Every finding on record at The Emerald Peek Rehabilitation and Nursing Center

Based on observation and interview conducted during the survey, the facility did not ensure infection control prevention practices were maintained by one (1) of three (3) nurses (Licensed Practical Nurse #3) observed during medication administration, for one (1) of seven (7) resident reviewed for infection control, and two staff (Licensed Practical Nurse #5 and Certified Nurse Aide #6 during a meal observation. Specifically, 1) Licensed Practical Nurse #3 did not practice hand hygiene prior to administering medications; 2) Physical Therapist #4 did not wear a gown while performing range of motion exercises for Resident #52 who was on Enhanced Barrier Precautions; and 3) during meal observation Licensed Practical Nurse #5 touched the lip of cups with bare hands after touching the beverage cart handle and moved a chair to sit to feed Resident #79 and did not complete hand hygiene before feeding the resident, and Certified Nurse Aide #6 positioned Resident #36 for lunch and proceeded to feed Resident #36 without completing hand hygiene. Findings include: The policy and procedure titled Enhanced Barrier Precaution, dated 10/08025, documented this facility's policy to implement enhanced barrier precautions to prevent the spread of multidrug-resistant organisms to residents. The policy titled Passing Trays reviewed 01/06/2026, documented the Nursing staff will perform hand hygiene prior to passing trays and in between assisting each resident. 1) During an observation on 5/6/2025 at 8:56AM, Licensed Practical Nurse #3 did not perform hand hygiene before getting medication blister packs out from the medication cart, putting medications in a pill cup or when returning to administer the medications to the resident. During a second observation on 5/6/26 at 9:12AM, Licensed Practical Nurse #3 was observed preparing medications, dropping pills in cups, unscrewing medication bottles, returning bottles to the medication cart then walking into a resident's room to administer medications without any hand hygiene. During an interview with Licensed Practical Nurse #3 on 5/6/26 at 11:07AM, they stated they should have used hand sanitizer before putting pills in the medicine cup and then right before they went into the room to administer the medications but did not do so because they were focusing on getting all the different medicines in the cup. They stated they should have used hand sanitizer before reaching into the medication cart. During an interview on 5/6/26 at 11:46AM, with the Director of Nursing, they stated nurses should be performing hand hygiene before preparing the medications and right before going to the resident with the meds. They stated the Licensed Practical Nurse#3 should have done more hand hygiene and there were other opportunities to do that at the time. They stated hand hygiene was emphasized at the yearly competencies that all nurses attended. 2) Resident #52 had diagnoses of Parkinson's Disease, pressure ulcer of the sacral region and dementia. The quarterly Minimum Data Set assessment tool dated 5/2/26 documented the resident had severe cognitive impairment and one unhealed pressure ulcer. The nursing care plan dated 2/16/26 documented Enhanced Barrier Precautions with interventions; staff to wear a clean gown and gloves while performing high contact resident care activities with residents who are at increased risk of carrying or acquiring a resistant organism. The physician's order dated 4/20/2026, documented Enhanced Barrier Precautions-staff to war a clean gown and gloves while performing high contact resident care activities with residents who are at increased risk of carrying or acquiring a resistant organism. The physician order dated 5/4/26 documented skilled physical therapy once a day for five (5) times a week for four (4) weeks for wound healing, muscle weakness and decreased mobility. During an observation on 5/5/26 at 10:07AM, Resident #52's doorway had a sign documenting the resident was on Enhanced Barrier Precautions and staff performing high contact tasks were to wear a gown and gloves. Physical Therapist #4 was in Resident #52's room performing range of motion exercises, lifting up the resident's leg with skin exposed and bending their knee. Gloves were observed on their hands, but no gown was worn. Physical Therapist #4 leaned over the bed with their clothes making contact with the resident's bed sheets. During an interview on 5/5/26 at 10:07AM, Physical Therapist #4 stated they missed the sign on the resident's doorway which indicated they were on Enhanced Barrier Precautions and should have been wearing a gown because the resident had a wound and they had been in close contact with the resident. They stated the gown would have prevented contamination. During an interview on 05/11/2026 at 1:31 PM, the Director of Nursing stated they expected staff to read the signs and adhere to them by applying full personal protective equipment anytime they entered a resident's room. The Director of Nursing stated they are responsible along with Supervisors to ensure the Enhanced Barrier Precautions are being followed correctly. They stated they expect all staff to read the signage and follow the directions on the signs. 3) During a meal observation on 05/05/2026 at 12:02 PM, Licensed Practical Nurse #5 was passing beverages to residents in the dining room. Licensed Practical Nurse #5 touched the handle of the beverage cart as they pushed it to each table and then placed bare fingers in the lip of the cups to pull them apart before picking up the handle of coffee carafe or juice pitcher and then pouring beverages into the cups to serve the residents. They did not perform hand hygiene before serving the next resident, and then Licensed Practical Nurse #5 touched the arms of a chair to move it to the table to feed Resident #79 and touched the resident's shoulder and did not perform hand hygiene before assisting Resident #79. When interviewed at 12:20 PM, Licensed Practical Nurse #5 stated they gave out hand wipes to the residents before the beverages were served but did not perform hand hygiene before serving and setting up trays for the residents. During an observation on 05/05/2026 at 12:23 PM, Certified Nurse Aide #6 positioned Resident #26 in their chair by putting their hands under Residents #26's arm to pull them up in the chair for safe eating and then proceeded to serve and feed Resident #26 and did not perform hand hygiene. During an interview at that time, Certified Nurse Aide #6 stated they should have used hand sanitizer before feeding a resident. 10 NYCRR415.19

