceding six (months). The minimal staffing for each of the three (3) units was documented as the following:One (1) to two (2) direct care nurses on the day shift and two (2) to four (4) certified nurse aides for each unit totaling three (3) to six (6) direct care nurses and six (6) to 12 certified nurse aides for the facility on the day shift.One (1) to two (2) direct care nurses on the evening shift and two (2) to three (3) certified nurse aides for each unit, totaling three (3) to six (6) direct care nurses and six (6) to nine (9) certified nurse aides for the facility on the evening shiftOne (1) direct care nurse on the night shift and one (1) to two (2) certified nurse aides for each unit, totaling three (3) direct care nurses and three (3) to six (6) certified nurse aides for the facility on the night shift.The staffing sheets dated 03/24, 04/01, 04/05, 04/07, and 04/13/2026 documented that there were two direct care nurses for the three units working on the overnight shift, with one of the two also working as the supervisor. The staffing sheet dated 03/24/2026 documented five (5) certified nurse aides, 04/01/2026 documented six (6) certified nurse aides, 04/05/2026 documented three (3) certified nurse aides, 04/07/2026 documented six (6) certified nurse aides, and 04/13/2026 documented five (5) certified nurse aides on the overnight shift in the facility. The staffing sheet dated 04/13/2026 documented that there were two direct care nurses working on the day shift with one nurse covering two units. The staffing sheet dated 04/13/2026 documented eight (8) certified nurse aides on the day shift in the facility.Staffing on 03/20, 03/21, 03/22, 03/23, 03/24, 03/26, 03/27, 03/28, 03/29, 03/30, 03/31, 04/02, 04/03, 04/4, 04/05, 04/06, 04/8, 04/10, 04/11, 04/12, 04/13, 04/14, 04/15, 04/16, 04/17, 04/18, 04/19, 04/20/2026 documented that for at least one shift and one unit there was minimal certified nurse aide coverage.During an interview on 04/21/2026 at 10:03 AM, Resident #17 stated that there were not enough staff to get people up in morning and the food was cold because it took too long to pass out trays.During an interview and observation on 04/21/2026 at 1:00 PM, Resident #31 was observed in bed in a hospital gown and stated that staffing was poor and there was no one around during the night. They stated there were not enough staff to get out of bed some days.During an interview on 04/22/2026 at 1:36 PM, Certified Nurse Aide #17 stated working day shift with only three (3) certified nurse aides on a unit was challenging but they worked hard to get everything done. However, on days when they only had two (2) certified nurse aides on a unit., it was difficult. Showers may not get done so they would try to make up missed showers on a day with more staff.During an observation on Unit 200 on 04/23/2026 at 9:15 AM, the breakfast cart was on the unit, and most residents were eating breakfast in their rooms, and 28 out of 39 residents were still in bed or in a hospital gown sitting up in their room. Breakfast time on Unit 200 was 8:00 AM. There were four (4) certified nurse aides scheduled.During an interview on 04/23/2026 at 12:10 PM Certified Nurse Aide #3 stated they did not always document all resident cares every day/shift due to lack of time and short staffing. They stated cares for some residents frequently would be performed late in the shift or left for the next shift to complete due to short staffing and high acuity of unit. Certified Nurse Aide #3 stated facility supervisors/unit managers were aware that cares were not always documented on the electronic medical record and they have been in-serviced regarding documentation policy. During an interview on 04/23/2026 at 12:28 PM, Licensed Practical Nurse #4 stated they oversee certified nurse aide task completion on units. They stated they were aware that certified nurse aides frequently did not document completion of tasks on the electronic medical record. They stated when they observed cares not completed for a resident, they addressed it with certified nurse aide staff. They stated short staffing delayed cares and that Unit 3 had high acuity that increased difficulty in completion of tasks. During an interview on 04/24/2026 at 6:42 AM, Licensed Practical Nurse #18 stated that there were two (2) certified nurse aides overnight last night, and they have had only one (1) at times. They stated it was very challenging overnight when they only had one certified nurse aide because they could only so much could get done.During an interview on 04/27/2026 at 1:41 PM, the Human Resources and Staffing Manager stated that the nursing staff minimums were one (1) nurse on each unit for every shift, two (2) certified nurse aides on each unit on the day and evening shifts, one (1) nurse on each unit on the night shift, and one (1) certified nurse aide on each unit on the night shift. The nursing supervisor may act as the direct care nurse for one of the units. They stated that they tried to stay above the minimum, but it was not always possible. They stated they did not have all the nurses on 03/24/2026 because there was a nurse that did not call or show up for work. On 04/01/2026 and 04/05/2026 they were short one nurse on the night shift. On 04/07/2026, they were short one nurse on the night shift, but another nurse came in early to assist with the morning medication pass. On 04/13/2026, they were short a nurse on the day and night shifts. They stated that staffing was a challenge. They offered incentives and bonuses. They also tried to adjust the schedules to meet their needs for other appointments and things. There stated there were open positions for nurses and certified nurse aides. They did not think that the facility offered sign-on bonuses, and no agency staff was used. They stated they would be participating in a job fair on 05/28/2026 and that they advertised. They stated they were actively looking for more nurses and certified nurse aides but not certain of how many open positions there were. They were not certain if it was the location or wages that made it difficult to find more staff.During an interview on 04/27/2026 at 4:23 PM, the Administrator stated that they needed more and were hiring more nursing staff. They stated that the two (2) certified nurse aides on a unit were the minimal numbers, but four (4) would be ideal. They were trying to adjust times for activities, so they were not missed due to minimal numbers of staff and delays in getting out of bed. Other disciplines try to assist as they can as well.During an interview on 04/28/2026 at 11:55 AM, the Director of Nursing stated that the minimum staffing numbers were as the Human Resources Staffing Manager provided. They did not think there was enough nursing staff and stated that the minimum numbers had to be reviewed again. They started at the facility in February and planned to review the staffing. They were aware of the shortage of nurses on the units, and they did not want only two certified nurse aides on the units for days and evening or one at night. They did not believe the current staffing numbers were adequate or safe, or that cares could not be completed as they should be either. They stated showers were affected as well with minimal staffing numbers. They stated they were realistic about what was possible when there was minimal staff. They stated they started a conversation with Corporate Human Resources to discuss the numbers and current openings.During an interview on 04/28/2026 at 12:26 PM Certified Nurse Aide #7, who was working on Unit 200, stated that it was not possible to give all showers as scheduled on days when there were only two certified nurse aides on the floor, especially for dependent residents. 10NYCRR 415.13(a)(1)(i-iii)

Based on observation, interview and record review, it was determined the Governing Body failed to ensure consistent and responsible management of the facility. Specifically, 1) the facility has had a change in Director of Nursing seven times in the last two (2) years. 2) the facility has had 3 Administrators in the last two years. 3) The facility had 11 repeat deficiencies from the recertification survey of 05/06/2025, and 12 repeat deficiencies from the recertification survey of 09/17/2024. 4) The facility has had one (1) elevator that has been out of service for at least 3 years, and a 2nd elevator that has not been functional at times and has caused residents to miss appointments (see F698).Findings include:1) Notifications from the facility to the New York State Department of Health dated 07/30/24 to 02/02/2026, documented 7 changes for the Director of Nursing. The facility hired four (4) Directors of Nursing during this period and had three (3) interim Directors of Nursing. The longest tenure of a Director of Nursing was less than 6 months. At time of survey, the current Director of Nursing started on 02/03/2026. During interviews for F600, F609, F610 the Director of Nursing stated they were not at the facility at the time of the incident. The last recertification survey ended 05/06/2025, the Director of Nursing has changed 3 times since then.2) The Administrator at the time of survey started 01/02/2026 and the prior Administrator worked from 09/25/2025 to 01/02/2026.3) The facility had 11 repeat citations from the recertification survey of 05/06/2025 including F558, F584, F609, F628, F640, F656, F698, F725, F756, F812 and F880. The facility had 12 repeat deficiencies from the survey of 09/17/2024 including F584, F600, F609, F610, F656, F677, F686, F689, F695, F725, F756, and F812.Sufficient nursing staff (F725) was cited during the 2 prior recertification surveys. Interviews with the Director of Nursing, Human Resources and nursing staff identified low staffing and the ability to complete tasks with the minimum staffing levels in the Facility Assessment was not adequate.4) Based on staff and resident interviews, the facility's one functional elevator was out of service on multiple occasions resulting in residents missing appointments. Residents complained of food being late and cold due to only one functioning elevator (see F804).10 New York Codes, Rules, Regulations 415.26(b)(3)(1)

Based on interviews and record review during the post-survey revisit from 06/24/2026 to 06/29/2026, the facility did not ensure an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. Specifically, the Director of Nursing/Infection Preventionist was unable to provide documentation of facility antibiotic surveillance / line listing from 06/18/2026 through 06/25/2026. Findings include:During an interview on 06/25/2026 at 3:15 PM, the Director of Nursing stated they could not provide antibiotic surveillance/line list for the month of June 2026 for the facility. They stated the unit managers were responsible for the completion of the surveillance reports, and they did not receive reports for May or June 2026. They stated the last time a full monthly antibiotic surveillance report was completed in the facility was in April 2026. The Director of Nursing stated that a full house audit of residents prescribed antibiotics was not completed as stated in the plan of correction (F684 recertification surevey). The Director of Nursing stated they have also not received reports documenting missed antibiotic administrations and since no audits were completed, there were no corrective measures put in place if applicable. The Director of Nursing stated there were two Assistant Directors of Nursing who were Infection Preventionists since April 2026, however they did not remain employed at facility long and did not complete surveillance and lines listings. During an interview on 06/25/26 at 3:51 PM, Licensed Practical Nurse Unit Manager #6 stated they started employment at the facility in 02/2026 and were not aware of antibiotic surveillance/tracking at the facility until the Director of Nursing requested audits of unit antibiotic usage in April 2026. They stated there was no official tool such as McGreer used in the facility to track antibiotic usage and there was not an official conversation or policy stating unit managers were responsible tracking daily antibiotic surveillance / line listings. They stated they did not complete the requested antibiotic surveillance/tracking in May or June 2026 due to workload and time constraints. They stated the facility has had three (3) Assistant Directors of Nursing since they started at facility in 02/2026 who were involved in infection control/antibiotic surveillance in the facility and all three ended employment after a few weeks. During interviews on 06/25/2026 at 4:17 PM and 06/29/2026 at 2:15 PM, Licensed Practical Nurse Unit Manager #1 stated they were requested by the Director of Nursing to audit new antibiotic physician orders for their unit in April or May 2026. They stated they were provided with audit tools and were not aware of daily log to monitor antibiotic administration. They stated the audit tools were to be completed and submitted weekly to the Director of Nursing. They stated they have not been completing the audit tools since the beginning of May 2026 due to workload and short staffing. During an interview on 06/26/26 at 11:15 AM, the Administrator stated they were not aware antibiotic surveillance / line listings were not being completed, and the Director of Nursing did not request help/assistance with the task. They stated the Director of Nursing had delegated tasks to an Assistant Director of Nursing who only worked at the facility for a couple of weeks. 10 NYCRR 415.19 (c)

Based on observations and interviews conducted during the survey, the facility did not store food or maintain equipment with food contact surfaces in accordance with professional standards for food service safety. Specifically, 1) unlabeled and undated food were stored in the kitchen freezer, and dry storage; 2) insufficient supply of emergency food; 3) food, water and supplies were not stored six (6) inches off the floor; and 4) food preparation and service equipment was not maintained. The findings are: The undated facility policy titled Dietary Department documented No boxes of food shall be stored on the floor. Food must be covered when stored. Cutting boards should be inspected frequently for wear and replaced as needed.During the initial tour of the kitchen on 04/20/2026 at 10:25 AM with the Food Service Director an observation of frozen hashbrowns, box of farina, pan of thickener, pan of instant potato and pan of sugar all unlabeled and undated; an opened box of cornstarch undated; and an open box of salt unsealed. The emergency food supply was short cans of tuna, beef stew, mixed vegetables, and canned fruit. The emergency water supply was stored directly on the floor; a rack of food in the freezer was observed on the floor; six (6) five (5) gallon buckets of detergent were stored on the floor, and a box of napkins were stored on the floor in the main kitchen. There were three (3) observed damaged meal service trays with sharp edges and two (2) cutting boards with deep cuts and nicks.During the initial tour the Food Service Director was interviewed. They stated they were not sure why the food items were not dated, labeled and sealed. They stated the emergency food supply was low because they could only order within the budget and ordered a little each time to replenish the supply. The Food Service Director did not know if there was shelving available for the items that were stored on the floor. During an interview on 04/23/2026 at 11:14 AM the Food Service Director stated they found out new staff had been using the food from the Emergency food supply racks on the weekend and using it for the current meal service and that was why it was deficient in supplies.During an interview on 04/27/2026 at 1:33 PM the facility Administrator stated they would purchase shelving to make sure food, and supplies were not stored on the floor. 10 NYCRR 415.14(h)

Based on observation and interviews conducted during the survey, the facility did not ensure residents were provided with food and drink that was palatable, and at an appetizing temperature. Specifically, 1) during a lunch observation on Unit 1, temperatures take at the time the last resident tray was served, revealed the chicken parmesan had a temperature of 107.6 degrees Fahrenheit, the pasta was 95.5 degrees Fahrenheit, the green beans were 105 degrees Fahrenheit and milk was 63 degrees Fahrenheit; and 2) for the lunch meal on 04/20/2026, hotdogs and french fries were served with no condiments (ketchup and/or mustard) available. The findings include: The facility policy, Dietary Department Policy and Procedure, documented that hot food should be held at 140 degrees Fahrenheit above and cold food at 46 degrees Fahrenheit or below. 1) During an observation on 04/23/2026 at 11:59 AM, with the Food Service Director, temperatures of the lunch tray line were tested before being served. Temperatures of the hot food were tested, and all were above 140 degrees Fahrenheit. During an interview on 4/27/2026 at 10:19 AM, the Registered Dietitian stated the complaints about the food had decreased. The food quality was pretty good, but they knew the food was cold. The food was hot out of the kitchen but the delivery was slow. They only had one working elevator which delayed the food trays being delivered to the units. Additionally, the plate warmer had not been working, and they did not have heating pellets under the plates. During an observation and interview on 4/27/2026 at 12:14 PM, the food tray carts arrived on Unit 1 and staff began passing out the food trays to the residents. At 12:33 PM, The Food Service Director tested the temperatures of the last tray served on Unit 1 and the chicken parmesan had a temperature of 107.6 degrees Fahrenheit, the pasta had a temperature of 95.5 degrees Fahrenheit, the green beans had a temperature of 105 degrees Fahrenheit and milk had a temperature of 63 degrees Fahrenheit. The Food Service Director stated they would like the food to be hotter, at least 140 degrees Fahrenheit. They stated the food was hot in the kitchen, but it took time to get delivered to the residents. They stated they needed to fix the plate warmer and needed the right tools to get food to the residents. During an interview on 04/28/2026 at 12:17 PM, Resident #2 stated most of the food served was always cold. They stated they did not know why the food was cold but had to eat it and did not like it. 2) During an observation on 04/20/2026 at 1:16 PM lunch meal trays were delivered to Unit 3. The lunch meal was a hotdog on a bun with french fries. All trays served did not have condiments (ketchup and mustard). Multiple residents requested the condiments, and staff reported the facility was out of ketchup and mustard. The staff offered residents mayonnaise or barbeque sauce. During an interview on 04/20/2026 at 4:46 PM, Resident #98 stated the food was sometimes bad. During an interview on 04/20/26 at 5:00 PM, the Food Service Director stated the kitchen aide opened the box of ketchup packets before tray line and the packets were moldy and they did not have any other ketchup to use. The box was not expired, but maybe an open packet may have caused the entire box to become moldy. They stated the facility ran out of mustard packets, and it was out of stock when they tried to place the order. The Food Service Director stated they must follow a budget and did not have an extra supply of the condiments. During an interview on 04/20/2026 at 5:15 PM, Resident #98's family member stated when they first visited Resident #98, they saw a sandwich wrapped lying by the bed and the bun was stale and rock hard. During an interview on 04/23/2026 at 11:46 AM, the Registered Dietitian stated the Food Service Director went to the local grocery store to get items for meals if needed. During an interview on 04/27/2026 at 1:33 PM, the facility Administrator stated the facility had no problem obtaining food items that were needed for residents' meals. 10NYCRR 415.14 (d)(1)(2)