Based on record review and interview conducted during the survey, the facility did not ensure Minimum Data Set Assessments were completed and submitted within 14 days after the facility completed the resident's assessments for 27 of 29 residents reviewed for Minimum Data Set Resident Assessments (Resident #s 3, 9, 10, 23, 24, 34, 38, 39, 42, 49, 50, 52, 55, 57, 60, 64, 65, 70, 81, 84, 86, 88, 89, 93, 99, 102, 105).The findings are:The 1/02/2026 facility policy, Minimum Data Set Completion Policy and Procedure, documented a Minimum Data Set Assessment shall be made for each resident as per the RAI (Resident Assessment Instrument) Manual. The Omnibus Budget Reconciliation Act regulations require nursing homes that are Medicare/Medicaid certified to conduct initial and periodic assessments for all residents. Must be submitted electronically and accepted into the Internet Quality Improvement and Evaluation System within 14 days after completion.The Centers for Medicare and Medicaid Services Validation Reports and the Resident's Minimum Data Set (MDS 3.0) Summaries in the electronic health record, Point Click Care, documented the following:Resident #3's quarterly assessment reference date of 3/21/2026 was completed on time on 4/04/2026, however it was submitted late on 5/02/2026,Resident #9's quarterly assessment reference date of 3/28/2026 was completed on time on 4/11/2026, however it was submitted late on 5/02/2026,Resident #10's quarterly assessment reference date of 3/14/2026 was completed late on 4/18/2026 and submitted late on 5/07/2026,Resident #23's quarterly assessment reference date of 3/21/2026 was completed late on 4/07/2026 and submitted late on 5/02/2026,Resident #24's End of Perspective Payment System assessment reference date of 3/11/2026 was completed on time on 3/25/2026, however it was submitted late on 5/02/2026,Resident #34's quarterly assessment reference date of 3/21/2026 was completed late on 4/07/2026 and submitted late on 5/02/2026,Resident #38's quarterly assessment reference date of 3/21/2026 was completed on time on 4/04/2026, however it was submitted late on 5/02/2026,Resident #39's quarterly assessment reference date of 3/14/2026 was completed late on 4/19/2026 and submitted on 5/02/2026,Resident #42's quarterly assessment reference date of 3/14/2026 was completed late on 4/19/2026 and submitted late on 5/07/2026,Resident #49's quarterly assessment reference date of 3/14/2026 was completed late on 4/19/2026 and submitted on 5/02/2026, Resident #50's quarterly assessment reference date of 3/28/2026 was completed on time on 4/11/2026, however it was submitted late on 5/02/2026,Resident #52's quarterly assessment reference date of 3/14/2026 was completed late on 4/17/2026 and submitted on 5/02/2026, Resident #55's quarterly assessment reference date of 3/21/2026 was completed on time on 4/04/2026, however it was submitted late on 5/02/2026,Resident #57's quarterly assessment reference date of 3/07/2026 was completed on time on 3/21/2026, however it was submitted late on 5/02/2026,Resident #60's quarterly assessment reference date of 3/14/2026 was completed late on 4/19/2026 and submitted late on 5/07/2026,Resident #64's quarterly assessment reference date of 3/14/2026 was completed late on 4/18/2026 and submitted late on 5/07/2026,Resident #65's annual assessment reference date of 3/21/2026 was completed on time on 4/04/2026, however it was submitted late 5/02/2026,Resident #70's quarterly assessment reference date of 3/14/2026 was completed late on 4/18/2026 and submitted on 5/02/2026,Resident #81's quarterly assessment reference date of 3/21/2026 was completed late on 4/07/2026 and submitted late on 5/02/2026,Resident #84's quarterly assessment reference date of 3/21/2026 was completed late on 4/07/2026 and submitted late on 5/07/2026,Resident #86's quarterly assessment reference date of 3/21/2026 was completed late on 4/07/2026 and submitted late on 5/02/2026,Resident #88's quarterly assessment reference date of 3/21/2026 was completed on time on 4/04/2026, however it was submitted late on 5/02/2026,Resident #89's annual assessment reference date of 2/28/2026 was completed on time on 4/2026, however it was submitted late on 5/07/2026,Resident #93's annual assessment reference date of 3/07/2026 was completed on 3/20/2026 and submitted late on 5/02/2026,Resident #99's quarterly assessment reference date of 3/07/2026 was completed late on 3/22/2026 and submitted late 5/02/2026,Resident #102's quarterly assessment reference date of 3/07/2026 was completed on time on 3/21/2026, however it was submitted late on 5/02/2026,Resident #105's quarterly assessment reference date of 3/21/2026 was completed on time on 4/04/2026, however it was submitted late on 5/02/2026.On 05/07/2026 at 10:52 AM during an interview, the Regional Minimum Data Set Manager stated they were responsible for overseeing the facility's Minimum Data Set department. They stated the per diem Minimum Data Set Coordinator was responsible for assuring that all departments completed their assessment sections and for submitting the completed assessments. The Regional Minimum Data Set Manager stated they were responsible for assuring that the facility's Minimum Data Set assessments were submitted timely to Centers for Medicare and Medicaid Services.On 05/07/2026 at 11:47 AM during a review of the CMS Validation Reports and follow-up interview with the Regional Minimum Data Set Manager, they stated that 27 Minimum Data Set assessments were late. They stated their former fulltime Minimum Data Set Coordinator left at the end of February and several Per Diem Minimum Data Set Coordinators had been filling in. They stated they were responsible to assure the per diem Minimum Data Set Coordinators who were filling in submitted the Minimum Data Set assessments to the Centers for Medicare and Medicaid Services timely. On 05/07/2026 at 12:08 PM during an interview, the per diem Minimum Data Set Coordinator stated they had been working at this facility since February 20, 2026. They stated they knew they were behind when they first started at the facility. They stated they submitted the assessments, but some were submitted late. They stated they were back on track now and have been submitting assessments timely. They stated it was their responsibility to assure all sections of each assessment was completed timely and that the assessments were submitted to the Centers for Medicare and Medicaid Services timely. On 05/11/2026 at 11:07 AM during a follow-up interview, the Regional Minimum Data Set Manager clarified the Minimum Data Set assessment completion and submission dates of the residents listed above. They stated the completion dates were documented in each resident's Minimum Data Set (MDS 3.0) Summary in their electronic health record, Point Click Care. They stated that the submission dates were documented at the top of the Centers for Medicare and Medicaid Services Validation Reports on each batch of submissions.10 NYCRR 415.11

Based on record review and interview conducted during the survey, the facility did not ensure the Resident Assessment was accurate for one (1) of one (1) resident (Resident #105) reviewed for Restraints. Specifically, for Resident #105, the resident was coded as having a restraint, which was incorrectly coded.Findings include:The 1/02/2026 facility policy, Minimum Data Set Completion Policy and Procedure, documented a Minimum Data Set Assessment shall be made for each resident as per the Resident Assessment Instrument Manual. The Omnibus Budget Reconciliation Act regulations require nursing homes that are Medicare/Medicaid certified to conduct initial and periodic assessments for all residents. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity, as well as medical, cognitive, and emotional needs.Resident #105 had diagnoses including osteoarthritis of the hip, hypertension, and cerebrovascular accident.The 12/26/25 Quarterly Minimum Data Set assessment documented bed rails were used daily. No physical impairments in functional limitation to upper or lower extremities, used a walker and wheelchair. Resident #105 was independent rolling in bed, sit to lying, and ambulation, and required set-up assistance with transfers.On 05/05/2026 at 10:26 AM bilateral enablers were observed on Resident #105's bed.On 05/11/2026 at 1:26 PM, observed Resident #105 lying on their back in bed, observed Resident #105 grab the left enabler and pull themself to a sitting position on side of the bed. The physician's orders dated 9/30/2025 to the current date documented bilateral grab bars were indicated and served as enablers to promote independence.The 9/30/25 side rail assessment documented bilateral grab bars were indicated and served as enablers to promote independence. Care giver educated.On 05/11/2026 at 1:51 PM during an interview, the Regional Minimum Data Set Manager stated Resident #105's quarterly assessment dated [DATE] documented that bed rails were used daily. They stated that bed rail used daily was coded incorrectly. They stated the physician's order was for bilateral grab bars which were not side rails and were not restraints. They stated they would submit a modification. 10NYCRR 415.11(c)(1)

Based on observation, record review, and interview conducted during the Recertification survey (2657230) conducted from 5/05/26 to 5/12/25, the facility did not ensure residents were free of significant medication errors for 1 of 7 (Resident#26) residents reviewed for Medication Administration. Specifically, Licensed Practical Nurse#3 crushed a 50-milligram dose of Metoprolol Succinate extended release, an antihypertensive, and two (2) 120mg dose of Verapamil (an anti-hypertensive), but was stopped immediately prior to bringing the crushed mixture of medications and applesauce to the resident The findings included:The policy titled Medications: Crushing Medications revised 10/07/26 documented medications will be crushed only when it is appropriate and safe to do so consistent with physician orders.Resident#26 had diagnoses which included atrial fibrillation, hypertension and dysphagia.The quarterly Minimum Data Set assessment tool dated 2/21/26 documented Resident #26 had impaired cognition and needed some assistance with Activities of Daily Living.A care plan titled coronary artery disease dated 11/29/25, documented administer medications as ordered by the physician. Document side effects. Report adverse reactions to physician.A physician order dated 11/19/25 documented Metoprolol Succinate 50mg tablet extended release one tablet once a day for hypertension.A physician order dated 11/19/25 documented Verapamil Hydrochloride 120 milligram extended release two tabs once a day for hypertension. During an observation on 5/6/26 at 9:12AM Licensed Practical Nurse#3 prepared medications that were due or Resident#26 including Metoprolol Succinate extended release 50milligrams and Verapamil extended release 120 milligrams (two tabs) then crushed all pills, poured them into a medicine cup with applesauce and was about to administer the medications to the resident but was stopped.During an interview on 5/6/26 at 9:12 AM Licensed Practical Nurse #3 reviewed the blister pack of Verapamil and Metoprolol and confirmed a sticker on the pack documented Do Not Crush, administer whole. They stated when they prepare medications they look at the resident's name and dosage but missed the small print, Do Not Crush. They stated they should have looked closer because the resident would have gotten a bigger dose all at once and not spread over the day since it was a time released medication. During an interview with the Director of Nursing on 5/6/26 at 11:46 AM they stated if a resident could not swallow their medications and only can take it crushed they would first try to get a liquid form if possible. They stated a change could be made to more frequent time at a lower dose. They stated the nurses need to look carefully at the blister packs and read all alerts. They stated there could have been a bad outcome if it was administered. During an interview on 5/6/26 at 12:11PM with Nurse Practitioner#1 they stated it is their expectation all nurses administer the resident's medications as prescribed. They stated the Verapamil and Metoprolol extended release was not administered correctly and the resident could have had a blood pressure drop and would have been at risk for cardiac arrest. Stated it was a good thing, it was not administered, and nurses need to pay closer attention to the alerts. 10 NYCRR 415.12(m)(2)

Based on record review and interview conducted during the recertification survey from 11/4/2024 to 11/8/2024, the facility did not ensure Annual Performance Reviews were completed at least once every 12 months. Specifically, the facility was unable to provide Annual Performance Reviews for 5 of 5 Staff Members ( #11, #12, #13, #14, #15) reviewed. The findings are: The facility policy titled Job Performance Review, dated 10/01/2024, stated: The job performance of each employee shall be reviewed and evaluated at least annually. During an interview with Assistant Director of Nursing/Nurse Educator on 11/06/24 at 4:14 PM, they stated the facility had just resumed Annual Performance Appraisals for nursing staff. The Assistant Director of Nursing/Nurses Educator stated they were unable to provide performance appraisals for the 5 staff members requested (#11, #12, #13, #14, #15). During an interview with the Administrator on 11/08/24 at 3:17 PM, the Administrator stated the facility had not completed staff Annual Performance Appraisals for the last few years. They stated the facility was in the process of resuming Annual Performance Appraisals at the current time and they were aware that the Assistant Director of Nursing/Nurse Educator was unable to provide the requested Annual Performance Appraisals requested during the survey. 10NYCRR 415.26 (c)(2)(iii)

Based on observation, interview, and record review conducted during the recertification survey from 11/4/2024 to 11/8/2024, the facility did not ensure the resident's right to a sanitary environment. This was evident during environmental observation of 1 (3rd Floor) of 2 resident units. Specifically, the shared resident bathrooms between rooms [ROOM NUMBERS] and rooms [ROOM NUMBERS] were observed with a strong odor of urine on multiple occasions. The findings are: The facility policy titled Terminal Cleaning Complete Room Cleaning dated 1/5/2024 documented Housekeeping staff allowed the floor in resident rooms to dry after damp-mopping it with disinfectant. On 11/05/2024 at 11:05 AM and 11/06/2024 at 04:42 PM, the shared bathroom between rooms [ROOM NUMBERS] was observed with a strong odor of urine. The caulking around the bottom edge of the toilet bowl was stained a dark yellow/orange color. There were 2 broken tiles at the base of the toilet bowl. There were no obvious signs of urine on the toilet bowl or on the floor. Across the hallway, room [ROOM NUMBER] was observed with a strong odor of urine emanating from the far side of the room by the window. The closed door of the shared bathroom between rooms [ROOM NUMBERS] was opened and an intensely strong odor of urine was present. The toilet bowl was stained with yellow dried urine and the caulking at the base of the toilet bowl was stained a dark yellow/orange color throughout. On 11/07/2024 at 12:41 PM, Certified Nursing Assistant #5 was asked to observe the shared bathroom between rooms [ROOM NUMBERS]. Certified Nursing Assistant #5 stated the bathroom smelled like urine and mildew. There were 2 of 4 residents in the adjoining rooms that were able to use the toilet. Certified Nursing Assistant #5 stated Housekeeper #9 cleaned the resident bathrooms often and sprayed air freshener but did not clean these rooms yet today. After observing the strongest urine smell in room [ROOM NUMBER]'s bathroom, Certified Nursing Assistant #5 stated this bathroom smelled like urine on previous occasions. Certified Nursing Assistant #5 stated the bathroom probably smelled that way because the residents used it throughout the day, but the bathroom did not always have a foul odor. On 11/07/2024 at 12:56 PM, Housekeeper #9 was interviewed and stated they were responsible for cleaning resident bathrooms on the 3rd Floor several times a day with bleach and a 3M neutralizer chemical solution. The Director of Environmental Services prepared the neutralizing solution for the Housekeeping staff by mixing a concentrated form of cleaning solution with water and pouring it into spray bottles. Housekeeper #9 stated they cleaned the floors throughout the unit at least once daily. After observing the strong urine smell in room [ROOM NUMBER]'s bathroom, Housekeeper #9 stated they made the Director of Environmental Services aware a few weeks ago that this bathroom had a strong foul odor that did not go away with standard cleaning and neutralizing solutions. Housekeeper #9 stated no matter how much they clean the bathroom in room [ROOM NUMBER], one of the residents in the room had a behavior of not urinating in the toilet bowl and the urine smell persisted. On 11/08/2024 at 11:55 AM, the Director of Environmental Services was interviewed and stated the urine smell in room [ROOM NUMBER] and its bathroom shared with room [ROOM NUMBER] was a chronic issue the Housekeeping staff have tried to address since one of the residents was admitted to the facility a few months ago. The resident had a behavior of urinating in various areas of the room, including the wall, air conditioning/heating radiator unit, and floor. The resident was also known to urinate on the bathroom floor, walls, and all over the outside of the toilet bowl . The Director of Environmental Services observed the foul odor in room [ROOM NUMBER] and stated the facility bought special odor neutralizers to address the issue but ran out and needed to purchase more. The Housekeeping staff were instructed to pay special attention to room [ROOM NUMBER]. Housekeeper #9 mopped the room and cleaned the bathroom several times a day. The night Housekeeper also made sure to clean the room at least once on the night shift during their rounds throughout the facility. Using bleach intensified the smell and the facility's current floor cleaning solution did not mitigate the intensity of the urine smell. The Director of Environmental Services stated they ripped out and replaced the caulking and sealant around the toilet bowl several times, but this was not the root cause of the lingering smell. The Director of Environmental Services stated they informed their Regional Director of the facility's efforts to address the foul odor in room [ROOM NUMBER] and made them aware that the issue remained unresolved. The Interdisciplinary Team, including the Administrator and Director of Nursing, discussed the concern often in morning report. The Director of Environmental Services stated the resident may have been exhibiting inappropriate behavior by urinating throughout their room but was unsure whether behavioral interventions were developed to try and address the behavior. On 11/08/2024 at 01:01 PM, the Director of Nursing was interviewed and stated the Director of Environmental Services discussed the concerns with a strong odor of urine in room [ROOM NUMBER] during morning report several times. The Director of Nursing stated they made rounds on the units and was recently in room [ROOM NUMBER] but was unaware the resident was urinating in various areas of the room and not in the toilet bowl. The Director of Nursing stated they thought the resident had episodes of incontinence and, as a result, their clothes ended up smelling of urine. The resident was offered a urinal but threw it away and Nursing staff try to change the bed linens in the room more quickly to address the smell. More frequent showering was also offered to the resident but none of the interventions were effective in addressing the smell of urine in room [ROOM NUMBER] and shared bathroom. 10 NYCRR 415.5(h)(2)