Based on observations, interviews, and record review conducted during the survey, the facility did not ensure the attending physician documented in the resident medical record, review of identified drug regimen review recommendations, and completion of any actions taken to address the recommendations for two (2) of five (5) residents (Resident #4 and Resident #23) reviewed for unnecessary medications, psychotropic medications, and medication regimen review, and one (1) of one (1) resident (Resident #13) reviewed for psych/opioid medications. Specifically, 1) Resident #4 had five (5) drug regimen reviews from 11/19/2025to 03/22/2026, with no documented evidence the Medical Director reviewed; 2) Resident#23 had five (5) drug regimen reviews from 10/28/2025 to 03/18/2026 and there was no documented evidence that the Medical Director reviewed; and 3) Resident #13 had six (6) drug regimen reviews from 10/27/2025 to 03/18/2026 and there was no documented evidence that the Medical Director reviewed or responded. The findings are: The Policy and Procedure titled Pharmacy Services Drug Regimen Review, revised 05/2025, documented the drug regimen of each resident will be reviewed at least monthly by a licensed pharmacist. The pharmacist will report any irregularities to the attending physician, the facility medical director, and the director of nursing, and reports will be acted upon. Additionally, the attending physician must document in the resident's medical record the review of identified irregularities and any action taken to address them. If no change in medication is made, the attending physician must document the rationale in the resident's medical record. 1) Resident #4 had diagnoses of diabetes mellitus, dementia, and bipolar disorder. The Quarterly Minimum Data Set (MDS), an assessment tool, dated 01/29/2026, documented Resident #4 had moderately impaired cognition, was usually able to understand others, and was able to make needs understood. Resident #4 received antipsychotic, anti-anxiety, antidepressant, hypoglycemic, and anticonvulsant medications during the prior seven (7) days. The drug regimen review for Resident #4, dated 11/19/2025, documented no rationale for initiation of Fluoxetine on 11/06/2025. The drug regimen review documented a recommendation to obtain a carbamazepine level for seizure management. During a review of Resident #4's record on 4/24/2026 there was no documentation addressing the rationale for Fluoxetine use. There was no evidence carbamazepine levels were obtained. The drug regimen review for Resident #4, dated 12/22/2025, documented Coreg required daily pulse monitoring and weekly blood pressure monitoring. Review of January 2026 and February 2026 Medication Administration Records (MAR) had no documentation of daily pulse or weekly blood pressure monitoring. The drug regimen review documented the use of antipsychotic medications required monitoring for orthostatic hypotension, with monitoring to be documented on the medication administration record monthly. Review of January and February 2026 medication administration records and the electronic health record (EHR) did not indicate documentation of daily pulse, weekly blood pressure, or orthostatic hypotension monitoring. The drug regimen review for Resident #4, dated 01/26/2026, documented hepatic impairment. Laboratory values included alanine aminotransferase (ALT) 79, aspartate aminotransferase (AST) 54, and alkaline phosphatase (ALP) 376. The drug regimen review documented that medications such as carvedilol and metformin should be avoided with hepatic impairment. Review of Resident #4's record on 4/24/2026 revealed no documented evidence the attending physician addressed the drug regimen review recommendations. The drug regimen review for Resident #4, dated 02/23/2026, documented current orders for acetaminophen with the potential to exceed three (3) grams per day maximum dosage. The drug regimen reviews documented recommendations to adjust orders to reduce this risk. Review of the electronic health record (EHR) on 4/24/2026, documented acetaminophen 325 milligram tablet, two (2) tablets (650 milligrams) by mouth every six (6) hours as needed for pain level one (1) to five (5). Record review also documented acetaminophen 325 milligram tablet, two (2) tablets (650 milligrams) by mouth two (2) times daily. The drug regimen review documented a recent elevation in liver function tests (LFTs) and recommended consideration of reducing the acetaminophen dose or frequency or discontinuation. There was no documented evidence that the acetaminophen dose was reduced or reviewed. The psychiatric evaluation dated 03/22/2026 documented disorganized behavior. The evaluation included recommendations to discontinue Tegretol, initiate Depakote 500 milligrams two (2) times daily, increase Fluoxetine (Prozac) to 20 milligrams, increase Clonazepam (Klonopin) 2.5 milligrams three (3) times daily, and follow up in two (2) weeks. A review of Resident #4's electronic health record (EHR) revealed no documented evidence that these recommendations were reviewed or implemented. During an interview with the Medical Director on 04/27/2026 at 12:37 PM, the Medical Director stated this was the first time they had seen the psychiatric recommendations, which included decreasing carbamazepine, initiating divalproex (Depakote), increasing fluoxetine (Prozac), and increasing clonazepam (Klonopin). The Medical Director explained that, as a new psychiatrist, they were unfamiliar with the facility process. The Medical Director stated that follow-up would occur to ensure the recommendations were reviewed and addressed by the appropriate staff. During an interview on 04/28/2026 at 1:48 PM, the Director of Nursing stated the psychiatric consultation dated 03/22/2026 for Resident #4, in which recommendations were made without documented physician follow-up, would be investigated. The Director of Nursing later confirmed that no documented follow-up had been provided to the physician. 2) Resident #23 had diagnoses that included dementia, anxiety, and depression. The Annual Minimum Data Set, dated [DATE] documented moderately impaired cognition and medications including antipsychotic, anticoagulant, and hypoglycemic. The pharmacy progress notes dated 10/28/2025, 12/22/2025, 01/26/2025, 02/23/2026 and 03/18/2026 all documented medication regimens reviewed, irregularities noted, see report. The unsigned pharmacy recommendation dated 10/28/2025 documented please obtain complete blood count, comprehensive metabolic panel, lipid panel and HbA1C (lab to monitor average blood sugar levels). The physician notes dated 11/07/2025, 11/20/2025, 11/28/2025 documented continue medications and contained no documented evidence that the pharmacy recommendations were reviewed or responded to by the physician. Labs results were reviewed and documented that a complete blood panel and basic metabolic panel were completed on 11/29/2025. There was no documented evidence of a comprehensive blood panel, lipid panel, or HbA1C at that time. The unsigned pharmacy recommendation dated 12/22/2025 documented Resident #23 was on seroquel, naltrexone, namenda, paxil, and more than six (6) months since last psychiatrist evaluation. Please consider psychiatry follow up to evaluate effectiveness, adverse effects and gradual dose reduction. Receives antipsychotic Seroquel, black box warning of increased mortality in elderly patients with dementia receiving antipsychotics. Please consider gradual dose reduction and discontinuation and or document risk/benefit evaluation if this med continues. The last documented Psychiatry Consultation was dated 05/25/2025. The physician notes dated 12/26/2025, 01/02/2026, 01/06/2026, 01/13/2026, and 01/23/2026 documented continue medications and contained no documented evidence that the pharmacy recommendations were reviewed or responded to. There was no documented evidence of the pharmacy reviews from 01/26/2026, 02/23/2026, or 03/18/2026 or that the physician reviewed and responded to any recommendations. 3) Resident # 13 had diagnoses that included bipolar disorder, seizure disorder, and anxiety. The Quarterly Minimum Data Set, dated [DATE] documented moderately impaired cognition, no behaviors, and medications including antipsychotic, antianxiety, antidepressant, diuretic, opioid, hypoglycemic, and anticonvulsant. The pharmacy progress notes dated 10/27/2025, 11/19/2025, 12/22/2026, 01/26/2026, 02/23/2026, and 03/18/2026 documented medication review completed, irregularities noted, see report. There was no documented evidence of the pharmacy recommendations or that the physician reviewed and responded to the recommendations. During an interview on 04/27/2026 at 11:14 AM the Medical Director stated when they received the pharmacy reviews they should be responded to in 48 hours. The Nurse Practitioner also reviews the recommendations. All recommendations should be reviewed. They could not say if any reviews were missed or not reviewed as they are forwarded to them when they come in and left for review. They could not recall the unsigned reviews presented from months ago. During an interview on 04/28/2026 at 9:07 AM, the Director of Nursing stated that they were uncertain where the requested missing pharmacy reviews were. They only started at the facility in February and could not speak to those before they arrived. They stated that the medication recommendation review process needed to be evaluated and fixed. The Psychiatrist did recently start and would be completing assessments as recommended and psychotropic medication evaluations. During an interview on 04/28/2026 at 10:27 AM, Licensed Practical Nurse (LPN) Unit Manager #6 stated there was a breakdown in the process for handling pharmacy consultant recommendations. Under normal procedures, the pharmacy consultant reports were submitted to the Director of Nursing , who then forwardsed the reports to the physician for review and follow-up. Due to the absence of the Director of Nursing, this process was not consistently followed, and resulted in missed or unaddressed recommendations. During an interview on 04/28/2026 at 10:43 AM, the Nurse Practitioner stated there was a breakdown in the process for handling pharmacy consultant recommendations. The Nurse Practitioner stated reports were submitted to the Director of Nursing, then forwarded to the physician for review and follow-up. The Nurse Practitioner stated due to the absence of a Director of Nursing, recommendations were not consistently addressed. During an interview with the Director of Nursing on 04/28/2026 at 1:48 PM, the Director of Nursing stated that, before their current appointment, the facility did not have a Director of Nursing and that drug regimen reviews were not consistently conducted. They stated that since assuming the role, pharmacy consultant reports were reviewed and forwarded to physicians. 415.18 (C) (1)

Based on record reviews and interviews conducted during a survey, the facility did not ensure that each resident received adequate supervision/assistance to prevent accidents for two (2) of five (5) residents reviewed for falls. Specifically, Resident #116 required two (2) person assistance for bed mobility and was provided one (1) staff assistance by Certified Nurse Aide #10 which resulted in a fall from bed. 2) Resident #114 sustained an unwitnessed fall on 06/04/2025. A thorough investigation to prevent re-occurrence was not completed, the Accident/Incident report dated 06/04/2025 did not document injuries sustained due to the fall, or notification of the resident representative and physician. Neurological checks were not completed as per facility policy for a head injury. The Accident/Incident Report was not reviewed by the Medical Director. The findings Include: 1) The May 2025 policy titled 'Activities of Daily Living Care' documented it was the procedure to assist residents to appropriate positions for time of day; check transfer status and bed mobility status to make sure proper support is provided per care plan. Ask co-worker for assistance as indicated by Kardex/care plan. Resident #116 had diagnoses of Diabetes Mellitus, Cerebrovascular Accident, and Adult Failure to Thrive. The admission Minimum Data Set, dated [DATE] documented the resident had severe cognitive impairment and was dependent on staff for rolling from back to left and right. They had physical limitations on one side for upper and lower extremities. They were occasionally incontinent of urine and was dependent on staff for toileting hygiene. A Care Plan for Rehab dated 4/26/25 documented the resident was dependent for bed mobility requiring total assistance for effective turning and positioning while in bed. A Care Plan for Activities of Daily Living dated 05/21/2025 documented the resident required two (2) person assistance with bed mobility and transfer. The Certified Nurse Aide Care Guide (care instructions) dated 8/21/25, documented the resident was totally dependent with a two (2) person physical assist for bed mobility and totally dependent with a 1 person assist for toilet use, used incontinence briefs. The facility Investigation Summary documented, on 08/22/2025, Resident #116 sustained a fall from bed witnessed by Certified Nurse Aide #10, while performing incontinent care. The resident fell onto the mat next to the bed. The nurse and nurse supervisor were notified; the physician and family were notified. Certified Nurse Aide #10 was terminated upon the conclusion of the investigation. Certified Nurse Aide #10's written statement, dated 08/22/2025, documented they were doing cares(changing) for the resident and the resident slipped out of the bed while on their side while being cleaned. The resident fell onto the mat next to their bed. A statement from Licensed Practical Nurse#12 dated 08/22/2025, documented they were outside the resident's room refilling the transmission precautions cart when they heard a noise and went to the resident's room and saw the resident on the floor. Then they went to get Registered Nurse Supervisor #5. During an interview on 4/23/26 at 3:13 PM, Registered Nurse Supervisor #5 stated they were called to the unit on 8/22/25 and the resident was on the floor mat next to their bed. It was a witnessed fall, and the Certified Nurse Aide #10 remained in the room. The resident was assessed then returned to bed. The resident was asked if they had pain and they stated no. They stated there were no observed injuries. They stated they got the story from Certified Nurse Aide #10 who stated they did not have another person to help them and thought they could do the cares by themselves and when the resident was on their side they slipped off of the bed. They stated the Certified Nurse Aides were supposed to go to the assignment sheet, and the nurse gave them report for any new changes. They stated all instructions about resident care were in the care guide and they should have checked there as well. Certified Nurse Aide #10 knew they were responsible for checking the guide, and they did not do that. They stated the Licensed Practical Nurse #12 was right outside the door and could have helped them if they asked. They stated Certified Nurse Aide #10 did not follow the care plan or look in the care guide for instructions. During an interview on 04/24/2026 at 11:19 AM, the Director of Nursing stated they read the Accident and Incident report and saw the resident required extensive assistance for care and turning was provided by one certified nurse aide. There was a licensed practical nurse right outside the door and they could have asked them for help. They stated Resident #116 required extra help, was an amputee and had just come back from the hospital. It was important to check to see if the residents' Activity of Daily Living status changed. They stated the accident could have been prevented if the Certified Nurse Aide got help according to the plan of care. 2) Resident #114 diagnoses included diabetes mellitus, Wernicke's encephalopathy (brain dysfunction) and cognitive communication deficit. The quarterly Minimum Data Set, dated [DATE] documented Resident #114 had severe cognitive impairment, was at risk for falls and required supervision/touch assistance for chair to bed transfers. An untitled facility policy last reviewed 10/2024 documented: it is the purpose of the Facility to investigate and document all accidents and incidents and develop corrective measures to prevent reoccurrence. The Nurse/Nursing Supervisor is responsible to evaluate the resident for injury. The attending physician will be notified to receive orders for treatment, in the event the attending physician cannot be reached, the Medical Director will be notified of the resident's condition. The Accident/Incident Report shall be forwarded to the Medical Director and Administrator for review and signatures. An undated facility policy titled Neurological Check Policy documented purpose to ensure prompt identification of neurological deterioration following any unwitnessed fall, fall with head strike, or incident with suspected or potential head injury, and to ensure safe monitoring, evaluation, intervention, and escalation of care consistent with CMS regulations and evidence-based practice. A neurological assessment (neuro check) must be initiated immediately for any resident who has experienced an unwitnessed fall, experienced a witnessed fall in which the head did or may have struck an object, or been involved in any incident where head injury cannot be ruled out. Unless otherwise directed by the medical provider, neuro checks must be completed as follows: Every 15 minutes for one (1) hour, every 30 minutes for one (1) hour, every hour for four (4) hours and every four (4) hours for 24 hours. Minimum duration of monitoring: 30 hours. The physician/nurse practitioner may extend or shorten the schedule based on clinical condition. An Accident/Incident Report dated 06/04/2025 at 4:15 PM documented Resident #114 had an unwitnessed fall in the resident's room and the resident was not able to describe the event. The report documented the resident's baseline prior to the fall was alert, oriented X 1, and confused. The resident used a wheelchair and required extensive assist of one (1) staff for ambulation, transfers and bed mobility, and was dependent on one staff for toileting and dressing. The rest of first page of the report was blank including if safety/preventative measures were in place, new interventions to minimize re-occurrence, type of injury, notifications of resident representative or physician/nurse practitioner, and there was no nurse signature. The post fall investigation documented the resident was last toileted/care provided at 2 PM and incontinence status was dry. The last time the resident was observed by staff prior to fall was 4 PM. The resident was self-transferring in their room from the wheelchair to the bed. Certified Nurse Aide #21's statement dated 6/4/2026 documented they were not assigned to the resident, the last time they saw the resident, they were rolling around in their chair, and they were on a break when the accident happened. Certified Nurse Aide #9's statement dated 6/4/2025 documented Resident #114 was on their assignment and the last they saw the resident; they were in their chair in the hallway. They documented another certified nurse aide told them that Resident #114 was on the floor, and the nursing supervisor was called. They did not witness the incident. Certified Nurse Aide #9's statement did not include what time they last saw the resident or when they last provided care. Certified Nurse Aide #22's statement dated 6/4/2026 documented they heard hello, hello coming from Resident #114's room and found Resident #114 on the floor at foot of bed and notified the nurse. There were no other statements and none of the statements documented the time the resident was last seen prior to the fall, or the last time care was provided to the resident. Registered Nurse Supervisor #8's progress note dated 06/04/2025 at 6:37 PM documented at approximately 4:15 PM, Resident #114 was found in their room lying on right side beside the bed in a sitting position on the floor with legs extended towards foot of bed. The fall was unwitnessed. Due to poor cognition, the resident was unable to verbalize what led to the fall. There was an abrasion to the right mid-back, a laceration to right parietal scalp (upper part of head) region, and Resident #114 complained of head pain. Tylenol was administered with positive effect. Neurological assessment was performed per fall protocol and within normal limits. The resident was assisted by two (2) staff from the floor back into wheelchair. A message was left for the resident representative with fall update. The Nurse Practitioner made aware and provided orders to cleanse laceration, apply topical ointment, and leave laceration open to air. A rehabilitation screen was ordered for a mobility and safety evaluation. Interventions documented wound care initiated as per provided order, fall precautions reinforced, and resident monitored closely post fall. A physician order dated 06/04/2025 documented cleanse left parietal lobe with normal saline and apply bacitracin daily open to air, every day during 7:00 AM to 3:00 PM shift. The Neurological Flow Sheet dated 6/4/2025 to 6/5/2025 documented vital signs and Neuro Checks to be done every 15 minutes for one (1) hour, every 30 minutes for 1 hour, every hour for 4 hours, then every 4 hours for 24 hours. The vital signs and neuro checks were documented on 6/4/2025 at 4:15 PM, 4:30 PM, 4:45 PM, 5:00 PM, 5:15 PM, 5:45 PM, 6:15 PM, 7:15 PM, 8:15 PM and 9:15 PM. There were no documented neuro checks or vital signs after 9:15 PM on 6/4/2025. The resident's blood pressure was not documented after 4:30 PM on 06/04/2025. A resident care plan dated 06/05/2025 titled Falls: at high risk for falls related to incident of fall in the past 30 days, documented interventions including anticipate resident needs with regard to activities of daily living, fall mat to right side of bed and rehabilitation referral for evaluation secondary to fall. There were no nursing notes or evidence of monitoring documented after 06/04/2025 at 6:37 until 06/09/25 at 5:31 PM. Registered Nurse #27's progress note dated 06/09/2025 at 5:31 PM documented the resident representative was updated on Resident #114's status as baseline, and the representative requested for scalp abrasion area to be re-evaluated. The nurse practitioner was made aware and ordered an x-ray per the resident representative's request. The nurse practitioner's order dated 06/09/2025 at 2:01 PM documented STAT (immediate) AP and Laterals (3 Views) x-ray of the skull. The nurse practitioners progress note dated 06/10/2025 at 4:16 PM documented they reviewed the x-ray of the skull status post fall with injury, resident's chart, medications, and nursing notes. The x-ray was negative. The plan was to continue to monitor. There was no documented evidence that the nurse practitioner observed the resident at any time since the fall. During an interview on 04/24/2026 at 2:40 PM, the Director of Nursing reviewed the Accident/Incident Report dated 06/04/2025 and stated it was not complete. They stated injuries sustained by Resident #114 should have been documented, signatures and notifications sections completed, statement obtained from unit nurse, and neurological checks should have been completed as per facility policy. During an interview on 04/27/2026 at 10:53 AM, the Medical Director stated Accident/Incident Reports were reviewed and signed when provided by the Director of Nursing. 10NYCRR 415.12(h)(2)

Based on observation, record review and interview during the survey, the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene for three (3) of nine (9) residents (Resident #114, Resident #6, Resident #1) reviewed for activities of daily living. Specifically, 1) Resident #114's did not receive showers or assistance as planned for activities of daily living. 2) Resident #6 did not receive showers as scheduled; and 3) Resident #1 was observed with scruffy stubble whiskers and stated they wanted to have their face shaved.The findings included: A policy titled Activities of Daily Living/AM/PM Care, last revised 05/2025 documented residents of the facility will be maintained at the highest practicable of well-being and will receive hygienic care at routine intervals during a 24-hour period as well as when needed to achieve above stated goal. A facility policy titled Certified Nurse Aide Documentation, last revised 12/2025 documented that documentation of activities of daily living performance will be maintained in the certified nurse aide record area of the electronic medical record. Certified Nurse Aides are expected to document the following items in the electronic medical record each shift: bathing/showers (includes complete bed bath), personal hygiene (includes wash by sink, partial hygienic care), toileting/bowel movements, eating/meal consumption, dressing, transfers, bed mobility, ambulation, skin condition and safety interventions. It is the responsibility of the certified nurse aide to document care provided for residents upon/following provision of care by certified nurse aide but no later than the end of the shift. Oversight of certified nurse aide documentation will be provided by Nursing Leadership; failure to complete documentation as required may result in outcomes including re-education, verbal and written counseling and up to and including suspension and termination for persistent failure to remediate practice. 1) Resident #114's diagnoses included diabetes mellitus, Wernicke's encephalopathy and cognitive communication deficit. The quarterly Minimum Data Set, dated [DATE] documented Resident #114 had severe cognitive impairment, no rejection of cares, required partial/moderate assistance with toileting, showering/bathing and dressing and was occasionally incontinent bladder/always incontinent bowel. The resident's care plans, dated 04/18/2025, Elimination: bowel incontinence and Elimination/Urinary Incontinence documented Resident #114 was incontinent of bowel and bladder function and required incontinent care. Interventions included monitoring redness or broken areas during toileting/diaper change every two (2) to four (4) hours. A review of the certified nurse aide documentation record documented Resident #114 did not receive a shower during the month of June 2025 and did not receive assistance with dressing, personal hygiene, toilet use, certified nurse aide care or skin check care for 12/30 days or transfers for 11/30 days for the month of June 2025. During an interview on 04/23/2026 at 12:10 PM Certified Nurse Aide #3 stated they did not always document all resident cares every day/shift due to lack of time and short staffing. They stated cares for some residents frequently would be performed late in the shift or left for the next shift to complete due to short staffing and high acuity of unit. Certified Nurse Aide #3 stated facility supervisors/unit managers were aware that cares were not always documented on the electronic medical record and they have been in-serviced regarding documentation policy. During an interview on 04/23/2026 at 12:28 PM, Licensed Practical Nurse #4 stated they oversee certified nurse aide task completion on units. They stated they were aware that certified nurse aides frequently did not document completion of tasks on the electronic medical record. They stated when they observed cares not completed for a resident, they addressed it with certified nurse aide staff. They stated short staffing delayed cares and that Unit 3 had high acuity that increased difficulty in completion of tasks. They stated the Supervisor and Administration were aware of certified nurse aides not documenting cares and certified nurse aides had been in-serviced in the past. During an interview on 04/23/2026 at 2:56 PM Registered Nurse Supervisor #5 stated they were aware that some facility certified nurse aides did not document task completion. They stated they recently provided the Director of Nursing with daily reports of certified nurse aide tasks that were not documented. They stated the Director of Nursing had discussed this with certified nurse aide staff and provided in-services on documentation. They stated certified nurse aides had reported login/password problems and short staffing as primary barriers to completing task documentation. They stated that when certified nurse aides did not document task completion, it could not be determined if tasks were completed. They have reminded certified nurse aide staff that if tasks were not documented, they were not completed. During an interview on 04/24/2026 at 2:40 PM, the Director of Nursing stated they were aware of problems with certified nurse aides not documenting task completion in the electronic medical record and addressing this has been a priority improvement area since they started employment at the facility in 02/2026. They stated certified nurse aides have been in-serviced and disciplinary action has been started for not completing task completion during shift. They stated unit managers/supervisors were responsible for ensuring task completion on units. 2) Resident #6 had diagnoses that included multiple sclerosis (disease of the nervous system affecting mobility), neurogenic bladder (bladder dysfunction caused by nerve function), and anxiety. The Quarterly Minimum Data Set, dated [DATE] documented Resident #6 had intact cognition and was dependent on staff for showers. The March 2026 Certified Nurse Aide Accountability Record for Resident #6 documented omissions for bathing on 03/03, 03/06, 03/10, 03/13, 03/20, 03/27, and 03/31/2026. The April 2026 Certified Nurse Aide Accountability Record for Resident #6 documented omissions for bathing on 04/03, 04/10, 04/14, and 04/17/2026. During an interview and observation on 04/20/2026 at 10:49 AM, Resident #6 was observed in bed and stated they were waiting for morning care. They stated that showers rarely happen. They stated they were often given bed baths instead but wanted their showers when they were scheduled. During an interview and observation on 04/21/2026 at 10:35AM, Resident #6 arrived in their wheelchair for Resident Council and stated they had not received their shower and complained about their hair being dirty. Their hair appeared greasy. During an interview on 04/22/2026 at 11:14 AM Licensed Practical Nurse #2 stated that the assigned showers were listed on the daily assignment. The certified nurse aides documented the showers in the electronic medical record. During an interview on 04/23/2026 at 3:58 PM, Licensed Practical Nurse #6 stated that showers were scheduled once to twice a week. They had been reviewing and adjusting the shower schedule to make sure all residents were offered showers twice weekly. They received a few complaints about missed showers but not from Resident #6. When reviewing the certified nurse aide documentation for Resident #6 from March and April 2026, they stated that bathing was not signed for Resident #6 on 04/03, 04/10, 04/14, and 04/17/2026, as well as 03/03, 03/06, 03/10, 03/13, 03/20, 03/27, and 3/31/2026. During an interview on 04/28/2026 at 12:26 PM Certified Nurse Aide #7 stated that Resident #6 was dependent on staff assistance for showers. They stated that it was not possible to give all showers as scheduled on days when there were only two certified nurse aides on the floor, especially for a dependent resident like Resident #6. It was possible some showers were missed. A bed bath should have been completed on those days instead. Both showers and bed baths should be signed for under the bathing section on the certified nurse aide documentation. 3) Resident #1 had diagnoses that included metabolic encephalopathy, unspecified psychosis not due to a substance or known physical condition and respiratory failure. The 5-day Minimum Data Set, dated [DATE] documented Resident #1 had moderate cognitive impairment and was independent for activities of daily living. A resident care plan titled Activities of Daily Living effective 03/11/2026 documented self-care deficits for personal hygiene related to cognitive status and medical condition requiring daily support of staff. Interventions included to set supervision for personal hygiene and supervision for bathing was effective 04/20/2026. During an observation and interview on 04/21/2026 at 12:50 PM, Resident #1 was had scruffy stubble whiskers on their face and stated they wanted to be shaved. The April 2026 Certified Nurse Aide Accountability Record for Resident #1 documented omissions for bathing from 04/01/2026 through 04/26/2026 and not performed on 04/27/2026; and documented omissions for personal hygiene from 04/01/2026 through 04/20/2026, 04/22/2026, and 04/24/2026-04/26/2026. During an observation and interview on 04/23/2026 at 9:56 AM Resident #1 still appeared with visible scruffy stubble whiskers. An interview at that time with Certified Nurse Aide #9 stated they provided assistance for Resident #1 with dressing, brushing teeth and shaving with an electric razor and that residents were offered a shave on their assigned shower days. Shaving did not occur every day, but they ensure Resident #1 has a clean shave. During an interview on 04/23/2026 at 2:00 PM the Director of Nursing stated Certified Nurse Aides should offer a shave to residents on their assigned shower day but can also offer everyday and as the resident requests. During an interview on 04/24/2026 at 11:10 AM Certified Nurse Aide #7 stated Resident #1 has a shower day on Monday 7-3 shift. During an interview on 04/27/2026 at 4:31 PM the Director of Nursing stated shaving would be documented under the Certified Nurse Aide task as personal hygiene. The lack of documentation for Resident #1 bathing and personal hygiene tasks were reviewed and the Director of Nursing stated they were aware of certified nurse aides not documenting task completion in the electronic medical record. 10 NYCRR 415.12 (a)(3)

Based on observations, interviews, and record review conducted during the survey, the facility did not ensure residents' rights to a safe, clean, comfortable, and homelike environment on three (3) of three (3) units (Unit 1, 2 and 3). Specifically, 1. On Unit 2, room [ROOM NUMBER] had stains on the floor, a puddle of water near the radiator, spackle stains, molding peeling under the window, and the closet door was missing. In the bathroom, brown stains were on the toilet, wall tiles were missing. There were brown stains on the ceiling, and insect or debris accumulation inside the light fixture. room [ROOM NUMBER] had unpacked cardboard boxes, no closet doors, and broken drapes. 2) On Unit 1, room [ROOM NUMBER] had a hospital bed electrical power cord plugged into an electrical outlet that did not have an outlet cover in place. Exposed wires were observed in the electrical outlet. 3) On Unit 3, rooms [ROOM NUMBER] had either no curtains or curtains in disrepair. room [ROOM NUMBER] had broken dresser drawers.The findings are: The Policy and Procedure titled Resident Rights: Safe, Clean, Comfortable, and Homelike Environment, last revised 06/2025, documented that the facility will provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. 1.During the observation on 4/6/2026 at 12:15 PM, room [ROOM NUMBER] had stains on the floor measuring approximately three (3) to four (4) centimeters on either side of the bed. There was a puddle of water near the radiator. A large spackle stain was above the bed and spackle residue was above the sink. Approximately 10 centimeters of molding was peeling under the window, and the closet door was missing. In the bathroom, brown stains were present on the toilet, and three (3) wall tiles were missing. [NAME] stains were visible on the ceiling, and insect or debris accumulation was inside the light fixture. Review of the Unit 2 maintenance logbook on 4/23/2026, had no documentation of repairs needed for room [ROOM NUMBER]. During an interview on 04/23/2026 at 11:26 AM, Maintenance Supervisor #2 stated that the stained ceiling tiles resulted from a water leak caused by flooding on the floor above. The three (3) missing tiles would be replaced. Regarding the discolored flooring, the resident urinate on the floor, and repairs to the molding around the room would be completed. The spackle was work that was initiated. The debris in the light fixture would be cleaned. They stated the issues had not been addressed earlier as one staff member was absent and they were the only staff member currently working. They were responsible for maintaining the building and stated that the issues would be addressed immediately. During an interview on 04/23/2026 at 12:30 PM with the Licensed Practical Nurse Unit Manager #6, they stated room [ROOM NUMBER] required housekeeping and maintenance services. They stated that a process was in place to document maintenance concerns in a logbook when identified by unit staff. The Maintenance Department reviewed the log and addressed identified issues. The issues in room [ROOM NUMBER] were neither reported nor addressed. 2. During observations on 04/20/2026 at 10:50 AM and 04/24/2026 at 09:12 AM room [ROOM NUMBER] had a hospital bed electrical power cord plugged into an electrical outlet that did not have an outlet cover in place. Exposed wires were observed in the electrical outlet. During an interview on 04/24/2026 at 9:18 AM, the Maintenance Supervisor #1 stated the electrical cover was missing and someone probably changed the outlet and did not put the cover plate on. They stated they knew it was not good to have an electrical outlet with wires exposed and so close to the resident's bed. 3) During an observation and interview on 04/20/2026 at 11:04 AM, cardboard boxes were piled along the wall by the closet in room [ROOM NUMBER], there were no closet doors exposing all the items in the closet, and the drapes were not completely affixed to the track. The resident was present and stated they had a lot of boxes and things they wanted to put away. They purchased a shelf on 03/16/2026, but it had not been assembled, and they were waiting for approval. They stated the drapes had been broken since their arrival in the room. During observations of Unit 3 on 04/21/2026 between 10:39 AM and 2:24 PM, room [ROOM NUMBER] had no curtains or blinds on the window. room [ROOM NUMBER] had curtains falling, the rod was falling on left side of window and the hem was coming out on both sides. room [ROOM NUMBER] had a broken privacy curtain with 6 clips missing, and the window curtain was falling apart. room [ROOM NUMBER] had broken dresser drawers. During an interview on 04/22/2026 at 11:38 AM, Maintenance Supervisor #2 stated that housekeeping would fix the curtains, and maintenance would hang closet doors. Extra pieces of furniture needed approval prior to assembly. They rounded on the units daily, but they did not go to individual rooms on a regular basis. They stated they received work orders for specific repairs or requests, and rooms should have closet doors, but they did not have the doors for room [ROOM NUMBER], and they would need to be ordered. They stated the Director of Maintenance would need to approve and order the doors, but they were currently out on leave. The Administrator would cover approvals in their absence. During an interview on 04/22/2026 at 11:47 AM, the Administrator stated they were aware of the shelf that the resident in room [ROOM NUMBER] purchased and was not sure of the status. They stated all rooms should have closet doors and they would be ordered for room [ROOM NUMBER]. They stated the drapes were an ongoing project as they were replacing them instead of repairing them. They stated they ordered some of the replacements and have not put them up in all the rooms. 10NYCRR 415.15 (h)(1)

Based on interviews and record reviews conducted during the post survey revisit from 08/12/2026 to 08/14/2026, the facility failed to ensure resident records were complete, accurately documented, accessible, and systematically organized in accordance with professional standards of practice for four (4) of four (4) residents reviewed (Residents #18, #24, #126 and #127). Specifically, 1) the facility could not provide documented evidence that wound treatments were administered as ordered, and documentation did not include who provided the treatments or when the treatments were completed for Resident #126 for 4 of 13 dates reviewed for a coccyx wound and 8 of 14 dates reviewed for a right heel wound, 2) the facility could not provide documented evidence that medications were administered as ordered, and documentation did not included who administered the medications or when the medications were administered for physician ordered antibiotics for Residents #24 on 08/08/2026 and 08/09/2026 and 3), the facility could not provide documented evidence that medications were administered as ordered, and documentation did not included who administered the medications or when the medications were administered for physician ordered antibiotics for Residents #127 on 08/06/2026, 08/07/2026, 08/08/2026 and 08/10/2026. 4) There was no documented evidence that Resident #18 received wound care daily to right plantar foot on 08/09/2026. This is continuing non-compliance cited during the recertification survey conducted from 04/20/2026-04/28/2026 and post-survey review survey conducted from 06/24/26-06/29/2026.The findings included:1) Resident #126 diagnoses included unspecified organism sepsis, pressure ulcer of unspecified site, unspecified stage, and unstageable pressure ulcer of right heel.The Re-entry Minimum Data Set (a resident assessment tool) dated 07/18/2026 documented Resident #126 had severe cognitive impairment, was dependent for activities of daily living and had one unstageable pressure ulcer present upon admission.A physician order dated 07/15/2026 documented apply betadine to right heel unstageable. Cover with protective dressing once a day and as needed, every day at 3:00 PM-11:00 PM. A physician order dated 07/31/2026 documented cleanse coccyx area, pat dry and apply Medi honey and a dry protective dressing every day at 7:00-3:00 PM.During a review of the Treatment Administration Records for July and August 2026, there was no documented evidence that wound care to Resident #126's right heel was completed 8/14 days reviewed and the coccyx wound was not documented as completed 4/13 days reviewed.During interviews on 08/12/2026 at 2:09 PM and 08/13/2026 at 3:55 PM, Licensed Practical Nurse #16 stated they attempted to document treatments after completion but frequently documented only when they have time. They stated they understood documentation of treatments was important and had recently been inserviced on documentation requirements. They stated they had completed the wound treatments for Resident #126 and did not document in the electronic medical record. They stated they were frequently the only nurse on the unit, the unit did not have a unit manager for months, had a high acuity of residents with behavioral concerns and dementia and frequently low certified nurse aide staffing, leaving little time to complete documentation. 2) Resident #24's diagnoses included acquired absence of left leg below knee, unspecified peripheral vascular disease, unspecified and type two (2) diabetes mellitus with hyperglycemia.The Quarterly Minimum Data Set, dated [DATE] documented Resident #24 was cognitively intact and was taking antibiotics.A physician order dated 08/04/2026 documented doxycycline hyclate 100 milligram tablet. Give one (1) tablet by oral route two (2) times a day for seven (7) days. A review of the Medication Administration Record on the electronic medical system did not include documentation that doxycycline hyclate 100 milligram tablet, give one (1) tablet by oral route two times a day for seven days was administered for the 9:00 AM dose on 08/08/2026 and 08/09/2026.3) Resident #127's diagnoses included other acute osteomyelitis (infection and swelling of the bone and bone marrow) right ankle and foot, chronic gout (inflammatory arthritis) and infective myositis right toes (chronic inflammation and weakness in skeletal muscles).A physician order dated 08/03/2026 documented cephalexin 500 milligram capsule. Give one capsule (500 milligrams) by oral route every 8 hours for 7 days. Every day at 10:00 PM, 2:00 PM and 6:00 AM.During a review of the Medication Administration Record on the electronic medical record, there was no documented evidence that cephalexin 500 milligram capsule, give one (1) capsule (500 milligrams) by oral route every eight (8) hours for seven (7) days, every day at 10:00 PM, 2:00 PM and 6:00 AM was administered on 8/06/2026 2:00 PM dose, 08/07/2026 10:00 PM dose, 08/08/2026 10:00 AM, 2:00 PM, or 6:00 AM doses and 08/10/2026 2:00 PM dose.During interviews on 08/13/2025 at 8:50 AM and 08/14/2026 at 9:13 AM, Licensed Practical Nurse #11 stated cares, treatments and medication administration were completed during their assigned shifts but not always documented. They stated they attempted to complete required documentation but frequently do not have the time to complete. They stated on Thursdays, they were the only nurse on Unit 1 and were responsible for all medication administration and treatments. They stated they also frequently were assigned Nurse Supervisor role during shifts. They stated they do not run reports for missing documentation for nurses or certified nurse aides and were unaware if they were required to run reports. Licensed Practical Nurse #11 stated they were the only nurse on the unit on 08/09/2026 for the day shift. Upon review of the Resident #18's Treatment Administration Record on the electronic medical record, they stated they did not document wound cares for Resident #18 on 08/09/2026 but the wound cares were completed. They stated they did not have time to complete documentation of treatments and medication administration. They stated they frequently had to stay late to complete treatments and medication administration documentation.During an interview on 08/13/2026 at 12:33 PM, Licensed Practical Nurse Unit Manager #1 stated Unit Managers were supposed to run missing documentation reports daily for the day shift and ensure that staff documentation of medication administration and treatments were completed and documented. They stated they try to run the reports daily however there had been dates when they were unable to do so due to time constraints including 08/06/2026 and 08/07/2026 for the day shift. Licensed Practical Nurse Unit Manager #1 stated the Nurse Supervisor on duty was responsible for running reports for weekend, evening and night shifts. They stated they should have ran the documentation reports daily and ensured the medication administration cart nurse had completed their medication administration and treatments documentation. They stated they could not confirm whether residents without documentation received medications or treatments. They stated medications and treatments that were not documented could be considered not administered/completed. During interviews on 08/12/2026 at 3:34 PM, 08/13/2026 at 1:02 PM and 08/13/2026 at 6:02 PM, the Director of Nursing stated they text the unit managers and nurses daily at 2:00 PM to remind staff to complete their documentation. They stated documentation has improved but still not perfect and the evening supervisor also reminds facility staff to document medication administration, cares, and treatments. They stated some facility staff just do not care. Nurse supervisors and unit managers should be running reports at the end of every shift to ensure medication administration and treatments were completed and documented. They stated all wound cares should be completed as ordered by the physician and when a nurse was unable to complete, the Nurse Supervisor on duty should be made aware/asked for assistance and report provided to incoming shift nurse staff. The Director of Nursing stated the unit managers and supervisors provided them with documentation reports to review. They reviewed the reports and discussed them with staff who did not complete documentation and staff were offered extra time to document. The Director of Nursing stated unit nurse staff were responsible for administering and documenting all medications and treatments as physician ordered. They stated staff had been under repeated training since April 2026 regarding the importance of documentation completion. 10 NYCRR 415.22(a)(1-4)