Based on record review and interviews during the Recertification survey from 11/3/2024 to 11/8/24, the facility did not ensure that a complete preadmission screening for individuals with a mental disorder was conducted. This was evident for 1 of 24 residents (Resident #82) reviewed for Preadmission Screening and Resident Review (PASARR) out of 24 sampled residents. Specifically, the SCREEN DOH 695 form was incomplete and a determination of a resident's need for Level II services had not been documented. Findings include: Resident #82 arrived at the facility on 8/12/24 with diagnoses that included, chronic pain, bipolar disorder, and major depressive disorder. The resident refused to proceed with admission upon arrival at facility and was discharged against medical advice on 8/12/24. The facility policy titled PASRR dated 7/15/24 stated that it is the policy of the facility that all residents have the required pre-admission screen prior to admission to the facility, and any time that there is a significant change that has bearing on the resident's specialized service needs. Procedure: Prior to a Resident's admission, the Admissions Department/designed will obtain: A SCREEN and Level I referral since the resident was referred for rehabilitation. A level II if the Level referral indicates that the resident is known to be affected by serious mental illness/and/or mental retardation/developmental disability per the guidelines. During review of the SCREEN Form DOH-695 completed for Resident #82 dated 8/12/2024, the day of admission to the facility, the section Level 1 Review for Possible Mental Illness (MI), included Item #23 Does this person have a serious mental illness?. Item #23 was not completed. The Level 1 Review for Possible Mental Retardation/Developmental Disability (MRDD) section, which includes items 23-26, were not completed. The guideline on the SCREEN form documented that if item 23 or any of item 24-26 were marked YES, proceed to Categorical Determination (items 27-30). Items 27-30 on the SCREEN form were not completed. The guideline for items 27-30 documented that if items 27-30 are marked NO, proceed to LEVEL II REFERRALS (Item 33). Item 33 was not completed. During an interview with the Admission Director on 11/08/24 at 01:37 PM, they stated that the PRI/Screens forms are sent to facility and reviewed by Admission Director. They stated that the SCREEN form is reviewed for patient and screener signatures. They also review SCREEN forms to determine if a level 2 evaluation was required. During the interview, the SCREEN form for Resident #82 was reviewed. The Director of Admissions stated that question #23, questions #24-#30 and question #33 were not answered. They were not aware why the SCREEN form for Resident #82 was not reviewed for completion. They stated that the SCREEN should have been returned to referring facility Social Work department with a request that the SCREEN form be accurately completed and returned for review. They stated accurately completed SCREEN forms are required prior to resident admission to ensure that services a resident may need are available prior to accepting admission. During an interview on 11/08/24 at 02:17 PM with the Director of Nursing, they stated that SCREEN forms should be fully completed before a decision is made to accept a resident. Admission Director is responsible for ensuring completion of level I and level II information has been completed on SCREEN forms submitted to the facility. They stated that the SCREEN form for Resident #82, reviewed during interview, was not complete and should have been returned to facility requesting admission for completion. Any concerns on SCREEN forms or Level II reviews should be discussed with the Interdisciplinary team prior to admission to ensure that the Resident requesting admission to facility can receive the necessary services. 10 NYCRR 415.11(e)

Based on observation, interview, and record review conducted during the recertification survey from 11/4/2024 to 11/8/2024, the facility did not ensure services provided met professional standards of quality. This was evident for 1 (Resident #20) of 4 residents reviewed for pressure ulcers out of 22 total sampled residents. Specifically, Licensed Practical Nurse #1 discontinued a physician ordered wound care treatment for Resident #20 without notifying the provider for an order to discontinue. The findings are: The facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol dated 6/24/2024 documented the Physician will authorize pertinent orders related to wound treatments. The facility policy titled Pressure Injury Risk assessment dated [DATE] documented a skin assessment tool was used to document findings of skin inspections. Care plan interventions must be current and recognized standards of care. Report information in accordance with professional standards of practice. The facility Role of Licensed Practical Nurse Supervisor, signed by Licensed Practical Nurse #1 on 7/2023, documented the nurse will work in collaboration with physician and/or other health care professionals by sharing information relevant to changing the plan of care. Resident #20 had diagnoses of sacrococcygeal moisture-associated skin damage and in-house acquired deep tissue injury to the right heel. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #20 was severely cognitively impaired and had an unhealed unstageable deep tissue injury that was not present upon admission to the facility. The Comprehensive Care Plan related to right heel wound was initiated 9/19/2024 and documented Resident #20 should have treatments administered as ordered. Physician Order dated 10/25/2024 documented Resident #20 was ordered grey foam covered by kerlix tape to their coccyx and right heel every 48 hours. Both orders for treatment were discontinued on 11/6/2024 at 7:53 AM. Weekly Skin Observation dated 10/30/2024 documented Resident #20 had a deep tissue injury to their right heel and moisture-associated skin damage to their coccyx region. The Treatment Administration Record for 11/2024 documented the treatment order for grey foam to Resident #20's right heel and coccyx was discontinued on 11/6/2024. The Nursing Note dated 11/6/2024 documented Resident #20's wounds had resolved to the right heel and sacral coccyx region. On 11/06/2024 at 11:38 AM, Licensed Practical Nurse #1, the medication and treatment nurse on Resident #20's unit, was interviewed and stated Resident #20 did not have any prescribed wound care treatment orders. Licensed Practical Nurse #1 stated they had no planned skin observations or treatments for Resident #20 because the resident did not have any open areas on their skin that required wound care. On 11/06/2024 at 02:20 PM, Certified Nursing Assistant #5 assisted with observing Resident #20's sacral area. Resident #20's coccyx was observed with a small open excoriated area. Resident #20's right heel was observed with a dressing to their right heel dated 11/4/2024. At 2:21 PM, Licensed Practical Nurse #1 entered Resident #20's room and stated the dressing on the resident's right heel was a protective dressing. Licensed Practical Nurse #1 removed the right heel dressing and Resident #20's right heel was observed with red, moist skin and a skin flap with an open area. Licensed Practical Nurse #1 stated Resident #20 was not on wound rounds and had not been receiving wound treatment for their right heel or sacral area. Licensed Practical Nurse #1 stated they would place Resident #20 on wound rounds for the Wound Care Nurse Practitioner to assess starting tomorrow, 11/7/2024. On 11/07/2024 at 05:08 PM, the Wound Care Nurse Practitioner was interviewed and stated Resident #20 had wound treatments ordered for their right heel and sacral/coccyx area. The Wound Care Practitioners stated they did not receive any calls from the facility or Licensed Practical Nurse #1 to inform them that wound care treatments were discontinued on 11/6/2024. The Wound Care Nurse Practitioner stated they would not have discontinued the wound care orders for Resident #20 on 11/6/2024 because the resident required ongoing wound treatment to the right heel and sacral/coccyx area for wounds that had not resolved. On 11/08/2024 at 12:41 PM, Licensed Practical Nurse #1 was interviewed and stated they did not speak with the Wound Care Practitioner or any other physician prior to discontinuing Resident #20's wound treatments for their right heel and coccyx/sacral area on 11/6/2024. Licensed Practical Nurse #1 stated they heard from the Director of Nursing that Resident #20's wounds might be resolving and the placed the order to discontinue treatment without observing Resident #20's wounds or speaking with the Wound Care Nurse Practitioner. Licensed Practical Nurse #1 stated it was not in their scope of practice to be able to assess a resident's wounds, order treatments, or discontinue treatments without consulting a physician. On 11/08/2024 at 01:27 PM, the Director of Nursing was interviewed and stated it was not the facility policy or a standard of practice for Licensed Practical Nurses to order or discontinue wound care treatments without first consulting a physician or nurse practitioner. 10 NYCRR 415.11(c)(3)(i)

Based on observation, interview, and record review conducted during the recertification survey from 11/4/2024 to 11/8/2024, the facility did not ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing. This was evident for 1 (Resident #20) of 4 residents reviewed for pressure ulcers. Specifically, Licensed Practical Nurse #1 discontinued a physician ordered wound care treatment for Resident #20 without notifying the provider and getting an order to discontinue. The findings are: The facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol dated 6/24/2024 documented the Physician will authorize pertinent orders related to wound treatments. The facility policy titled Pressure Injury Risk assessment dated [DATE] documented a skin assessment tool was used to document findings of skin inspections. Care plan interventions must be current and recognized standards of care. Report information in accordance with professional standards of practice. Resident #20 had diagnoses of sacrococcygeal moisture-associated skin damage and in-house acquired deep tissue injury to the right heel. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #20 was severely cognitively impaired and had an unhealed unstageable deep tissue injury that was not present upon admission to the facility. The Comprehensive Care Plan related to right heel wound was initiated 9/19/2024 and documented Resident #20 should have treatments administered as ordered. Physician Order dated 10/25/2024 documented Resident #20 was ordered grey foam covered by kerlix tape to their coccyx and right heel every 48 hours. Both orders for treatment were discontinued on 11/6/2024 7:53 AM. Weekly Skin Observation dated 10/30/2024 documented Resident #20 had a deep tissue injury to their right heel and moisture-associated skin damage to their coccyx region. The Treatment Administration Record for 11/2024 documented the treatment order for grey foam to Resident #20's right heel and coccyx was discontinued on 11/6/2024. The Nursing Note dated 11/6/2024 documented Resident #20's wounds had resolved to the right heel and sacral coccyx region. On 11/06/2024 at 11:38 AM, Licensed Practical Nurse #1, the medication and treatment nurse on Resident #20's unit, was interviewed and stated Resident #20 did not have any prescribed wound care treatment orders. Licensed Practical Nurse #1 stated they had no planned skin observations or treatments for Resident #20 because the resident did not have any open areas on their skin that required wound care. On 11/06/2024 at 11:43 AM, Certified Nursing Assistant #5, assigned to Resident #20, was interviewed and stated they planned to place Resident #20 back into bed at approximately 2 PM and would coordinate an observation of the resident's sacrum and right heel. On 11/06/2024 at 02:20 PM, Certified Nursing Assistant #5 assisted with observing Resident #20's sacral area. Resident #20's coccyx was observed with a small open excoriated area. Resident #20's right heel was observed with a dressing to their right heel dated 11/4/2024. At 2:21 PM, Licensed Practical Nurse #1 entered Resident #20's room and stated the dressing on the resident's right heel was a protective dressing. Licensed Practical Nurse #1 removed the right heel dressing and Resident #20's right heel was observed with red, moist skin and a skin flap with an open area. Licensed Practical Nurse #1 stated Resident #20 was not on wound rounds and had not been receiving wound treatment for their right heel or sacral area. Licensed Practical Nurse #1 stated they would place Resident #20 on wound rounds for the Wound Care Nurse Practitioner to assess starting tomorrow, 11/7/2024. On 11/07/2024 at 05:08 PM, the Wound Care Nurse Practitioner was interviewed and stated Resident #20 had wound treatments ordered for their right heel and sacral/coccyx area. The Wound Care Practitioners stated they did not receive any calls from the facility or Licensed Practical Nurse #1 to inform them that wound care treatments were discontinued on 11/6/2024. The Wound Care Nurse Practitioner stated they would not have discontinued the wound care orders for Resident #20 on 11/6/2024 because the resident required ongoing wound treatment to the right heel and sacral/coccyx area for wounds that had not resolved. On 11/08/2024 at 12:41 PM, Licensed Practical Nurse #1 was interviewed and stated they did not speak with the Wound Care Practitioner or any other physician prior to discontinuing Resident #20's wound treatments for their right heel and coccyx/sacral area on 11/6/2024. Licensed Practical Nurse #1 stated they heard from the Director of Nursing that Resident #20's wounds might be resolving and the placed the order to discontinue treatment without observing Resident #20's wounds or speaking with the Wound Care Nurse Practitioner. Licensed Practical Nurse #1 stated it was not in their scope of practice to be able to assess a resident's wounds, order treatments, or discontinue treatments without consulting a physician. On 11/08/2024 at 01:27 PM, the Director of Nursing was interviewed and stated it was not the facility policy or a standard of practice for Licensed Practical Nurses to order or discontinue wound care treatments without first consulting a physician or nurse practitioner. 10 NYCRR 415.12(c)(1)

Based on observation, record review, and interviews conducted during the recertification and abbreviated survey (NY00338157) conducted 11/4/2024 to 11/8/2024, the facility did not ensure they provided medications and/or biologicals, as ordered by the prescriber, to meet the needs of 1 (Residents #184) of 2 residents reviewed for Pharmacy Services. Specifically, Resident #182 did not receive methylprednisolone (a medication used to treat lupus) on 3/30/24 and 3/31/24. The medication was not acquired from the pharmacy and administered as ordered. Findings include: The facility policy titled Medication Administration dated 10/05/2024 stated: Medication shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time. If medication is unavailable from the pharmacy or E-box or First Done Machine (Med-bank) for the scheduled time, the practitioner will be contacted for further instructions. Resident #184 was admitted [DATE] with diagnoses including fracture of one rib, fracture of surgical neck of left humerus, and systemic lupus erythematosus. The Admission Minimum Date Set Admission, dated 3/31/24, documented Resident #184 had intact cognition. A Physician order dated 3/29/24 documented methylprednisolone oral tablet 2 milligrams. Give 6.5 tablet by mouth one time a day for systemic lupus starting 3/30/24. Resident #184's Medication Administration Record for 3/30/2024 and 3/31/2024 documented methylprednisolone oral tablet 2 milligram, give 6.5 tablet by mouth one time a day for systemic lupus, starting 3/30/24 was not administered. The documented reason was Code 9: other/see Nurse notes. A review of Nurse Progress Notes and Physician notes from 3/29/24 to 3/31/24 did not include documentation related to methylprednisolone administration concerns. There were no other Progress Notes related to medications being unavailable or physician notification of medications not being administered as ordered. During a telephone interview with Resident #184's family member on 11/06/24 at 9:36 AM, they stated that Resident #184 did not received steroid (methylprednisolone) during their stay at the facility. The family member stated a facility staff member told them the facility would not have the medication in-house until the following Wednesday. The family member stated that resident and family decided to have resident transferred to the hospital on 3/31/24. During an interview with the facility Administrator on 11/08/24 at 10:14 AM, they stated Resident #184's medications were ordered the evening of 3/29/24. They stated that the expectation was that the medications ordered would be delivered to facility the next morning which did not occur. The Administrator stated that the medication (methylprednisolone) was not administered on 3/30/24 or 3/31/24. The Administrator stated the facility Medical Director was not notified on 3/30/24 regarding missing medications. They stated that there was a failure in communication between facility and the pharmacy. During an interview with the Pharmacist on 11/08/24 at 12:47 PM, they stated the order received was for methylprednisolone 2 milligram tablet, to give 6.5 tablets by mouth one time a day. Pharmacist stated that the 2 milligram tablets were not available and the closest dose available would be 4 milligram tablets and made a recommendation to give three 4 milligram tablets to equal 12 milligrams. They stated that when the pharmacist was unable to reach the facility nurse supervisor to discuss recommendations, the follow-up call should have remained in the pharmacy queue so further follow-up could be completed. This did not occur which led to no further follow-up with the facility. The Pharmacist stated the policy was not followed correctly and communication did not continue, and the methylprednisolone was not delivered to facility. During an interview on 11/08/24 at 02:05 PM with the Director of Nursing, they stated that the medication (methylprednisolone) not being available and communication with the pharmacy was a concern. They stated that the facility did not stock methylprednisolone tablets in E-box or First Done Machine (Med-bank). They stated communication did not occur between nurse staff during change of shift rounds on 3/30/24 regarding Resident #184 not receiving methylprednisolone due to not being received from pharmacy during morning delivery. The evening nurse on duty did not know to contact the pharmacy when it was not delivered in afternoon delivery. 10 NYCRR 415.18(a)