Based on observation and interview during the survey, the facility did not ensure residents needs and preferences were considered to create an individualized home-like environment for one (1) of two (2) residents (Resident #6) reviewed for choices. Specifically, Resident #6 purchased a shelf for their room and asked about purchasing a recliner for their room. The were waiting for approval to install the shelf and purchase a recliner; there was no documented evidence the facility responded to their request. The Personal Items in Resident Rooms policy dated 03/31/2026 documented that the Facility will accommodate, within reason, items of resident choice within the room environment that will enhance the homelike atmosphere. Items that may be considered for screening and approval may include: floor standing shelving unit (1) that does not extend outward from the wall at a distance that impedes safe passage, does not extend upward at a height that is at risk for tipping forward and does not extend along the wall at a distance that intrudes upon a roommate's environment; smooth or upholstered seating that accommodates one person, ie recliner or upright chair, given that the upholstery has been treated with a moisture-proofing material and meets requirements for fire-retardation and infection control.Resident #6 had diagnoses that included multiple sclerosis (disease of the nervous system affecting mobility), neurogenic bladder (bladder dysfunction caused by nerve function), and anxiety.The Quarterly Minimum Data Set, dated [DATE] documented the resident had intact cognition and required maximal assistance with most activities of daily living and was dependent on staff for transfers.An email from the Director of Rehabilitation to the Regional Nursing Coordinator dated 12/15/2025 documented a request for the policy on recliners because Resident #6 was requesting a recliner for their room. During an observation on 04/20/2026 at 11:04 AM, cardboard boxes were piled along the wall by the closet in Resident #6's room. When interviewed during the observation, Resident #6 stated they had a lot of boxes and things they wanted to put away. They stated they purchased a shelf on 03/16/2026, but it had not been assembled, and they had to wait for approval. They also asked about a recliner so that they would have somewhere to sit other than the wheelchair and bed but were told that they could not have the recliner. Resident #6 stated they had purchased a shelf and wanted to purchase a recliner for their room to make it more comfortable, organized, and homelike, but needed approval. Observation of the resident's private room appeared large enough to accommodate a recliner.During an interview on 04/22/2026 at 11:24 AM, the Director of Nursing stated that they were aware of the shelf that was purchased and it was being stored in their office. The shelf has been at the facility for a month, but it was not approved until a couple of weeks ago and no one had time to assemble it. The policy on recliners had been pending so they had not approved that yet. Residents were not supposed to have them, but they were uncertain why. The Administrator was aware of the requests.During an interview on 04/22/2026 at 11:38 AM, Maintenance Supervisor #2 stated that extra pieces of furniture needed approval prior to assembly. During an interview on 04/22/2026 at 11:47 AM, the Administrator stated they were aware of the shelf that Resident #6 purchased, and the shelf was at the facility but they were not sure of the status. They knew that staff were concerned about Resident #6 hoarding and Social Work discussed that with them. They stated residents were allowed to bring in the personal items if they were deemed safe. They stated they would have to check again about the recliner policy. They were not aware of the recliner request. During an interview on 04/22/2026 at 12:03 PM Director of Rehabilitation stated that they did request the policy for personal recliners back in December but never received the policy. They stated that they were going to obtain it. They stated that they would evaluate the chair prior to purchase if it was permitted. 10NYCRR 415.15 (h)(1)

Based on observation, interview, and record review during the survey, the facility did not ensure the residents right to participate in care planning meeting for 1 of 3 residents (Resident #68) reviewed for Activities. Specifically, Resident #68's quarterly care plan meeting was cancelled due to snow in January 2026 and not rescheduled.Findings include:Resident #68 had diagnoses that included, but not limited to Non-Alzheimer's Dementia, Multiple Sclerosis, and depression.The Minimum Data Set assessment dated [DATE] documented Resident #68 had moderately impaired cognition, and required set-up assist for eating, and was dependent on staff for rolling, sit to lying and transfers.During an interview on 04/21/2026 at 11:26 AM, Resident #68 stated they were supposed to have had a care plan meeting, and it was canceled due to snow, and not rescheduled. Resident #68 stated care plan meetings were important to them for communication with their family members.During a record review of social work progress notes, there was documentation regarding care plan meetings. A care plan meeting note dated 09/17/2025, a quarterly assessment note dated 01/20/2026 with no corresponding meeting note, and an invitation sent to a family member for an upcoming care plan meeting dated 04/20/2026.During an interview on 04/23/2026 at 9:27 AM, the Social Worker stated there was an upcoming quarterly care plan meeting scheduled for 04/29/2026 and Resident #68's family member had been invited to attend. They did not recall why the January 2026 care plan meeting was not rescheduled. They were aware they should hold quarterly care plan meetings for residents. During an interview on 04/23/2026 at 2:01 PM the Director of Nursing stated quarterly care plan meetings should be held for all residents and if needed, the facility should reschedule a care plan meeting if necessary.10 NYCRR 415.11(c)(2)(i-iii)

Based on record review and interviews conducted during survey, the facility did not electronically transmit encoded and completed Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) system within 14 days of the final MDS completion date, as required for payment information and quality measure purposes. This was evident for one (1) resident (Resident #101).The findings are: The facility policy titled Minimum Data Set, last revised 07/2025, required each resident to have a comprehensive functional capacity assessment recorded on a designated Minimum Data Set (MDS) form and electronically submitted to the State Department of Health in accordance with federal and state regulations. Review of facility Minimum Data Set assessment data completion and submission activities conducted on 04/27/2026 revealed the following. The Minimum Data Set record exceeded fourteen (14) days from the date of completion. It was not electronically transmitted to the Centers for Medicare and Medicaid Services system within the required timeframe. The 12/22/2026 Discharge Minimum Data Set assessment for Resident #101 had a completion date of 04/22/2026 and a transmission date of 04/25/2026, which was eighty-nine (89) days past the required submission timeframe. During an interview conducted on 04/27/2026 at 10:24 AM, the Director of Minimum Data Set stated the delay in completion occurred due to a pending registered nurse sign-off on the assessment. The Director of Minimum Data Set stated transmission occurred after completion and acknowledged responsibility for submission. 10 NYCRR 415.11

Based on interview and record review the facility failed to ensure a grievance process that was clear and consistent, and prompt efforts were made to resolve grievances for one (1) of nine (9) residents (Resident #114) reviewed for activities of daily living, and 3 of 12 residents (Resident #61, Resident #107, and Resident #121) at a Resident Council meeting. Specifically, 1) Resident #114's resident representative reported a grievance on 06/16/2025 and there was no documented evidence that a thorough investigation was conducted, and the complainant was notified of the resolution. 2) Resident #7 filed a grievance on 04/07/2026 and did not receive a response. 3) Resident #61, Resident #107, and Resident #121stated at the Resident Council meeting that the grievance process was unclear and inconsistent.The findings included: An undated facility policy titled Grievance/Complaint Procedure documented that the Administrator was the Grievance Officer and that the Nursing and Social Service Departments participate in the implementation of the process. The facility must act upon grievances and recommendations promptly and must be able to demonstrate its response and rational. Grievance/Complaint forms should be filled out completely with as much detail as possible, including date of event, date of report and signature. Within ten working days of date filed, complainant will be informed orally of the results of the investigation and receive a written summary of the investigation. 1) Resident #114's diagnoses included diabetes mellitus type two (2) without complications, Wernicke's encephalopathy and cognitive communication deficit. The quarterly Minimum Data Set, dated [DATE] documented Resident #114 had severe cognitive impairment, no rejection of cares, required partial/moderate assistance with toileting, showering/bathing and dressing and was occasionally incontinent bladder/always incontinent bowel. A Concern Form dated 06/16/2025 at 8:30 AM documented it was reported by Resident #114's representative that on Sunday 06/15/2025 at 3:00 PM, Resident #114 was found with a soiled adult brief, in a gown, with no sheets on the bed and was wrapped in a throw cover. In addition, Resident #114's wheelchair had a towel soiled with feces. The rest of the form was blank; there was no documentation of investigation, follow-up, resolution, complainant notification of outcome or facility staff signatures. During an interview and observation on 04/22/2026 at 9:19 AM, the Director of Social Work stated the Concern Form dated 06/16/2025 was not completed, investigated or resolved. The Concern Form only contained the Documentation of Concern, and no facility signatures were present. They stated that when a resident/representative completed a Grievance/Concern form, usually found on the units, the nursing staff would provide the form to Social Work. Social Work, along with unit nursing staff perform an investigation and complete the form. Upon completion of the investigation, the Social Work Department will contact the resident/representative with resolution and plan of action to resolve the concern. They stated they started working at facility in 10/2025 and could not provide an answer as to why concern was not addressed. During an interview and observation on 04/22/2026 at 9:30 AM, the Director of Nursing stated the Grievance/Concern Report dated 06/16/2025 was not completed, investigated or resolved. They stated the Grievance Report should have been presented to Social Work, an investigation and resolution including resident/representative notification of resolution completed. They stated the nursing staff involved should have been counselled/in-serviced. The Director of Nursing stated they were not aware why the concern was not addressed as they were not employed at the facility at the time. 2) During a Resident Council meeting on 04/21/2026 at 10:27 AM, Resident #107 stated they completed a grievance regarding a sleeping staff member recently on an overnight shift but there was no follow up and they did not know what happened. During an interview on 04/23/2026 at 1:47 PM, the Director of Social Work stated they were aware of the grievance filed by Resident #107 and did not have it. They stated that they forwarded it to nursing and were unaware of the result. A Resident Concern/Grievance Form completed by Resident #107 documented an event on 04/07/2026 when they allegedly found a staff member sleeping during the night. The grievance had a response to the allegation from the staff member dated 04/24/2026 and an undated disciplinary action. There was no documentation of any follow-up with Resident #107. 3) During a Resident Council meeting on 04/21/2026 at 10:27 AM, Resident #121 stated they were unaware of the grievance process and there was poor follow up when a complaint was made. Resident #61 stated that when they made a complaint, staff said they would investigate but there was little follow-up. Resident #107 stated they completed a grievance regarding a sleeping staff member recently on an overnight shift but there was no follow up and they did not know what happened. During an interview on 04/22/2026 at 10:41 AM Licensed Practical Nurse #2 Unit 200 stated grievance forms were available in the dining area on Unit 200 and were placed in a locked box when completed. They were uncertain whether the Administrator or the Social Worker collected the forms. They would refer to Social Work for grievances. During an interview on 04/23/2026 at 1:47 PM, the Director of Social Work stated that there were grievance forms and collection boxes on Unit 100 and Unit 200. They collected the grievances and would address if applicable to Social Service, or they would be forwarded to the appropriate department. They stated the Grievance Policy needed to be reviewed. The new administration team was trying to review the facility policies and procedures, including grievances. Review of the Grievance binder had grievances from 2025 and none from 2026, the Director of Social Work stated they had a file with copies of others, and they did not keep a log to track them. During an interview on 04/27/2026 at 10:23 AM, the Director of Nursing stated that according to the policy, the Administrator was the Grievance Officer. The grievance boxes were installed on Unit 100 and Unit 200 recently, and the Administrator should be collecting the grievances from the box. The Grievance Officer should track the status of and response to grievances. During an interview on 04/27/2026 at 3:56 PM, the Administrator stated that according to the policy, they were currently the Grievance Officer and would be monitoring the grievances. There was no tracking process or log for grievances, but they would be working to fix the process. The grievance boxes were in the dining rooms on the 1st floor and 2nd floor units, but they were uncertain who collected the forms. The Administrator stated that the process was unclear and would be reviewed again. The grievances needed to be responded to in a few days. 10 New York Codes Rules and Regulations 415.3 (d)(1)(ii)

Based on observations, interviews, and record reviews, the facility did not ensure that residents remained free from abuse from one (1) of four (4) residents (Resident #23) reviewed for behavioral-emotional concerns. Specifically, Resident #37 was not kept free from abuse when Resident #23 was observed by staff touching Resident #37's breast on 08/23/2025. Additionally, Resident #23 had psychiatric diagnoses that included sexual disorders there were no interventions in place prior to the incident that would ensure Resident #37 and other residents were free from being abused by Resident #23.The findings include:Resident #37 had diagnoses including dementia, anxiety and bipolar disorder. The Minimum Data Set (resident assessment tool) dated 06/10/2025 documented Resident #37's cognition was severely impaired, had no behavior symptoms and mobility devices included a walker and wheelchair.Resident #23 had diagnoses that included dementia, hydrocephalus (chronic condition of accumulation of fluid within the brain), and anxiety. The Quarterly Minimum Data Set, dated [DATE] documented Resident #23 had severely impaired cognition, no behaviors, and was independent with activities of daily living and ambulation.A physician order dated 02/06/2025 documented Resident #23 was prescribed naltrexone 50 milligram tablet, give one- and one-half tablets once daily for sexual disorders.Resident #23's At Risk for Unsafe Behavior Care Plan initiated 03/25/2025 and entered on 04/29/2025 documented at risk for unsafe behavior due to cognitive deficit. There were no related diagnoses, behaviors, or interventions documented.The most recent Psychiatric Consultation dated 05/13/2025 documented Resident #23 had psychiatric diagnoses that included frontotemporal neurocognitive disorder with speech/language deficits, major depressive disorder, and sexual disorders.Resident #23's At Risk for Unsafe Behavior Care Plan dated 07/03/2025 documented at risk for unsafe behavior due to cognitive deficit due to significant mental health and neurological diagnoses including frontotemporal neurocognitive disorder. Interventions included maintaining safety devices, anticipating and meeting needs, observing for signs and symptoms of evolving mood or temperament change and intervening promptly.The Accident and Incident Report dated 08/23/2025 at 1:00 PM documented that Resident #23 was observed touching Resident #37's breast with their hands. A recreation staff member was present and witnessed the interaction. Residents were separated immediately. No injuries noted. Relevant diagnoses were listed for Resident #23 as dementia and cognitive communication. Other contributing factors listed were cognitive deficit, perceptual impairment, and poor safety awareness. The physician was notified with no interventions or new orders listed. No investigation was completed. The report was signed by the supervising nurse and the Administrator. There was no signature from the Director of Nursing or the Medical Director.Activity Aide #26's written statement dated 08/23/2025, documented they and a coworker took a few residents outside for some fresh air. Resident #37 was strolling around in their wheelchair. Activity Aide #26 saw Resident #23 walking around Resident #37, and they decided to keep an eye on Resident #23. Time went by and they (Activity Aide #26 and the coworker) were bringing people back in and they were also bringing in tables for a party that was happening later. As they opened the door to get the rest of the people, they saw Resident #23 grabbing Resident #37's private areas. Resident #37 screamed to stop, and Activity Aide #26 screamed for Resident #23 to stop and told them to go the their room.The Registered Nurse #8 nursing progress note dated 08/23/2025 at 1:49 PM documented they were made aware of Resident #23's behavior during shift. Residents involved were immediately separated and assessed; no signs or symptoms of injury noted. Resident denied pain or discomfort. Resident #23 was educated on appropriate behavior and the importance of reporting any concerns to staff. Administration notified of the incident. Will continue to monitor for any changes in behavior or condition.The Medical Director note dated 08/26/2025, in Resident #23's record, documented assessment completed, resident to resident interaction. Residents were separated immediately and assessed. Continue present medications.There were no nursing notes or evidence of monitoring Resident #23 from 08/23/2025 to 08/29/2025.The Licensed Practical Nurse Regional Nursing Coordinator's note dated 08/29/2025 at 2:17PM, in Resident #23's record, documented a request was communicated to the attending physician for medication review related to intrusive behavior.The Licensed Practical Nurse Regional Nursing Coordinator's note dated 08/29/2025 at 2:41PM documented attending physician (Medical Director) reviewed medications for Resident #23, order received for Namenda five (5) milligrams.The physician phone order dated 08/29/2025 at 2:43 PM documented Resident #23 to receive Namenda five (5) milligrams daily for other sexual disorders. The Behavior Problem care plan dated 08/29/2025 documented Resident #23 with sexual and socially inappropriate behavior. Interventions included medical and psychiatric management per physician orders, psychiatric evaluation and follow up, and provide sight supervision when out of room.The Sexual Disorders Care Plan dated 08/29/2025, by the Licensed Practical Nurse Regional Nursing Coordinator, documented that Resident #23 has exhibited sexually inappropriate behavior. Interventions included medical management to minimize signs and symptoms of sexual behaviors, psychiatric evaluation and follow up, administer psychoactive and sexually suppressive medication per physician order, sight supervision when out of bed, and observe when out of room and near female residents; do not leave unattended in room with female resident; if approaches female resident, redirect and report any behavior to nurse immediately.The Other Sexual Disorders/Hypersexuality care plan dated 08/29/2025 documented Resident #23 has a diagnosis of and has demonstrated behavior which is sexually and socially inappropriate behavior. Interventions included sight supervision when out of bed, observe when out of room and near female residents; do not leave unattended in room with female resident; if approaches female resident, redirect and report any behavior to nurse immediately, Namenda five (5) milligrams orally daily added to medication regimen.During an interview on 04/23/2026 at 12:15 PM, Licensed Practical Nurse Unit Manager #1 stated they could not recall all the details of the incident, they may have been on leave on or around that time. They stated Resident #23 has had 1:1 supervision due to the inappropriate touching incident on 08/23/2025.During an interview on 04/23/2026 at 1:04 PM, the Director of Nursing stated that they were not at the facility when the incident occurred on 08/23/2025 and could not speak to Resident #23's behaviors prior to the incident or about incident specifics. During an interview on 04/27/2026 at 11:47 AM, the Medical Director stated Resident #23 had frontotemporal neurocognitive disorder. They did not recall the incident with the resident touching another inappropriately and would have to review notes. During an interview on 04/27/2026 at 4:04 PM, the Administrator stated that they were not at the facility at the time of the incident so they could not provide details about Resident #23's behaviors prior to the incident or about incident specifics.10NYCRR 415.4(b)(1)(i)