Based on record review and interviews during a survey from 11/4/24-11/8/24, the facility did not ensure each resident's drug regimen was free from unnecessary drugs, use for 1 (Resident #73) of 5 residents reviewed for unnecessary drugs. Specifically, Resident #73 had an order for Tramadol 50 milligrams three times a day for a pain scale of 5-10 and was administered 12 times from 11/1/24-11/6/24 with a pain scale less than 5. Findings included: Resident # 73 had diagnosis including Cerebral infarction, Aphasia, and Type 2 diabetes. A Policy and Procedure titled Medication Administration dated 10/5/2024 documented Medication must be administered in accordance with orders, including any required time frames. If a dosage is believed to be inappropriate or excessive for the resident, the person preparing or administering the medication will contact the resident's attending physician or the facility medical director to discuss concerns. A quarterly Minimum Data Set (an assessment tool) dated 10/1/2024 documented the resident's cognition was severely impaired. The resident required supervision or touching assistance with eating and was dependent on staff with all other care. The resident received insulin all 7 days during the look back period. Additionally received an opioid. A physician order dated 10/18/2024 documented Tramadol 50 milligrams, give 1 tablet every 8 hours for pain scale of 5-10. The November 2024 Medication Administration Record documented Resident #73 received Tramadol 50 milligram with a documented pain scale of 0 (zero) at 6:00 AM on 11/5/24 and 11/6/24; at 2:00 PM on 11/1/24, 11/2/24, 11/3/24, and 11/5/24; and at 10:00 PM on 11/2/24 and 11/5/24. A review of the Narcotics book documented that Tramadol 50 milligrams was signed out every 8 hours standing from 11/1/2024 to current. The drug regimen review recommended for the physician to evaluate the use of Tramadol, dated 9/19/24 the Medical Director responded the resident moaned and was nonverbal, the current dose was required with no gradual dose reduction. During an interview with Registered Nurse #8 on 11/06/24 at 10:03 AM they stated it was a standing order for Tramadol and they did not know why the pain scale was included. The resident was nonverbal and would be unable to use the pain numerical pain scale. During an interview with Licensed Practical Nurse Unit Manager #7 on 11/06/24 at 10:05 AM, they stated they believed the order may have changed from an as needed (PRN) order to a standing order. They stated they needed to get the order clarified. During an interview with Physician #1 on 11/08/24 at 10:21 AM, they stated they would not write a standing order with a pain scale, but if the order had a pain scale it should have been followed. If the order was to give Tramadol for pain scale of 5-10, and the resident's pain scale was 0, then the nurse should have called them prior to giving the medication. During an interview with Physicians Assistant #9 on 11/08/24 at 10:31 AM, they stated they were the last person who had signed off on the resident's medications on 10/18/24. The resident required the medication for chronic pain, was nonverbal and unable to provide a numeric pain scale. The order should have been clarified by the nurse. 415.12(l)(1)

Based on observation and interview conducted during a recertification survey from 11/04/24 to 11/08/2024, the facility failed to provide separately locked, permanently affixed compartments for storage of controlled substances on 1 of 2 facility units (Third Floor) reviewed for drug storage. Specifically, injectable Ativan (a controlled substance) was not stored in a double locked permanently affixed compartment. The findings are: Facility policy on Medication Labeling Storage dated 10/5/2024 documented the facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys. Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. Controlled substances (listed as Schedule II-4 of the Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. During an observation of the third-floor medication room at 10:16 AM on 11/6/2024, a clear plastic narcotic box was inside the medication refrigerator. The narcotic box had 2 keys. License Practical Nurse #2 attempted to but was unable to open the narcotic box with her keys. License Practical Nurse #2 removed the narcotic box from the refrigerator; it was not affixed inside the medication refrigerator. Inside the narcotic box were six (6) injectables of Ativan for Resident #4. When interviewed on 11/6/2024 at 10:16 AM, License Practical Nurse #2 was not able to provide an answer as to why the narcotic box was not affixed to the refrigerator. When interviewed on 11/6/2024 at 11:23 AM, the Director of Nursing stated the narcotic box inside the medication refrigerator should have been permanently affixed and not removable. 10 NYCRR 415.18 (e) (1-4)

Based on observation, record review, and interviews conducted during a recertification survey from 11/4/2024 to 11/8/2024, the facility did not ensure infection control and prevention practices were maintained. This was evident for 2 (Resident #11 and #14) residents during a dining observation and 2 (Resident #70 and #38) of 4 residents during medication administration observation. Specifically, 1) Certified Nurse Aide #16 was observed feeding Residents #11 and #14 without performing hand hygiene between residents, and 2) Licensed Practical Nurse #1 was observed administering medication to Residents #70 and #38 without performing hand hygiene after touching other items in the room and administering eye drops. The findings are: 1) Residents #11 and #14 both had diagnoses of dysphagia and dementia. During a lunch meal observation in the Main Dining Room on 11/4/2024 at 12:43 PM, Certified Nurse Aide #16 picked up a spoon and fed Resident #11. Certified Nurse Aid #16 then set the spoon down, turned and picked up Resident #14 ' s spoon with the same hand and fed Resident #14. Certified Nurse Aide #16 continued to use the same hand to feed both residents without performing hand hygiene in between picking up and setting down the different spoons. During an interview on 11/06/2024 at 03:32 PM, Certified Nurse Aide #16 stated they fed Resident #11 and Resident #14 at the same time because there were not enough people to help feed those residents. Certified Nurse Aide #16 stated they did not realize they fed both residents with the same hand and should have sanitized their hands in between feeding each resident. During an interview on 11/06/2024 at 05:03 PM, the Infection Preventionist stated staff were not typically allowed to feed 2 residents at the same time. Certified Nurse Aide #16 should have sanitized their hands in between feeding residents and should not have used the same hand to feed both residents. 2) The facility policy titled Administering Medications dated 9/26/2024 documented staff follow established infection control procedures (handwashing, antiseptic technique, gloves, isolation precautions) for the administration of medications. During medication administration on 11/6/2024 from 9:17 AM to 10:13 AM, on 3rd Floor East, the following was observed: - Licensed Practical Nurse #1 prepared medication for Resident #70 at the medication cart, entered Resident #70 ' s room, touched the resident ' s wheelchair and Hoyer lift pad, did not perform hand hygiene, and administered oral medications to Resident #70. - Licensed Practical Nurse #1 donned a pair of gloves, entered Resident #38 ' s room with oral medications and eye drops. At Resident #38 ' s bedside, while waking up the resident and assisting the resident to a sitting position, Licensed Practical Nurse #1 touched and pulled the disposable incontinence pad underneath the resident. Licensed Practical Nurse #1 proceeded to get a spoon from the medication cart and with the spoon, administered oral medications to Resident #38 then grabbed a bottle of eyedrops, and administered eyedrops to Resident #38. Licensed Practical Nurse #1 did not perform hand hygiene in between touching the resident ' s bedding, administering the oral medications, and prior to administering eyedrops. On 11/06/2024 at 10:14 AM, Licensed Practical Nurse #1 was interviewed and stated they should have performed hand hygiene after touching other objects and prior to and after administering medications to Residents #70 and #38. Licensed Practical Nurse #1 stated they were aware of the infection control and prevention practices and forgot to do so during medication administration. 10 NYCRR 415.19(a)(1-3) 50816