Based on observations, interviews, and record reviews during the survey, the facility did not ensure that alleged violations involving abuse were reported no later than two hours after the incident for one (1) of four (4) residents reviewed for behavioral emotional. Specifically, Resident #23 was witnessed touching another resident inappropriately on 08/23/2025 and the incident was not reported to the State Agency.Findings include:The facility policy titled Resident Abuse Prevention and Reporting, last revised 05/2025, documented upon suspicion of abuse of any kind, all employees are required to stop the abuse, protect the residents, immediately notify immediate supervisor or person in charge of the building (if during off-hours), make immediate statement of observations or cause for suspicion and provide to above-identified person. If deemed a reportable incident, reporting of the incident is to be made in accordance with the requirements stated in manual for specific incident. Resident #23 had diagnoses that included dementia, hydrocephalus (chronic condition of accumulation of fluid within the brain), and anxiety.The Quarterly Minimum Data Set, dated [DATE] documented Resident #23 had severely impaired cognition, no behaviors, and was independent with activities of daily living and ambulation.The Accident and Incident Report dated 08/23/2025 at 1:00PM documented that Resident #23 was observed touching a female resident's breast with their hands. A recreation staff member was present and witnessed the interaction. The residents were separated immediately and no injuries were noted. The physician was notified with no interventions or new orders listed. The report was signed by the supervising nurse and the Administrator. There was no signature from the Director of Nursing or the Medical Director. Activity Aide #26's written statement dated 08/23/2026, documented they and a coworker took a few residents outside for some fresh air. Resident #37 was strolling around in their wheelchair. Activity Aide #26 saw Resident #23 walking around Resident #37, and they decided to keep an eye on Resident #23. Time went by and they (Activity Aide #26 and the coworker) were bringing people back in and they were also bringing in tables for a party that was happening later. As they opened the door to get the rest of the people, they saw Resident #23 grabbing Resident #37's private areas. Resident #37 screamed to stop and Activity Aide #26 screamed for Resident #23 to stop and told them to go the their room.Registered Nurse #20's note dated 08/23/2025 at 12:20 PM documented activities staff witnessed Resident #23 touching another resident's breast while out on back patio. Resident was in a supervised area and was immediately separated and redirected to room after incident. Supervisor was made aware, and psychology would follow up. During an interview on 04/24/2026 11:54 AM, the Regional Nursing Coordinator stated they could not recall if the incident was reported and they were unable to find any record of the reporting of the incident involving Resident #23.During an interview on 04/24/2026 at 1:02 PM, the Director of Nursing stated that the incident should have been reported while an investigation was completed. During an interview on 04/27/2026 at 11:14 AM, the Medical Director stated that the incident should have been reported. They stated that they do typically review the incident reports but do not recall seeing the report from 08/23/2025.During an interview on 04/27/2026 at 4:04 PM, the Administrator stated that a more thorough investigation should have been conducted. They stated they were working at a sister facility at the time of this incident, and the prior Administrator had asked them for guidance. They stated they explained to them that it needed to be reported and investigated due to the inappropriate touching. 10NYCRR 415.4(b)(3)

Based on observation, interview, and record review conducted during the survey, the facility did not ensure that they initiated and completed a thorough investigation to determine if alleged abuse could have been prevented and to prevent further abuse while the investigation was in progress for one (1) of four (4) residents (Resident #23) reviewed for behavioral-emotional concerns. Specifically, Resident #23 was observed touching another resident inappropriately on 08/23/2025. The Accident/Incident report dated 08/23/2025 did not document a thorough investigation to prevent reoccurrence of the situation and protect other residents during the investigation. Additionally, the Medical Director was not aware of the nature of the incident, and the report was signed by the supervising nurse and only reviewed and signed by the Administrator. Findings included: Resident #23 had diagnoses that included dementia, hydrocephalus, and anxiety. The Quarterly Minimum Data Set, dated [DATE] documented severely impaired cognition, no behaviors, and independent with activities of daily living and ambulation.The facility policy titled Resident Abuse Prevention and Reporting, last revised 05/2025, documented that upon receiving a report of suspicion of abuse of any kind, supervisory/administrative staff are required to immediately initiate an investigation into the alleged incident. The investigation will proceed per the criteria on the investigative report, with documentation of all actions taken on an ongoing basis for the duration of the investigation. All abuse investigations will be reviewed by the Administrator, Medical Director and Director of Nursing.The Dementia Care Plan initiated on 06/18/2025 documented resident has impaired decision making. Interventions included psychological services and psychiatric and medical management per physician orders.The At Risk for Unsafe Behavior Care Plan dated 07/03/2025 documented at risk for unsafe behavior due to cognitive deficit due to significant mental health and neurological diagnoses including frontotemporal neurocognitive disorder. Interventions included maintaining safety devices, anticipating and meeting needs, observing for signs and symptoms of evolving mood or temperament change and intervening promptly.Registered Nurse #20's nursing behavior note dated 08/23/2025 at 12:20PM documented activities staff witnessed Resident #23 touching another resident's breast while out on back patio. Resident #23 was in a supervised area and was immediately separated and redirected to room after incident. Supervisor was made aware; psychology would follow up. Registered Nurse #8's nursing progress note dated 08/23/2025 at 1:49 PM documented they were made aware of resident behavior during shift. Residents involved were immediately separated and assessed; no signs or symptoms of injury noted. Resident denied pain or discomfort. Resident was educated on appropriate behavior and the importance of reporting any concerns to staff. Administration notified of the incident. Will continue to monitor for any changes in behavior or condition.Review of the New York State Department of Health complaint database revealed the incident was not reported to the State Agency.When requested on 04/2302026, the Director of Nursing stated they would look for the investigation. On 04/24/2026 at 7:59 AM, the investigation was requested again. The investigation was received on 04/24/2026 at 10:30 AM. The investigation included an Accident/Incident Report dated 08/2302025, a written statement by Activity Aide #26, and an Inservice sign-in sheet dated 09/01/2025.The Accident and Incident Report dated 08/23/2025 at 1:00 PM documented that Resident #23 was observed touching a female resident's breast with their hands. A recreation staff member was present and witnessed the interaction. Residents were separated immediately. No injuries noted. Relevant diagnoses were listed for Resident #23 as dementia and cognitive communication. Other contributing factors listed were cognitive deficit, perceptual impairment, and poor safety awareness. The physician was notified with no interventions or new orders listed. The report was signed by the supervising nurse and the Administrator. There was no signature from the Director of Nursing or the Medical Director.Activity Aide #26's written statement dated 08/23/2025, documented they and a coworker took a few residents outside for some fresh air. Resident #37 was strolling around in their wheelchair. Activity Aide #26 saw Resident #23 walking around Resident #37 and they decided to keep an eye on Resident #23. Time went by and they (Activity Aide #26 and the coworker) were bringing people back in and they were also bringing in tables for a party that was happening later. As they opened the door to get the rest of the people, they saw Resident #23 grabbing Resident #37's private areas. Resident #37 screamed to stop, and Activity Aide #26 screamed for Resident #23 to stop and told them to go their room.There was a sign-in sheet dated 09/01/2025 for education that was signed by the two activity aides that documented Increased supervision for residents with behaviors. titled Supervising residents with behaviors. There was no other information regarding this in-service, and it lacked documentation as to who provided the in-service. There was no documented evidence that a thorough investigation was completed.During an interview on 04/24/2026 at 1:02 PM, the Director of Nursing stated that there should have been a more thorough investigation completed for this incident.During an interview on 04/27/2026 at 11:14 AM, the Medical Director stated that they could not recall the incident on 08/23/2025 involving Resident #23 touching another resident inappropriately. The incident should have been investigated and they stated they would have likely ordered a psychiatric consultation and medication review had they realized the nature of the incident. They stated that they do typically review the incident reports but do not recall seeing the report from 08/23/2025. During an interview on 04/27/2026 at 4:04 PM, the Administrator stated that a more thorough investigation should have been conducted. They stated they were working at a sister facility at the time of this incident, and the Administrator had asked for guidance. They stated they had explained to them that it should be reported and investigated due to the inappropriate touching. The Medical Director should have been involved and aware as well.10NYCRR 415.4(b)(3)

Based on interviews and record review during the survey, the facility did not ensure notification to the resident representative or ombudsman regarding transfer or discharge, including the reason for the transfer/discharge, in writing and in a language and manner understood, for three (3) of three (3) residents (Resident #111, Resident #3, and Resident #5) reviewed for hospitalization. Specifically, 1) Resident #111 was hospitalized on [DATE] and the facility did not complete a discharge notice or bed-hold notification, and the ombudsman did not receive notification; 2) Resident #3 was hospitalized [DATE] and the facility did not provide a discharge notice or bed-hold notification to Resident #3's representative and did not notify the ombudsman; and 3) Resident #5 was hospitalized [DATE] and the facility did not provide a discharge notice or bed-hold notification and did not notify the ombudsman. Findings include: The Policy and Procedure titled Notice of Transfer/Discharge, last revised 05/2024, documented that social workers, nurse supervisors, and unit managers are responsible for ensuring residents and resident representatives are notified of any transfers and discharges promptly, including the reason for the transfer or discharge. The policy documented that the social worker must provide a written discharge notice to the resident and the resident representative and must also provide a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman. 1) Resident #111 had diagnoses including cardiac arrest (heart stops suddenly), breast cancer, and chronic kidney disease. The Five-Day Minimum Data Set (an assessment tool) dated 02/05/2026 documented Resident #111 had intact cognition and required minimal assistance with activities of daily living. A Nursing Progress Note dated 01/30/2026 documented resident #111 was transferred to the hospital from the Heart Center due to lethargy and hypotension and was admitted for observation. There was no documented evidence that Resident #111 or the resident representative received a discharge notice or bed-hold notification. There was no documented evidence that the ombudsman was notified of Resident #111's hospitalization. During an interview with the Director of Social Work on 04/22/2026 at 4:44 PM, the Director of Social Work stated the resident was transferred from the Heart Center directly to the hospital on [DATE]. They stated the Ombudsman was not notified, the transfer/discharge notice was not mailed, and the resident representative was not notified of the bed-hold policy. The Director of Social Work stated they were responsible for all three (3) tasks; however, because the resident was transferred directly from the Heart Center to the hospital and did not leave the facility, the tasks were not completed. 2) Resident #3 had diagnoses that included Alzheimer's dementia, Schizophrenia, and diabetes mellitus. The Minimum Data Set assessment dated [DATE] documented Resident #3 had severely impaired cognition and required moderate assistance for sit to stand, transfers from chair to bed, and used a walker for ambulation. During an interview on 04/20/2026 at 4:34 PM Resident #3's adult child stated the Resident had been hospitalized a few months ago and they were unsure if Resident #3's spouse was notified. A nursing progress note dated 01/16/2026 documented that Resident #3 was observed to be sitting in a chair in their room, nonverbal with left sided weakness and head tilted to the right. Resident #3 was alert to self and unable to follow commands. The emergency medical service was called for possible stroke. The Assistant Director of Nursing, the physician and Resident #3 spouse were notified of transfer to the hospital. A Social Work progress note titled Transfer/Discharge Notice dated 1/16/2026 documented that Resident #3's representative had been notified by phone of the discharge but there was no documented evidence that the representative had received a discharge notice or bed-hold notification. There was no documented evidence that the ombudsman was notified of Resident #3's hospitalization. During an interview on 04/23/2026 at 9:39 AM the Social Worker stated they did notify Resident #3's spouse by phone and did not have documentation of sending notification by mail. The Social Worker was unable to provide documentation of notification to the ombudsman. 3) Resident #5 had diagnosis that included lung cancer, respiratory failure, and diabetes mellitus. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #5 was severely impaired cognition and required supervision for eating and was dependent on staff for sit to lying and transfers. A nursing progress note dated 12/10/2025 documented that Resident #5 had a decline of status. Oxygen at 60%, non-responsive to verbal and tactile stimuli, foaming at the mouth, labored/distressed breathing, change in mental status, not responding to breathing treatments. Nurse Practitioner at bedside to assess the resident and order to transfer to the hospital for respiratory failure. A nursing progress note titled Transfer/Discharge Notice dated 12/10/2025 documented that Resident #5's designated representative had been verbally informed of the discharge but there was no documented evidence that the representative had received a discharge notice or bed-hold notification. There was no documented evidence that the ombudsman was notified of Resident #5's hospitalization. During an interview on 04/23/2026 at 2:43 PM the Social Worker stated Resident #5 had no family to notify and no case worker. During an interview on 04/24/2026 at 9:15 AM the Social Worker stated they were unable to provide documentation that ombudsman was specifically notified about Resident #5's discharge. They did have an email to the ombudsman on 12/26/2025 about the monthly discharges but did not know if Resident #5's notification was included. 10NYCRR 415.3(i)