Based on record reviews and interviews during the abbreviated surveys (NY00321069), it was determined the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for one (1) of three (3) residents (Resident #1) reviewed for accidents. Specifically, Resident # 1 fell from their bed on [DATE] when the plan of care for a 2-person assist with bed mobility was not followed. Resident #1 sustained a subdural hemorrhage (brain bleed) and a lip laceration. The resident expired in the hospital on [DATE]. This resulted in actual harm that was not immediate jeopardy. Findings include: Resident #1 was admitted to the facility with diagnoses including a history of subarachnoid hemorrhage (bleeding in the space between the brain and the surrounding membrane) with residual neurological deficits, and a Stage IV sacral pressure injury. The Admission Minimum Data Set (a resident assessment tool) dated [DATE] documented the resident had severely impaired cognition and required total assistance for activities of daily living. The Activities of Daily Living Care Plan dated [DATE] documented the resident required total assist of 2 persons for all activities of daily living including bathing and bed mobility. The Kardex (instructions for direct care staff) dated [DATE] documented the resident required a 2 person assist for bathing, bed mobility, toilet use and transfers. The Certified Nurse Aide task documentation record dated [DATE], revealed the resident was totally dependent on staff for bathing and bed mobility and required a 2 person assist. For bathing and bed mobility during the 7:00 AM to 3:00 PM shift, the resident received a 1 person assist 59% of the time. For bed mobility during the 3:00 PM to 11:00 PM shift, the resident received a 1 person assist 67% of the time, and during the 11:00 PM - 7:00 AM shift, received a 1 person assist 89% of the time. The Registered Nurse Supervisor #1 progress note dated [DATE] at 8:56 AM, documented they were called to the resident's room around 7:48 AM for an assessment. The Certified Nurse Aide had been providing hygiene care when the resident rolled off the other side of the bed and ended up on the floor on their right side with a pillow underneath the right side of their face. There was a cut noted on top of the right lip. The resident was assessed, assisted back to bed, and hygiene care resumed. The physician progress note dated [DATE] at 10:20 AM, documented the resident was seen status post fall out of bed. The resident had a small laceration to their right upper lip and no other head trauma noted. The resident was on Eliquis (blood thinner) and would be sent to the emergency room for evaluation including head CT to rule out bleed. The Accident & Incidence Investigation dated [DATE] documented at approximately 8:00 AM the resident fell off the bed while receiving care. The resident was rolled to the side of the bed when their legs slid off the edge of the bed and their body followed. The resident landed on their right side with their head maintained on a pillow. The resident was assessed by the registered nurse with a laceration to the lip and no other visible signs of injury. The resident was returned to bed and seen by the primary care physician around 9:15 AM for evaluation and an order was given to transfer to the acute care setting for further evaluation, treatment of lip laceration and to rule out head trauma. Certified Nurse Aide #4's written statement dated [DATE] at 8:00 AM, documented they had given the resident a bed bath and was repositioning the resident during an incontinence brief change and went to reach for supplies when the resident fell . A typed statement written by the Assistant Director of Nursing, dated [DATE], documented they interviewed Certified Nurse Aide #4 who acknowledged the resident was care planned for a 2 person assist and they were providing the resident's care without a second person. The nursing progress note dated [DATE] at 2:27 PM documented Hospital #1 informed the facility Resident #1 had a subdural hematoma and was being transferred to Hospital #2. When interviewed on [DATE] at 10:00 AM, the Assistant Director of Nursing stated they arrived at work on [DATE] and were informed the resident had fallen out of bed. Registered Nurse Supervisor #1 assessed the resident and called the attending physician who stated they would be at the facility soon and would see the resident. Vital signs and neurological checks were within normal limits. Attending Physician #1 arrived, assessed the resident and ordered the resident be sent to the Emergency Department related to the lip laceration and the possible need for a Computed Tomography (CT) scan. The Assistant Director of Nursing stated Certified Nurse Aide #4 knew the resident should have been a 2 person assist with care. They did not know why Certified Nurse Aide #4 did not ask for help and they were not short staffed. They stated there was a care plan violation. When interviewed on [DATE] at 3:45 PM, Registered Nurse Supervisor #1 stated at the end of the shift on [DATE], they were called to the resident's room because the resident fell . The resident was on the floor, they were assessed, and vital signs were stable. The family and the attending physician were called. The attending physician stated they were on the way and would see the resident when they arrived. Certified Nurse Aide #4 was sent home (and later terminated) because the resident was a 2 person assist and Certified Nurse Aide #4 was caring for the resident alone when the resident fell . When interviewed on [DATE] at 9:00 AM, Attending Physician #1 stated they were notified of the resident's fall on their way to the facility and assessed the resident upon arrival. The resident was in no acute distress, but since the resident was on blood thinners, they decided to send the resident to the emergency room for further testing. The physician stated they were unaware of the hospital findings and the resident did not return to the facility. Review of hospital records from Hospital #2, on [DATE], revealed on [DATE] Resident #1 was transferred from Hospital #1 to Hospital #2 after a Computed Tomography of the head showed a subdural hematoma (brain bleed) after a fall from the bed at the nursing home. The laceration to the lip was repaired at Hospital #1. The resident expired at Hospital #2 on [DATE] at 6:10 PM. Review of hospital records from Hospital #1, received on [DATE], documented on [DATE] Resident #1 arrived via Emergency Medical Services from the skilled nursing facility. Reported to have a fall from bed while being turned, patient was noted with a laceration to right lip. Further notes documented a 1-centimeter jagged laceration to right maxilla/right upper lip, through and through with intraoral laceration (soft tissue wound). Computed Tomography scan of head was done with findings of acute subdural hematoma overlying the right cerebral hemisphere. The case was discussed with Neurosurgery who recommended the resident be transferred to Hospital #2. Clinical Impression was documented as a right-sided subdural hematoma with mass effect; fall from bed. The plan was to transfer the resident to Hospital # 2 for a higher level of neurological management. When interviewed on [DATE] at 11:40 AM, the neurosurgeon from Hospital #2 stated the resident had a subdural hematoma following a fall in the skilled nursing facility. The resident had an acute subdural hematoma with a large midline shift resulting in the need for surgery. The resident returned to baseline after the surgery, at that time the family decided to implement palliative care and the resident expired in the hospital. The subdural hematoma was most likely caused by the fall, and the resident's prior brain injury, the presence of a shunt and the use of anticoagulants put the resident at risk for this injury. During a telephone interview on [DATE] from 11:19 AM to 11:47 AM, the Director of Nursing and Assistant Director of Nursing stated they did not interview other certified nurse aides regarding how they performed care for Resident #1 as the fall was an isolated incident of one certified nurse aide not following the care plan. During review of the Certified Nurse Aide task documentation record dated [DATE], the Director of Nursing and Assistant Director of Nursing explained the resident's assistance level should be coded as a 3 for a 2 person assist. They reviewed the documentation and stated it was coded as a 2 which meant a 1 person assist for bed mobility and toilet use on multiple occasions. They stated it was a coding error and staff knew the resident required a 2 person assist. They stated they did not interview the individuals that documented the performed bed mobility or toilet use as a 1 person assist to determine if it was a coding error. They stated they did a full house education, and the consensus was the staff were using a 2 person assist. During the interview the Accident & Incidences Investigation dated [DATE] and signed off by the Director of Nursing on [DATE] was reviewed and the corrective actions including education and periodic audits on certified nurse aide's compliance/competency with care plan recommendations and understanding importance of ensuring residents safety was requested. Review of the In-Service Attendance Sign-In Sheet dated [DATE], ongoing Following assigned plan of care and assist levels for caregiving revealed, there is ongoing education of certified nursing staff. A sign in sheet dated [DATE], Topic/Meeting for Activities of Daily Living level of assistance for bed mobility, transfers and toileting for bed ridden residents in regular and air mattresses revealed, there is ongoing education of certified nursing staff. 10 NYCRR 415.12(h)(2)