Based on observation, interview, and record review during the recertification and abbreviated surveys (NY00345570) from 9/5/2024 through 9/17/2024, the facility failed to adequately equip the facility to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside and toilet and bathing facilities, or that each resident was consistently provided an alternate method for communicating needs to staff on 1 of 3 units (Unit 3). Specifically, on 9/10/2024 it was revealed there was no functioning centrally located audible call bell system and the current interim system was not functioning throughout the unit. The sound of the tap bells (desk bells with a black base) was not audible at the central nursing station or throughout the hall for 37 residents housed on the Unit 3 Dementia/Long Term Care Unit. Additionally, Resident #31, assessed at moderate risk for falls (fall with no injury on 8/27/2024), was observed on 9/10/2024 at 3:15 PM and 3:42 PM sitting on the toilet in the residents' bathroom. The bathroom call bell was not functioning either audible or visual, a tap bell was noted on the bedside table, and not within resident reach. This resulted in no actual harm with likelihood of serious harm that is Immediate Jeopardy to all Unit 3 residents' health and safety. The findings include: The facility policy, Call Bells, revised 4/2024 documented each resident has a call bell that is within reach to ensure each resident has a means to communicate their needs. The 4/11/2024 Call Bell Contract Proposal for work to be completed on the Unit 3 centrally located call bell light system documented a down payment of 50% was due at signing of the contract. A purchase order was required to process the proposal. By signing the proposal, the price, payment terms and all stipulations mentioned in the proposal have been agreed. The proposal was signed by the facility Assistant Chief Operating Officer on 4/16/2024. (The contractor did not receive the 50% downpayment until 8/29/2024.) Resident #31 was admitted with diagnoses including Parkinson's, Schizophrenia and Muscle Weakness. The 7/2/2024 Minimum Data Set (an assessment tool) documented Resident #31 had intact cognition, was independent with toileting, walking and ambulation, was always continent and received antipsychotic, antidepressant, and antianxiety medications. The 8/27/2024 Fall Risk Assessment documented a score of 18 (moderate risk for falls). The 8/27/2024 Incident and Accident Report documented Resident # 31 sustained a fall outside the bathroom in the resident's room. The 8/27/2024 Care Plan titled Risk for Fall documented the following 9/20/2021 interventions: call bell within reach/encourage use and assess the ability to use the call signal and provide alternate method(s) if necessary. Observations on 9/10/2024 at 3:15 PM and 3:42 PM revealed Resident #31 sitting on the toilet in the residents' bathroom. The bathroom call bell was not audible and did not illuminate above the room door. The designated interim system tap bell was observed on the bedside table and not within Resident #31's reach. During an interview and observation on 09/11/2024 at 3:24 PM, Resident #31 stated they fell coming out of the bathroom on 8/27/2024 because they were trying to pull up their pants and fell backwards. Resident #31 stated they found out today that the bathroom call bell did not work. Resident #31 stated a tap bell had not been in the bathroom prior to that day. Resident #31 stated they were aware of the bedside tap bell and knew how to use it. Resident #31 demonstrated how to use the bedside tap bell. Resident #31 stated when they tapped the bell, staff did not come to check on them for a long time because they could not hear it. During an observation on 9/10/2024 between 9:30 AM and 4:30 PM the call bells on Unit 3 were not audible at the central nursing station or throughout the hall for 37 residents. The call bell light did not illuminate above the room door for Residents #5, #11, #15, #31, #59, #75, #78, and #89. The interim communication tap-bells in the room of Residents #59, #78, and #89 were broken. The interim communication tap-bells in the room of Residents #7, #8, #50, and #56 were not audible in the corridor. Resident #23 did not have an interim communication tap-bell. The low side shower room toilet and front shower call bells were not audible. There was no documented evidence from 4/5/2024 through 9/11/2024 that the facility implemented tap bell function and placement logs. There was no documented evidence from 4/5/2024 through 9/11/2024 that care plans were updated, or that interventions were implemented to address the residents' ability to contact staff while Unit 3 had no functioning centrally located audible call bell light system. There was no documented evidence the facility increased monitoring for all residents on Unit 3 as per the 4/8/2024 Interim Quality Assurance Meeting which documented modification of usual operations that potentially impact routine safety and wellbeing. During an interview on 9/5/2024 at 10:41 AM and 9/10/2024 at 4:37 PM three Certified Nurse Assistants (#5, #6, and #7) stated they were not aware the Unit 3 call bell system was not functioning. During an interview on 09/10/2024 at 5:43 PM the Administrator stated they believed the call bell system on Unit 3 had been out since sometime in April 2024, and the Department of Health was notified. The Administrator stated they did not know why it was taking so long for the call bell system to be repaired. The Administrator stated tap bells had been placed in resident rooms on Unit 3 after the call system stopped working and staff were to provide increased monitoring. The Administrator stated they were not sure if there was documented evidence of such increased monitoring. During an interview on 9/10/2024 at 6:03 PM the Director of Maintenance stated the problem with the Unit 3 call bell system started in 4/2024. The problem was identified when the staff could not hear call bells, as there was a problem with the centrally located call bell system. Tap bells were provided by the maintenance department to all residents and the facility tried to replace the old call bell system. The Director of Maintenance stated the tap bells in some resident rooms often went missing. The Maintenance Director stated they did not receive a proposal to address the problem with the Unit 3 call bell system until late April early May. The Maintenance Director stated they inquired every week with the Regional Office and were told they did not know when the new call bell system would be installed. During an interview on 09/11/2024 at 10:57 AM, Licensed Practical Nurse #1 stated they were not sure if call bell logs were previously started because they did not normally work on the unit. Licensed Practical Nurse #1 stated after checking the binder, there was no documentation to indicate monitoring logs were being done. During an interview on 09/11/2024 at 11:00 AM, Registered Nurse #2 stated they worked per diem (works as needed), and they were not aware when or if call bell rounding logs and/or increased monitoring logs were being completed on Unit 3. During an interview on 09/11/2024 at 11:01 AM, the corporate Director of Nursing stated they did not have documented call bell rounding logs and could not confirm that increased monitoring logs were completed prior to 9/11/2024. During an interview on 09/11/2024 at 3:09 PM, Resident #23 stated there was no bedside tap bell yesterday, and they had to yell for help. Resident #23 further stated sometimes they would become upset/cry when no one came to help them. Resident #23 demonstrated use of the tap bell at that time. During an interview on 9/11/2024 at 1:53 PM the Controller at the contractor company that provided a proposal for the work to be done on the facility call bell system stated the 1st contract proposal was dated 4/17/2024. The Controller stated the proposal went out to the facility, but that no work could be started until after they received a deposit for work to be done. The Controller stated there had been a delay and issues with receiving payment from the facility, but they finally did receive the deposit on 8/29/2024. The Controller stated they thought someone was at the facility recently (Monday) to start the work. The facility was notified of the Immediate Jeopardy on 9/11/2024 at 6:27 PM. The Immediate Jeopardy was removed on 9/13/2024 prior to the completion of the survey. The facility implemented the following plan to remove the immediacy: - The facility assigned two to four staff members as monitors to make continuous rounds on Unit 3. Monitoring logs for room rounds dated 9/11/2024 through 9/13/2024 were presented to the survey team by the facility with no negative findings. -Staff education regarding room rounds on Unit 3 was conducted with 90.2% completion as of 9/13/2024. - Unit 3 residents were assessed for the ability to use the call bell system. Three residents were assessed by therapy as not being able to use a call bell. - The Policy and Procedure titled Alternate Call Bell System for use during a Partial or Full Call Bell System Downtime was initiated on 9/13/2024. -The Temporary Alternative Call Bell System was installed in Unit 3 rooms on 9/13/2024 with a receiver located at the desk. 10 NYCRR 415.29

Based on observations, staff interviews and record reviews conducted during an Abbreviated and Partial Extended survey (# NY 862), the facility failed to initiate Cardiopulmonary Resuscitation (CPR) to an unresponsive resident who had a Full Code status with Advance Directives in place. This was evident for 1 out of 6 residents sampled (Resident #1). Specifically, 1) on [DATE], Resident #1 who has an order for [REDACTED]. This resulted in actual harm and the potential for serious harm to the health and safety of all residents in the facility that is a Substandard Quality of Care. The findings are: Review of the facility Policy and Procedure titled, CPR / Code Blue Event revised on ,[DATE] and ,[DATE] showed that Basic Life Support (BLS) will be provided to all persons on the facility premises believed to be without a Do Not Resuscitate (DNR) order, who have ceased breathing and/or do not have a pulse but do not show signs of clinical death. Upon finding an unresponsive person whose DNR status is not immediately known or who is known to not have a DNR order, the staff member who knows CPR will shout Code Blue, to seek assistance and will initiate the life support techniques determined necessary. The code will be announced on the overhead speaker by calling Code Blue with the location of the code, three times by the responding staff member or designee. A staff member not trained in CPR who comes upon an unresponsive person whose DNR status is immediately known will shout Code Blue and will immediately call the code via the overhead paging system. The staff member will remain with the person after placing the call until staff members trained in CPR arrive on site. Review of the facility Policy entitled, Identifying Code Status dated [DATE] showed that if the resident is DNR status, the insert on the residents name band will indicate DNR; if the resident is full code, the insert on the name band will be blank; the residents code status will be recorded on the Medication Administration Record (MAR) and that the Social Worker (SW) will be responsible to maintain a list of residents and their code status provided via email to the following: each nursing unit, receptionist desk, Rehab, crash carts, activity room, front office, administration, Director of Nursing (DON) and SW Office. 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment tool) dated [DATE], documented that the resident had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation and ability to recall information) score of ,[DATE], associated with severely impaired cognition (,[DATE] severe impairment, ,[DATE] moderate impairment and ,[DATE] cognitively intact). The resident had no documented Advance Directive. Review of the Physician's Order from [DATE] to [DATE] revealed that the resident had a Full Code CPR Order with a check ID band for placement and code status: (full code). Review of Resident #1's Medication Administration Record (MAR) from [DATE] to [DATE] documented that the nurses are signing that they checked ID band placement and code status: (full code). A Facility Accident / Incident (AI) Report dated [DATE] documented that resident was found unresponsive with no pulse at 10:15 PM. The physician was notified at 10:20 PM. Resident #1 had a CPR order that was not initiated by the RN on duty. Review of Resident #1's Death Certificate dated [DATE] showed that Resident #1 died in the facility on [DATE] at 10:45 PM. The cause of death was Cardiopulmonary Arrest, [MEDICAL CONDITION] Infarction, [MEDICAL CONDITION], Dementia, [MEDICAL CONDITION] Disease, Dementia and Hypertension. Review of the the RN Supervisor's (Accused) Progress Note dated [DATE] at 11:34PM documented that the resident was last seen by LPN #1 at 9:40 PM. At 10:15 PM, CNA #1 checked on the resident, found her unresponsive then reported it to LPN #1. LPN #1 reported to the RN Supervisor (RNS), who then assessed that the resident was cold to the touch, fingernails were cyanotic, pupils fixed and dilated, and heart tones were not present. Review of the Licensed Practical Nurse's (LPN #1) Progress Note dated [DATE] at 11:52 PM documented that the resident's vital signs were within normal limits at 4:30 PM. LPN #1 documented that at 9:40 PM she assisted Resident #1's roommate and noted that Resident #1 was sitting at the edge of her bed. At approximately 10:15 PM, CNA #1 reported to LPN #1 that Resident #1 had passed. LPN #1 went to the room and noted the resident with no respiration and no pulse. The RN Supervisor was made aware who arrived and assessed the resident immediately. A statement given by LPN #1 on [DATE] showed that she informed the RNS that Resident #1 was to receive CPR based on the DNR list on the unit. The LPN stated that after the RNS called the DON and the Medical Director, the RN Supervisor stated that the Medical Director told her not to call a code. An interview conducted with LPN #1 on [DATE] at 4 PM revealed that when CNA #1 informed her that the resident has passed, she immediately went to the resident room. LPN #1 stated that the resident had no respiration, no pulse and was cool to touch but not cold. LPN #1 stated that she immediately informed the RNS and informed her that Resident is to receive CPR based on the Code Status List at the nurse's station. LPN #1 stated that she has an expired CPR certification that is why she did not start resuscitation. LPN #1 further explained that she did not announce a code since the RNS did not direct her to do so. An interview conducted with the Medical Director on [DATE] at 3:12 PM revealed that the RNS called him on the night of [DATE] to inform him that Resident #1 was not breathing, has no pulse and was cold to touch. He also stated that that the RNS told him that she could not find the resident's code status. The Medical Director stated that he informed the RNS that if she cannot find the code status then she must perform CPR. He stated that the only time it is not recommended to perform CPR is when there is Rigor Mortis. The RNS informed him that she will go check for Rigor Mortis and that she will call him back. The Medical Director stated that the RN Supervisor called him around 11 PM and stated that it looks like the resident has been like that for a long time. The Medical Director stated that he does not understand why the RNS did not perform CPR. The Administrator informed him that the facility called the Medical Examiner and that they will not do an autopsy because the resident died of natural causes. 2. Review of the facility Policy and Procedure titled, CPR / Code Blue Event revised on ,[DATE] and ,[DATE] showed that Basic Life Support (BLS) training is to be provided to all nursing staff. Copies of the certification cards ill be maintained file. In addition, the facility is responsible to arrange for retraining in CPR as needed. Interview with the facility Administrator on [DATE] at 2:00PM revealed that the Staff Educator no longer works at the facility (separated in ,[DATE]) and she was responsible to ensure that CPR certified staff are working on every shift. The Administrator further explained that no other staff have monitored CPR staffing since. Surveyor review of staffing records showed that of 31 total nursing staff, it cannot be ensured that 20 have current CPR certification as 6 have expired and 14 have no status in their records. Further review of the staffing schedule for [DATE] through [DATE] (21 shifts) showed that the 11PM to 7AM shift on [DATE] was not staffed with a nurse who is currently CPR certified. 415.3 (e)(2)(iii)

Based on medical record review and staff interviews conducted during an abbreviated survey, it was determined that the facility failed to ensurethat staff were aware of the regularly monitoring the clotting times of resident receiving anticoagulant therapy. Specifically, the facility ' s medical team (medical director, physicians, pharmacy consultant and nursing staff) did not obtain essential laboratory tests for [MEDICATION NAME] Time and International Normalized Ratio (PT/INR), (a test that monitors the effectiveness of the anticoagulant therapy) for 5 (Resident #1, #2, #7, #8, and #10) of 10 residents receiving [MEDICATION NAME] (a blood thinning medication) to prevent adverse complications. Resident #1 developed [MEDICATION NAME] toxicity and Resident #2 developed bleeding related to [MEDICATION NAME] therapy, which required acute care hospitalization for both residents. This resulted in actual harm to Resident #1 and #2 that is Immediate Jeopardy and the potential for serious harm to the health and safety of residents currently receiving [MEDICATION NAME] therapy. Complaint ID Number: NY 414, NY 797 This was evidenced by, but not limited to the following: Cross References: F 281- Services Meet Professional Standards of Care, - scope and severity - L F 428- Pharmacy Services, - scope and severity -L F 501- Medical Director, - scope and severity -L F 490- Administration- scope and severity -L F 386-Physician Services- scope and severity -L Resident # 1 is a [AGE] year-old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) a resident assessment tool dated 4/23/2015 documented residents Brief Interview for Mental Status (BIMS) score of 15 which indicates resident is cognitively intact. Review of a facility investigation dated 5/13/2015 documented that the resident was transferred to the emergency roiagnom on [DATE] for evaluation of nausea and vomiting after being treated with [MEDICATION NAME] (medication to prevent nausea and vomiting) at the facility on 5/10/2015. The resident was readmitted back to the facility 5/14/2015 with a [DIAGNOSES REDACTED]. Review of the facility policy and procedure for Anticoagulant Therapy dated 5/5/2009 documents, Physician will evaluate for the need to continue anti coagulation therapy for all new admissions and readmissions that are prescribed [MEDICATION NAME] and Physician orders INR levels for all new and re-admissions to be done on the next lab day post admission to the facility and weekly thereafter. Licensed Nurse will log results into Sigma Care (electronic medical record) and drop down box on the date the PT/INR is ordered and again once the orders are obtained. Each unit is to maintain anticoagulant binder which should be checked daily by the unit manager/RN Supervisor (Registered Nurse), (on off shifts) and update as necessary . Review of the resident ' s hospital discharge instructions that the facility received upon admitted d 3/26/2015 documented, [MEDICATION NAME] (generic [MEDICATION NAME]) 3 milligrams (mg) given 3/25/2015, next dose due on 3/26/2015, INR tonight . Review of the Physician ' s admission orders [REDACTED]. The Physician order did not contain the initial discharge instructions from the hospital for an INR tonight , Admission PT/INR or weekly monitoring for PT/INR as facility policy and procedure documented. Review of the physician ' s monthly progress notes dated from 3/26/2015 through 5/11/2015 did not include documentation regarding the status of resident's [MEDICATION NAME] therapy or the need for continuation. Review of the facility ' s policy and procedure for transcription of Physician Orders, that was updated 5/22/2015, documented, Nurses schedule lab draw should be included in the physician order and transcribed to the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. There was no documented evidence in the medical record or in the binders that routine or interim orders for monitoring [MEDICATION NAME] therapy was addressed or documented by the facility's medical staff from 3/26/2015 through 5/11/2015 (6 Weeks). Review of nurse ' s note documented: -05/08/2015 at 8:33 PM resident complained of not feeling well. -5/11/2015 at 8:15 PM, Resident c/o nausea this am with small amount of emesis noted, undigested food. - 8:54 PM, noted brown emesis, undigested food several times this shift, MD made aware and ordered [MEDICATION NAME] . -9:14 PM, Resident was transferred to Vassar Brothers Medical Center . Review of resident ' s emergency room hospital record dated 05/11/2015 documented, resident has Nausea and vomiting - patient with episodes of nausea and vomiting for a week, worse yesterday, still vomiting. The hospital lab report revealed resident ' s PT/INR, PT- 50.1 (high) (normal PT range 10-13 seconds), INR - 4.4 (high), (normal INR 2.0-3.0). Resident was returned to facility from hospital on [DATE], with the primary [DIAGNOSES REDACTED]. On 5/20/2015 at 10:35 AM the facility Director of Nursing was interviewed and stated, The resident was admitted on [DATE] and we discovered this problem on 05/11/2015. We did not check resident's PT/INR before that. There is a policy for residents on anticoagulants but the staff was not compliant with the policy. I have already revised the policy with the Medical Director the other day. There is nothing more to say the nurses did not follow facility policy, for [MEDICATION NAME] therapy. On 05/21/2015, at 11 AM Licensed Practical Nurse (LPN) #1 was interviewed and stated, I entered the admission orders [REDACTED]. On the discharge order from the hospital there was a handwritten order for INR tonight. I have never seen it written on the order and I don ' t think that it was there. All orders I ' ve ever seen from the hospital are typed not written in. There are not enough RNs here to do admissions, and everything they need to do. I did not call the doctor to clarify the orders, I don ' t know who did it. The admission orders [REDACTED]. She further stated, I never knew the policy on [MEDICATION NAME] and did not know about a binder where [MEDICATION NAME] therapy is tracked. I did have an in-service the other day, but never before that had I never known about it. On 05/21/2015, at 11:15 AM LPN # 2 was interviewed and stated, I know why you are here. I haven ' t done many medication passes, it is very hard to get done with one nurse on the unit. I had an in-service about a week ago about [MEDICATION NAME] monitoring. She stated that when she calls the physician with lab results and she follows through by doing whatever they order. She stated that there is no consistency, nurses come and go, administrators and directors of nurses come and go it ' s a difficult place to work, and has for years been a problem in this place. I never knew about a binder to track residents on [MEDICATION NAME] but I do now. On 05/21/2015, at 11:35 AM LPN # 3 was interviewed and stated, I don ' t pick up physician orders, if I don ' t hear from the doctor. The policy is that the RN does the admission assessments. I will listen on speaker phone while the RN goes over the orders with the physician and type the orders into the computer at that time. Every place I ever worked PT/INR labs were completed every 2-3 weeks but here we never had a monitoring system for checking PT/INR labs. I never knew that there was a log or binder kept for tracking residents on [MEDICATION NAME]. On 05/21/2015, at 11:50 AM the Medical Director was interviewed who stated that he is the Attending Physician for the resident. He further stated, This incident was an oversight due to not having consistency with staffing, and incompetent nurses. It is very difficult to work with an incompetent team, and I mean nurses. They will call you at 1:00AM to tell you about lab results, which they are not even sure about. The Acting DON told me this morning that a nurse called one of my Attending Physicians at 1:00 a.m. last night and told him about a PT/INR result which he already addressed few days ago. The physician thinking that it was a new lab result, ordered Vitamin K. On 05/21/2015, at 12:30 PM, Unit manager Registered Nurse #1 was interviewed and stated, I don ' t recall anything about this resident. I believe I started the admission but I never called the physician to verify the admission orders [REDACTED]. I would assume that it ' s the responsibility of the physician to monitor the PT/INR levels. I never knew the policy for monitoring PT/INR ' s or that there was binder for tracking patients on [MEDICATION NAME]. On 05/21/2015, at 9:00 PM, LPN # 4 was interviewed and stated, I have worked in many facilities and all had very good systems to monitor resident on anticoagulation, but not here. This facility did not have a policy or protocol that I was taught or knew of. I think it was only recently that the director of nursing wrote a policy and now she is rushing to get everyone educated. I think the new policy says for new admissions the PT/INR is supposed to be done once a week. I am the one who transferred the resident to the hospital. He was vomiting coffee ground material. Then when I heard that resident had [MEDICATION NAME] toxicity I told the Assistant Director of nursing (ADON) that we better do an audit on all on residents who are on [MEDICATION NAME]. I also told her that the hospital might call the Department of Health on us because of this. Education is really lacking here and the work on the evening shift is really too much for one nurse to do. I am always working alone on first floor, it is a very heavy floor for medication pass and treatments. A review of the pharmaceutical consulting service agreement from Pharmacon (a pharmacist consultant company) hired by facility to conduct Medical Record Review (MRR) documents that the consultant pharmacist reviews the drug regimen for recommendations of each resident monthly and distributes reports of irregularities to the attending physician, director of nursing, and medical director. Review of the MMR pharmacy consultant completed in April 2015 dated 4/14/2015 documented, No irregularities noted. A telephone interview was conducted with the pharmacist on 5/22/2015 at 11:55 AM concerning the monthly pharmacy reviews. He stated that he reviews medications and laboratory results, interactions, dosages and different treatments for residents on a monthly basis. He stated he did complete resident review on 04/14/2015 which documented, No irregularities noted. He stated his review includes a review of laboratory testing. The pharmacist said for this resident he did review residents PT/INR values, and did not see a problem because he thought monitoring was in place. In an interview with the resident on 5/23/2015 he stated that he did not recall that he had [MEDICATION NAME] toxicity. He stated that he had thought that he just had the flu or something. Resident states that he was pretty sick and can remember vomiting for a few days before they sent him out to the hospital. Resident # 2 is a [AGE] year-old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. The most current MDS dated [DATE] documented residents BIMS score of 15 which indicated resident was cognitively intact. Review of the physician orders dated 2/3/2015 documented, [MEDICATION NAME] 4 mg, one tablet by oral route once daily at bed time. PT/INR, one time order on 02/09/2015. There were no further orders written by the physician to obtain PT/INR values or changes in resident's [MEDICATION NAME] therapy after 2/9/2015. Review of the resident's laboratory test drawn on 02/09/2015 revealed the resident had a high value of PT 33.9 (normal reference range 10 - 13 sec), and INR 2.94 which is within normal limit (WNL). 02/20/2015, PT- 15.6 (High), INR- 1.34 (low), (normal INR 2.0-3.0) On 05/16/2015 PT was greater than 135.0, which was confirmed by a repeat analysis, INR value could not be calculated On 05/18/2015 PT- 32.1 (High), INR- 2.79. Review of Nurses note documented: On 05/15/2015 at 10:59 PM resident had some bruises on both antecubital spaces from PT/INR lab draws. Supervisor was made aware who also noted bruising on her right lateral thigh. Resident denied being injured. On 5/20/2015 at 2:48 (a late entry for 5/15/2015 11PM) note by the supervisor documented resident had some bruises on both antecubital spaces and a bruise on her right lateral leg. Resident has intermittent confusion, and doesn ' t remember being injured. On 5/16/2015 at 8:01 the labs were reviewed with physician and a new orders to give 10 mg. of vitamin K (antidote for [MEDICATION NAME] excess or overdose) hold [MEDICATION NAME] and recheck level tomorrow was ordered. On 5/16/2015 at 8:51 a call was received from Bio Reference (laboratory who draws/tests blood work) regarding resident PT level of > (greater than) 135. Physician was already notified this morning and ordered [MEDICATION NAME] (Vitamin K) 10 mg. stat (immediately). No signs of abnormal bleeding were noted. On 5/16/2015 at 10:51 PM nursing noted with bruising on her right toe, right leg and arm and blood in her stool. Her PT/INR was drawn on 05/15/2015 at 6 AM but had to be redrawn. Specimen was recollected on 05/15/2015 at 12 AM, results received at on 5/16/2015 at 8:15 PM with a PT value of greater than 135, Resident had previously received Vitamin K 10mg injection. Physician recommended to send resident out for evaluation to hospital. On 05/20/2015, 10:50 AM the ADON was interviewed and stated, After realizing the problem we did an audit and found out that we were tracking the PT/INR for some residents and others we were not. We have 8 residents on [MEDICATION NAME] therapy. Out of those 8 only 3 resident's PT/INR level were being monitored. We found another problem with [MEDICATION NAME] this weekend. One resident who is on [MEDICATION NAME] therapy was found with bruises on her body. When I checked her medical record it was noticed that her last PT/INR was done on 02/09/2015. When she was assessed to have blood in her stool the physician was called and given Vitamin K. She was then transferred to hospital. Do you think I should report it to Department of Health? During the investigation process on 5/22/2015 it was found that for 10 residents reviewed receiving [MEDICATION NAME] it was for 5 of 10 residents receiving [MEDICATION NAME] therapy 5 residents were not being monitored. Review of the residents Medical Record Review (MMR), a drug regimen review conducted by a pharmacist consultant revealed that pharmacist documented No irregularities noted on 02/17/2015, 03/17/2015, 04/14/2015, and 05/15/2015. 05/27/2015, 12:40 PM, attending Physician # 1 (resident # 2 ' s physician) was interviewed and stated, What can I say? I don ' t know what to tell you about this. I was supposed to monitor the PT/INR level but I didn ' t do it. The practice is when they call me with the lab report I give them the directions. We don ' t usually write standing orders for PT/INR ' s. I know the nurse called me and I told her to give Vitamin K for the lab report of 5/16/2015 and told them to redraw the next day . 415.12

Based on medical record review and staff interviews, the facility failed to ensure that reviews of the residents drug regimen was completed by by the pharmacist. Specifically, the consultant pharmacist failed to detect during comprehensive monthly medication regime review (MMR) that physicians did not order critical laboratory tests for 5 residents (Resident #1, #2, #7, #8, and #10) of 10 residents reviewed who were receiving Coumadin (a blood thinning medication) to prevent adverse complications. Resident #1 developed Coumadin toxicity and Resident #2 developed bleeding related to Coumadin therapy, which required acute care hospitalization for both residents. This resulted in actual harm to Resident #1 and #2 that is Immediate Jeopardy and the potential for serious harm to the health and safety of residents currently receiving Coumadin therapy. This was evidenced by, but not limited to the following: Cross References: F 309-Quality of Care, - scope and severity - L F 281- Services Meet Professional Standards of Care, - scope and severity - L F 501-Medial Director, - scope and severity- L F 490- Administration- scope and severity-L F 386-Physician Services- scope and severity-L Resident # 1 is a [AGE] year-old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) a resident assessment tool dated 4/23/2015 documented residents Brief Interview for Mental Status (BIMS) score of 15 which indicates resident is cognitively intact. Review of the Physician admission orders [REDACTED]. Review of the physicians monthly progress notes from 3/26/2015 through 5/11/2015 did not include documentation regarding the status of residents Coumadin therapy or indications for its continued use. The Medication Administration Record [REDACTED]. Review of nurse ' s note reveal the following : -05/08/2015 at 8:30 PM, resident complained of not feeling well, -5/11/2015 at 8:15 PM, Resident c/o nausea this am with small amount of emesis noted, -8:54 PM , noted brown emesis, undigested food several times this shift, MD made aware and ordered Zofran , -9:14 PM, Resident was transferred to the hospital . Review of resident ' s emergency room hospital record dated 05/11/2015 documented resident has Nausea and vomiting - patient with episodes of nausea and vomiting for a week, worse yesterday, still vomiting. The hospital lab report revealed resident ' s PT/INR INR - 4.4 (high), (normal INR 2.0-3.0), and PT- 50.1 (high) (normal PT range 10-13 seconds). Resident was returned to facility from hospital on [DATE], with the primary [DIAGNOSES REDACTED]. A review of the pharmaceutical consulting service agreement from Pharmacon (a pharmacist consultant company) hired by facility to conduct Medical Record Review (MRR) documents that the consultant pharmacist reviews the drug regimen for recommendations of each resident monthly and distributes reports of irregularities to the attending physician, director of nursing, and medical director. Review of the pharmacy consultants MMR dated 4/14/2015 documented, No irregularities noted. A telephone interview with the consulting pharmacist conducted on 5/22/2015 at 11:55AM concerning monthly pharmacy reviews for this resident which he completed on 04/14/2015 documenting, No irregularities noted. He states his review includes a review of medications the resident is receiving and corresponding laboratory testing. The pharmacist said for this resident he did review the resident's PT/INR values, and did not see a problem because he thought monitoring was in place. Resident # 2 is a [AGE] year-old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. The most current MDS dated [DATE] documented residents BIMS score of 15 which indicated resident was cognitively intact. Review of the physician orders [REDACTED]. PT/INR, one time order on 02/09/2015. There were no further orders to obtain PT/INR values or changes in residents Coumadin therapy doses. Review of the resident ' s laboratory test reveals: -On 2/9/2015, PT was 33.9 (high) (normal reference range 10 - 13 sec), INR 2.94 within normal limit (WNL). -On 02/20/2015, PT- 15.6 (High), INR- 1.34 (low), (normal INR 2.0-3.0). -On 05/16/2015 PT was greater than 135.0, which was confirmed by a repeat analysis, INR value could not be calculated -On 05/18/2015 PT- 32.1 (High), INR- 2.79. Review of Nurses note documented: On 05/15/2015 at 10:59 PM resident had some bruises on both antecubital spaces from PT/INR lab draws. Supervisor was made aware who also noted bruising on her right lateral thigh. Resident denied being injured. On 5/20/2015 at 2:48 (a late entry for 5/15/2015 11PM) note by the supervisor documented resident had some bruises on both antecubital spaces and a bruise on her right lateral leg. Resident has intermittent confusion, and doesn ' t remember being injured. On 5/16/2015 at 8:01 the labs were reviewed with physician and a new orders to give 10 mg. of vitamin K (antidote for Coumadin excess or overdose) hold Coumadin and recheck level tomorrow was ordered. On 5/16/2015 at 8:51 a call was received from Bio Reference (laboratory who draws/tests blood work) regarding resident PT level of > (greater than) 135. Physician was already notified this morning and ordered Mephyton (Vitamin K) 10 mg. stat (immediately). No signs of abnormal bleeding were noted. On 5/16/2015 at 10:51 PM nursing noted with bruising on her right toe, right leg and arm and blood in her stool. Her PT/INR was drawn on 05/15/2015 at 6 AM but had to be redrawn. Specimen was recollected on 05/15/2015 at 12 AM, results received at on 5/16/2015 at 8:15 PM with a PT value of greater than 135, Resident had previously received Vitamin K 10mg injection. Physician recommended to send resident out for evaluation to hospital. A review of Resident #2 monthly MRR written by the pharmacist consultant documented, No irregularities noted on 02/17/2015, 03/17/2015, 04/14/2015 and 05/15/2015. The pharmacy review documented no irregularities found when there were no PT/INR labs being drawn and furthermore documented there were no irregularities found when residents PT was elevated on 2/9/2015 to 33.9 (high) or on 2/20/2015 when PT was 15.6 (High), INR- 1.34 (low) there were no recommendations made to the medical staff by the pharmacist consultant documented. The consulting pharmacist was interviewed on via telephone on 5/22/2015 at 11:55 AM concerning monthly pharmacy reviews for this resident which he completed on 2/17/2015, 3/17/2015, 4/14/2014 and 5/15/2015 documenting, No irregularities noted. He states his review includes a review of medications the resident is receiving and laboratory testing. The pharmacist said for residents that are stable he does not always make recommendations for dosage. He stated he did not recall if he looked at the labs before writing no irregularities. In an interview with attending physician #1 on 05/27/2015, at 10:00 AM he stated that he did not receive notice from the pharmacist that the labs for resident had not been completed. He further stated, What can I say? I don ' t know what to tell you about this. I was supposed to monitor the PT/INR level but I didn ' t do it. The practice is when they call me with the lab report I give them the directions. We don ' t usually write standing orders for PT/INR ' s. I know the nurse called me and I told her to give Vitamin K for the lab report of 5/16/2015 and told them to redraw the next day . In a meeting at 10:30 AM on 5/23/2015 with the Administrator, Acting Director of Nursing all stated that they had not received any notice from the pharmacist consultant that there were irregularities or missed PT/INR labs for resident #1, #2,#7, #8, 10. 415.18(c)(2)

Based on interviews and record review conducted during an abbreviated survey, it was determined that the facility failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility Administrator failed to ensure that residents on Anticoagulant therapy ([MEDICATION NAME] a blood thinning medication) obtained the necessary laboratory testing [MEDICATION NAME] Time and International Normalized Ratio (PT/INR), (a test that monitors the effectiveness of the anticoagulant therapy), for 5 (Resident #1, #2, #7, #8, and #10) of 10 residents receiving [MEDICATION NAME] to prevent adverse complications. Resident #1 developed [MEDICATION NAME] toxicity and Resident #2 developed bleeding both related to [MEDICATION NAME] therapy, which required acute care hospitalization for both residents. This resulted in actual harm to Resident #1 and #2 that is Immediate Jeopardy and the potential for serious harm to the health and safety of residents currently receiving [MEDICATION NAME] therapy. Complaint ID Number: NY 414, NY 797 This was evidenced by, but not limited to the following: Cross References: F 281- Services Meet Professional Standards of Care, - scope and severity -L F 428- Pharmacy Services, - scope and severity -L F 501- Medical Director, - scope and severity -L F 490- Administration- scope and severity -L F 386-Physician Services- scope and severity -L During an abbreviated survey deficiencies for Professional Standards of Practice (F 281),Quality of Care (F309), Physician Services (F 386), Drug regime Review (F 428) and Medical Director (F 501), were cited at an Immediate Jeopardy level. The Administrator was interviewed on 3/21/2015 at 1:00 PM and stated that she became aware of the problem of monitoring, and follow- up with PT/INR laboratory tests at the facility after the first resident was sent to the hospital. She stated that she thought nursing was responsible for building a schedule in the Electronic Medical Record (EMR) when picking up physician orders, she further stated that she is new to the position was not aware that the medical staff did not note the absence of PT/INR laboratory test for some of the resident receiving [MEDICATION NAME] or have care plans with interventions in place for those residents until now. 415.26

Based on staff interviews and medical record review the facility failed to provide care and services in accordance with the standards of professional nursing practice. Specifically, the nursing staff failed to obtain physician ' s orders to monitor critical laboratory tests [MEDICATION NAME] Time and International Normalized Ratio (PT/INR), (a test that monitors the effectiveness of the anticoagulant therapy) for 5 (Resident #1, #2, #7, #8, and #10) of 10 residents reviewed who were receiving anticoagulant medication. Resident #1 developed [MEDICATION NAME] toxicity and Resident #2 developed bleeding related to [MEDICATION NAME] therapy, which required acute care hospitalization for both residents. This resulted in actual harm to Resident #1 and #2 that is Immediate Jeopardy and the potential for serious harm to resident health and safety for residents who receive [MEDICATION NAME] therapy. Complaint ID Number: NY 414, NY 797 This was evidenced by, but not limited to the following: Cross References: F 309-Quality of Care, - scope and severity - L F 428- Pharmacy Services, - scope and severity -L F 501-Medial Director, - scope and severity -L F 490- Administration- scope and severity- L F 386-Physician Services- scope and severity- L Resident # 1 is a [AGE] year-old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) a resident assessment tool dated 4/23/2015 documented residents Brief Interview for Mental Status (BIMS) score of 15 which indicates resident is cognitively intact. Review of the resident's hospital discharge instructions that the facility received upon admitted d 3/26/2015 documented, [MEDICATION NAME] (generic [MEDICATION NAME]) 3 milligrams (mg) given 3/25/2015, next dose due on 3/26/2015, INR tonight . Review of a facility investigation dated 5/13/2015 documented that the resident was transferred to the emergency roiagnom on [DATE] for evaluation of nausea and vomiting after being treated with [MEDICATION NAME] (medication to prevent nausea and vomiting) on 5/10/2015. The resident was readmitted back to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the facility policy and procedure for Anticoagulant Therapy dated 5/5/2009 and revised 5/13/2015 documented, Physician will evaluate the need to continue anti coagulation therapy for all new admissions and readmissions that are prescribed [MEDICATION NAME] and Physician orders INR levels for all new and re-admissions to be done on the next lab day post admission to the facility and weekly thereafter. Licensed Nurse will log results into Sigma Care (electronic medical record) and drop down box on the date the PT/INR is ordered and again once the orders are obtained. Each unit is to maintain anticoagulant binder which should be checked daily by the unit manager/RN Supervisor (Registered Nurse) (on off shifts) and update as necessary . Review of the Physicians admission orders [REDACTED]. The Physician orders did not contain the initial discharge instructions from the hospital for an INR tonight or orders to obtain PT/INR laboratory testing from 3/26/2015 through 5/11/2015. A review of the laboratory section of the resident's electronic medical record (EMR) and residents Treat Administration Record (TAR) (a record that nurses initial when treatment is performed and completed) revealed there was no PT/INR drawn from 3/26/2015 through 5/11/2015. (6 weeks) A review of the anticoagulant binder on the unit did not include documentation that a requisition for PT/INR labs had been completed by nursing staff from 3/26/2015 through 5/11/2015. The Medication Administration Record [REDACTED]. of [MEDICATION NAME] was given from 3/26/2015 through 5/11/2015 without monitoring the residents PT/INR values. A review of nurses notes dated 3/26/2015 through 5/11/2015 did not contain documentation that routine or interim orders for monitoring of resident [MEDICATION NAME] therapy was addressed by any of the facility ' s nursing staff from 3/26/2015 through 5/11/2015. Review of nurses noted dated 05/08/2015 at 8:30 PM documented that resident complained of not feeling well. On 5/11/2015 at 8:15 PM, Resident c/o nausea this am with small amount of emesis noted at 8:54 PM the note documented noted brown emesis, undigested food several times this shift, MD made aware and ordered [MEDICATION NAME] . At 9:14 PM, Resident was transferred to Vassar Brothers Medical Center . Review of resident ' s emergency room hospital record dated 05/11/2015 documented resident has Nausea and vomiting - patient with episodes of nausea and vomiting for a week, worse yesterday, still vomiting. The hospital lab report revealed resident ' s PT/INR INR - 4.4 (high), (normal INR 2.0-3.0), and PT- 50.1 (high) (normal PT range 10-13 seconds). Resident was returned to facility from hospital on [DATE], with the primary [DIAGNOSES REDACTED]. Review of the resident ' s Comprehensive care plans (CCP) dated 3/26/2015 had no documented evidence that the resident was on [MEDICATION NAME] or interventions which should have included monitoring laboratory work (PT/INR) to evaluate medication based on laboratory reports. There was no documented evidence in nurse ' s notes, treatment records or evaluation of care plan that PT/INR laboratory testing was obtained or monitored from 3/26/2015 through 5/11/2015. Resident # 2 is a [AGE] year-old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. The most current MDS dated [DATE] documented residents BIMS score of 15 which indicated resident was cognitively intact. Review of the physician orders dated 2/3/2015 documented, [MEDICATION NAME] 4 mg, one tablet by oral route once daily at bed time. PT/INR, one time order on 02/09/2015. There were no further orders to obtain PT/INR values or changes in resident's [MEDICATION NAME] therapy doses. Review of the resident's laboratory test that was received on 2/9/2015 for a PT/INR drawn on 02/09/2015 revealed residents value for PT was 33.9 (high) (normal reference range 10 - 13 sec), INR 2.94 within normal limit (WNL). 02/20/2015, PT- 15.6 (High), INR- 1.34 (low), (normal INR 2.0-3.0) On 05/16/2015 PT was greater than 135.0, which was confirmed by a repeat analysis, INR value could not be calculated On 05/18/2015 PT- 32.1 (High), INR- 2.79. Review of the resident ' s CCP ' s did not have documentation that the resident was on [MEDICATION NAME] or interventions for monitoring laboratory work (PT/INR) to evaluate medication based on laboratory reports. There was no documented evidence in nurse ' s notes, treatment records or care plan that PT/INR laboratory testing was obtained or monitored from 2/9/2015 through 5/15/2015. Review of Nurses note documented: On 05/15/2015 at 10:59 PM resident had some bruises on both antecubital spaces from PT/INR lab draws. Supervisor was made aware who also noted bruising on her right lateral thigh. Resident denied being injured. On 5/20/2015 at 2:48 (a late entry for 5/15/2015 11PM) note by the supervisor documented resident had some bruises on both antecubital spaces and a bruise on her right lateral leg. Resident has intermittent confusion, and doesn ' t remember being injured. On 5/16/2015 at 8:01 the labs were reviewed with physician and a new orders to give 10 mg. of vitamin K (antidote for [MEDICATION NAME] excess or overdose) hold [MEDICATION NAME] and recheck level tomorrow was ordered. On 5/16/2015 at 8:51 a call was received from Bio Reference (laboratory who draws/tests blood work) regarding resident PT level of > (greater than) 135. Physician was already notified this morning and ordered [MEDICATION NAME] (Vitamin K) 10 mg. stat (immediately). No signs of abnormal bleeding were noted. On 5/16/2015 at 10:51 PM nursing noted with bruising on her right toe, right leg and arm and blood in her stool. Her PT/INR was drawn on 05/15/2015 at 6 AM but had to be redrawn. Specimen was recollected on 05/15/2015 at 12 AM, results received at on 5/16/2015 at 8:15 PM with a PT value of greater than 135, Resident had previously received Vitamin K 10mg injection. Physician recommended to send resident out for evaluation to hospital. On 05/16/2015, at 10:00 PM the nurse ' s note documented, Noted blood in stool. Resident was transferred to the hospital where her PT/INR and revealed an INR result of 8 (normal INR 2.0-3.0). Interviews conducted with nursing staff from 05/21/2015, through 5/23/2015 identified that 9 of 9 Licensed Practical Nurses (LPN) stated that they did not check if resident's had regular PT/INR laboratory tests completed before administering anticoagulants. 8 of the 9 LPN ' s stated that they knew nothing about the anticoagulant binder located on the units to monitor resident PT/INR laboratory reports. On 5/20/2015 at 10:35 AM the facility Director of Nursing was interviewed and stated, We were not checking the PT/INR on some of the residents, we are not compliant with our policy for PT/INR. 415.11(c)(3)(i)

Based on staff interviews and record reviews the facility medical director failed to ensure that resident care policies were implemented and coordinated in regards to orderinh and monitoring the lab values for residents on Anticoagulant therpay. Specifically, the medical director failed to provide oversight for 5 residents (Resident #1, #2, #7, #8, and #10) of 10 residents reviewed who continued to receive daily [MEDICATION NAME] without having PT/INR ([MEDICATION NAME] Time/International Normalized Ration) testing to prevent adverse complications. Resident #1 developed [MEDICATION NAME] toxicity and Resident #2 developed bleeding related to [MEDICATION NAME] therapy, which required acute care hospitalization for both residents This resulted in actual harm to Resident #1 and #2 that is Immediate Jeopardy and the potential for serious harm to the health and safety of residents currently receiving [MEDICATION NAME] therapy that is Immediate Jeopardy. Complaint ID Number: NY 414, NY 797 This was evidenced by, but not limited to the following: Cross References: F 309-Quality of Care, - scope and severity - L F 281- Services Meet Professional Standards of Care, - scope and severity - L F 490- Administration- scope and severity-L F 386-Physician Services- scope and severity-L F 428- Pharmacy Services, - scope and severity-L Findings are: During the abbreviated survey deficiencies for Professional Standards of Practice (F 281),Quality of Care (F309), Physician Services (F 386), Drug regime Review (F 428), Administration (F 490) were cited at an Immediate Jeopardy level. On 05/21/2015, at 11:50 AM the Medical Director was interviewed and stated that he is the Attending Physician for resident and stated, This was an oversight due to not having consistency with staffing, and incompetent nurses. It is very difficult to work with an incompetent team, and I mean nurses. Medical director stated he was not familiar with the policy and procedures of the facility for monitoring PT/INR, If a patient is stable they don ' t need it as often. The DON just revised the policy and I signed it last night I believe . 415.15(a)

Based on medical record review and staff interviews, the facility failed to ensure that residents on anticoagulant therapy were adequately monitored by laboratory testing to determine the effectiveness of the medication and prevent complications related to Anticoagulant therapy. Specifically, physicians failed to order critical laboratory test for 5 (Resident #1, #2, #7, #8, and #10) of 10 residents reviewed who were receiving anticoagulant therapy. Resident #1 developed [MEDICATION NAME] toxicity and Resident #2 developed bleeding related to [MEDICATION NAME] therapy, which required acute care hospitalization for both residents. This resulted in actual harm to Resident #1 and #2 that is Immediate Jeopardy and the potential for serious harm to the health and safety of residents currently receiving [MEDICATION NAME] therapy. Complaint ID Number: NY 414, NY 797 This was evidenced by, but not limited to the following: Cross References: F 309-Quality of Care, - scope and severity - L F 281- Services Meet Professional Standards of Care, - scope and severity - L F 428- Pharmacy Services, - scope and severity-L F 501- Medical Director, - scope and severity-L F 490- Administration- scope and severity-L Resident # 1 is a [AGE] year-old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) a resident assessment tool dated 4/23/2015 documented residents Brief Interview for Mental Status (BIMS) score of 15 which indicates resident is cognitively intact. Resident ' s medical record documented that resident was transferred to the emergency room (ER) on 5/11/2015 at 9:12 PM for evaluation of nausea and vomiting of brown emesis. The residents laboratory result revealed a PT/INR INR - 4.4 (high), (normal INR 2.0-3.0), and PT- 50.1 (high) (normal PT range 10-13 seconds). Resident was diagnosed in the ER with the primary [DIAGNOSES REDACTED]. Review of the Physicians admission orders [REDACTED]. A review of the Medication Administration Record [REDACTED]. Review of nurses notes dated 05/08/2015 at 8:30 PM resident complained of not feeling well, on 5/11/2015 at 8:15 PM, Resident c/o nausea this am with small amount of emesis noted at 8:54 PM the note documented noted brown emesis, undigested food several times this shift, MD made aware and ordered [MEDICATION NAME] . At 9:14 PM, Resident was transferred to Vassar Brothers Medical Center . Review of resident ' s emergency room hospital record dated 05/11/2015 documented resident has Nausea and vomiting - patient with episodes of nausea and vomiting for a week, worse yesterday, still vomiting. The hospital lab report revealed resident ' s PT/INR INR - 4.4 (high), (normal INR 2.0-3.0), and PT- 50.1 (high) (normal PT range 10-13 seconds). Resident was returned to facility from hospital on [DATE], with the primary [DIAGNOSES REDACTED]. Review of the pharmacy consultants Drug Regimen Review dated 4/14/2015 documented, No irregularities noted. On 05/21/2015, at 11:50 AM the Medical Director was interviewed and stated that he is the Attending Physician for resident #1. He further stated, This was an oversight due to not having consistency with staffing, and incompetent nurses. It is very difficult to work with an incompetent team, and I mean nurses. Medical director stated he was not familiar with the policy and procedures of the facility for monitoring PT/INR, If a patient is stable they don ' t need it as often. The DON just revised the policy and I signed it last night I believe . Resident # 2 is a [AGE] year-old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. The most current MDS dated [DATE] documented residents BIMS score of 15 which indicated resident was cognitively intact. Review of the physician orders reveal: -On 2/3/2015 documented, [MEDICATION NAME] 4 mg, one tablet by oral route once daily at bed time. PT/INR, one time order on 02/09/2015. There were no further orders to obtain PT/INR values or changes in residents [MEDICATION NAME] therapy doses. -On 02/03/2015 MD Order: [MEDICATION NAME] 2 mg tablet, one tablet by oral route once daily at bedtime with 2.5 mg to equal 4.5 mg. -On 02/03/2015 MD Order: [MEDICATION NAME] 4 mg, one tablet by oral route once daily at bed time. - On 02/03/2015 MD Order: PT/INR, one time order for 02/09/2015. Review of the residents laboratory test are as follows: -2/9/2015, PT 33.9 (high) (normal reference range 10 - 13 sec), INR 2.94 within normal limit (WNL). -02/20/2015, PT- 15.6 (High), INR- 1.34 (low), (normal INR 2.0-3.0) - 05/16/2015 PT was greater than 135.0, which was confirmed by a repeat analysis, INR value could not be calculated - 05/18/2015 PT- 32.1 (High), INR- 2.79. Review of Nurses note documented: On 05/15/2015 at 10:59 PM resident had some bruises on both antecubital spaces from PT/INR lab draws. Supervisor was made aware who also noted bruising on her right lateral thigh. Resident denied being injured. On 5/20/2015 at 2:48 (a late entry for 5/15/2015 11PM) note by the supervisor documented resident had some bruises on both antecubital spaces and a bruise on her right lateral leg. Resident has intermittent confusion, and doesn ' t remember being injured. On 5/16/2015 at 8:01 the labs were reviewed with physician and a new orders to give 10 mg. of vitamin K (antidote for [MEDICATION NAME] excess or overdose) hold [MEDICATION NAME] and recheck level tomorrow was ordered. On 5/16/2015 at 8:51 a call was received from Bio Reference (laboratory who draws/tests blood work) regarding resident PT level of > (greater than) 135. Physician was already notified this morning and ordered [MEDICATION NAME] (Vitamin K) 10 mg. stat (immediately). No signs of abnormal bleeding were noted. On 5/16/2015 at 10:51 PM nursing noted with bruising on her right toe, right leg and arm and blood in her stool. Her PT/INR was drawn on 05/15/2015 at 6 AM but had to be redrawn. Specimen was recollected on 05/15/2015 at 12 AM, results received at on 5/16/2015 at 8:15 PM with a PT value of greater than 135, Resident had previously received Vitamin K 10mg injection. Physician recommended to send resident out for evaluation to hospital. On 5/27/2015, 12:40 PM, attending Physician # 1 (resident # 2 ' s physician) was interviewed and stated, What can I say? I don ' t know what to tell you about this. I was supposed to monitor the PT/INR level but I didn ' t do it. The practice is when they call me with the lab report I give them the directions. We don ' t usually write standing orders for PT/INR ' s. I know the nurse called me and I told her to give Vitamin K for the lab report of 5/16/2015 and told them to redraw the next day . 415.15(b)(2)(ii)

Based on staff interviews and record reviews during an abbreviated survey, the facility did not ensure that each resident received the necessary care and services to attain and maintain the highest practicable physical, mental and psychological well-being in accordance with standards of practice and the facility's policy and procedure for resident accident/incident reporting. Specifically, a Licensed Practical Nurse (LPN) supervisor assessed a resident (assessment is not in the LPN's scope of practice) after the resident fell , then lifted him from the floor to bed with the charge (LPN) and did not follow the facility policy to send the resident to an acute care facility for evaluation of possible injury. This was evident for one of three sampled residents (Resident #1), which resulted in actual harm that is not immediate jeopardy. Complaint Investigation: NY 016 The finding is: Resident #1 was a [AGE] year old male who was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 Patient Review Instrument (PRI) dated [DATE], documented the resident as requiring assistance with all activities of daily living and assistance of a two person transfer. Review of the facility's Accident/Incident report policy revised ,[DATE] and ,[DATE] under PROCEDURE #2 documents, " It is the responsibility of the Registered Nurse to examine and administer first aide as necessary and determine whether or not the resident may be moved. If RN is not on site, the resident is to be sent to acute care for evaluation of possible injury. " Review of the facility's Incident /Accident report dated [DATE] at 9:30 P.M., completed by staff (LPN) supervisor, under summary statement of event documented, " bed alarm sounding, found resident flailing around on floor in bowel movement and possible [MEDICAL CONDITION], fell out of bed. " It further documented that the Resident had injuries of the right temple, scratches upper mid back, abrasion right outer knee, and red bilateral hips, possible start of ecchymosis. The (LPN) supervisor described the resident as being, " disoriented and questionable [MEDICAL CONDITION]. " The CNA section of incident report dated [DATE] documented that the CNA toileted and changed the resident at 9P.M. The charge (LPN) written statement section of incident report dated [DATE] documented that she went to Resident's room at 9 P.M. to give medications and found the Resident on the floor flailing his arms and legs about, covered in feces. She then called the (LPN) supervisor to observe resident and assess his skin tears. It further documented that she and (LPN) supervisor transferred resident back to bed, and that the resident was unresponsive to his name with eyes rolling in his head. The nurse's note dated [DATE] at 11:17 P.M by (LPN) supervisor documented; "Nursing assessment shows no apparent injury. Transferred, questionable [MEDICAL CONDITION] activity, unresponsive to staff stimuli, resident cleaned up, VS [DATE] color poor, gray SPO2 50% on room air unable to palpate blood pressure, 02 applied at 4L/M, family and MD notified, MD orders transfer to hospital, family notified." Review of the Emergency Medical Service report dated [DATE] documented a call was received from the facility at 11:11PM, and arrival at 11:20. It further documented that upon arrival, the resident was unresponsive with agonal respirations. The Resident in care of skilled nursing facility, but there was no staff present with the resident. Respirations 4, pulse rate 36, B/P unobtainable. Resident with valid DNR, contacted hospital and resident transported to hospital. Review of hospital record dated [DATE] documented the resident expired upon arrival to ER at 12:11AM. Review of the facility daily staffing report for [DATE] documented that the supervisor for the ,[DATE] PM shift was a LPN, and the RN was on duty for the ,[DATE] shift. The CNA who was assigned to care for Resident #1 on [DATE] was interviewed on [DATE] at 3:30PM. She stated that the charge LPN called her into the room about 9:15 PM to help clean the resident who was covered in feces. She stated that the (LPN) supervisor and charge (LPN) lifted the resident back to bed so she could clean him up. While cleaning him up she noted the laceration to his head and redness on his hip and reported this to the (LPN) supervisor who looked at the areas. She stated that she checked the resident twice and both times he was sleeping until the (RN) came on duty at 11PM. She stated that when the (RN) arrived she sent the resident out to the hospital. During an interview with the Administrator on [DATE] at 10AM, she stated that she remembered learning about this incident in morning report after it occurred. She stated that when the (RN) came on duty at 11PM the Resident was sent out to the hospital. She stated, " I did not report this incident to the NYS DOH because I wrote disciplinary actions for the two LPNs for not following policy, and did not think that that abuse, neglect, mistreatment occurred. Since this interview, the disciplinary actions have not been found or presented to the DOH. The LPN supervisor was interviewed at 12:50 PM on [DATE] and stated, " I did not really lift the resident because he had a low bed, but rather slid him back to bed." She stated that the charge (LPN) found the resident on the floor, so it was not a witnessed fall. She stated, " I was the supervisor and completed the resident's assessment after he was put back to bed, that was my responsibility as a supervisor." She further stated, " I did not call 911 because it took a while to clean the resident and while writing the incident report the RN supervisor came on duty at 11PM who told her to call MD and have resident sent out to the hospital. She stated she only did the one assessment at 9:30 P.M. when resident was put back to bed. She did not recall the facility policy and procedure for incidents if there is not a (RN) on duty. The LPN supervisor further stated that she never received a disciplinary write up for this incident, and did not feel she did anything wrong. The charge LPN, RN and Medical Director have not been available for interview. 415.4(b)