Based on record review, and interviews during the Abbreviated Survey (NY 00315316) the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than two hours to the New York State Department of Health. This was identified for one (Resident #2) of 3 residents reviewed for abuse. Specifically, the facility received an accusation of abuse of Resident #2 on 4/24/2023 and did not report the allegation of abuse to the New York State Department of Health. Findings include: The facility Policy and Procedure titled Abuse, Neglect, Exploitation or Mistreatment - Reporting and Investigating, documented if resident abuse, neglect, exploitation, or misappropriation of resident property or injuries of unknown origin is suspected, the suspicion must be reported immediately to the administrator and other officials. The Care Plan titled Victim of Abuse dated 4/19/2023, documented a goal that the resident would not be a victim of abuse. Interventions included to investigate all allegations of abuse, provide support, and ensure resident is not a victim of abuse. The Accident & Incident Investigation dated 4/24/2023, documented the Administrator received an email alleging abuse and mistreatment of Resident #2 with no mention of time or staff. The reported also noted skin discoloration to Resident #2's left forearm. The facility closed out the abuse neglect or mistreatment investigation on 4/28/2023 noting no evidence of abuse, neglect, or mistreatment. A nursing progress note dated 4/24/2023 documented a phone conversation with a family member. The family member expressed concerns regarding staff getting angry with the resident when the resident did not move fast enough. The family member inquired about the bruise on the resident's arm and was informed it was the result of venipuncture. The Event Report dated 4/24/2023 documented Resident #2 had a lightly discolored area to the left forearm. The Accident &Incident report dated 4/24/2023 documented an alteration in skin integrity was investigated and the blueish discoloration on arm was related to a blood draw the previous day. A review of email dated 4/27/2023 from the Attorney General's office to the facility requested information be sent for an accusation of abuse. Review of New York State Department of Health intake records for facilities to report allegations of abuse revealed the facility did not report the allegation. When interviewed on 4/1/2024 at 2:45 PM, the Director of Nursing stated they began the investigation as soon as we were made aware of the allegation. They stated the Administrator was working with the New York State Attorney General's office, and they were told the Attorney General would report the allegation to the Department of Health and the ombudsman. When interview on 4/1/2024 at 3:15PM, the Administrator stated they were made aware of the concerns from the family late on 4/24/2023 and received a forwarded email from corporate which was written by the family about allegation of abuse. The nurse manager on the unit immediately investigated the allegation and ruled out abuse. The Administrator stated they thought the Attorney General's office would notify the Department of Health. When interviewed on 4/2/2024 at 10:49 AM, the investigator from the Attorney General's Office stated the first time they spoke with the facility about the allegation was on 4/27/2023. At the time the facility was advised the family made a complaint regarding abuse. The facility was aware of the complaint and sent us a copy of the investigation. The facility was not told that the Attorney General's office would report the allegation to the Department of Health. When interviewed on 4/2/2024 at 11:25 AM, the Assistant Director of Nursing stated they were notified there was an allegation of the overall treatment of the resident and bruising. The Assistant Director of Nursing stated they were aware that allegation of abuse it needed to be reported to the Department of Health. The Nurse Manager was able to assess the resident's physical status and at that time saw no signs of abuse. 10 NYCRR 415.4(b)(2)

F580 Based on record review and interviews conducted during an abbreviated survey on 3/20/2024 (NY00305021), the facility did not ensure that a resident representative or their physician was informed of the need to alter treatment to gradually reduce a resident's psychotropic medication for 1 of 3 residents reviewed. Specifically, on 9/9/2022 through 10/31/2022 the facility initiated a gradual reduction of Resident #1(who had a diagnosis of schizophrenia) psychotropic medications (Clozapine and Risperdal), despite a recommendation from the psychiatrist to maintain psychotherapy until the next follow up. Resident #1's representative or psychiatrist was not notified of significant alteration in treatment. On 10/14/2022 Resident #1 would not follow redirection and was yelling at staff and on 10/17/2022 Resident #1 reported to staff they did not feel like themselves and had outburst of cursing and yelling. The findings are: The Policy and Procedure titled, Notification of change, dated 1/15/2023 documented it will be policy of the facility to immediately inform resident, consult the physician and if known, notify the resident's legal representative of family representative when there has been a change in resident's condition. (3.) A need to alter treatment significantly (i.e. a need to discontinue an existing form of treatment due to adverse consequences), (e.g., an adverse drug reaction), or to commence a new form of treatment to deal with a problem (e.g., the use of any medical procedure, or therapy that has not been used on the resident before.) Resident #1 had diagnoses that included traumatic subdermal hemorrhage, dysphagia, dysarthria, schizophrenia, hyperlipidemia, hypertension, and hydrocele. Review of Resident #1 admission Minimum Data Set (MDS, an assessment tool) dated 9/9/2022 documented the resident had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score value of 14, which is means resident was cognitively intact for interview (00-7 severe impairment, 08-12 moderate impairment and 13-15 cognitively intact). Review of Resident #1's Care Plan dated 9/9/2022 documented that the resident uses psychotropic medications Clozapine and Risperdal for schizophrenia. The goal was resident will be free of drug related complications in movement disorder, discomfort, hypertension, gait disturbance, constipation, or cognitive behavioral impairment. Interventions administer medication as oriented. Consult with pharmacy, MD to consider dosage reduction when clinically appropriate. Resident #1's discharge instructions medications included Risperdal 3mg x2 daily and Clozapine 100mg x2 daily. Review of Physician Order dated 9/9/2022 documented Resident #1 was to receive Risperdal 3mg x2daily (for psychosis) and Clozapine 100mg x2daily (for psychosis) for 7days. Review of Physician order dated 9/18/2022 documented Resident #1 was to be given Risperdal 3mg (half a tablet daily at bedtime for psychosis) and Clozipine 100mg daily for 7days. Review of Physician Order dated 9/26/2022 documented to administer Clozipine 100mg (half tablet daily every other day for 10days) and Risperdal 3mg (half tablet every other day for 10days). Review of Psychological assessment dated [DATE] documented Risperdal 3 milligram tablet by mouth twice daily and Clozapine 100 milligram by mouth twice daily no recommendation for medication change at this time. Recommend continue psychotherapy. Will follow-up in 2 -4 weeks to ensure the patients mental health needs are being met. Review of Nursing progress note dated 10/13/2022 documented Resident #1 would not follow redirection and was yelling at staff. Physician was notified. Review of Physician order dated 10/14/2022 documented verbal orders given to administer Haldol Injection 1mg intramuscular x1 for schizophrenia. Review of Nursing progress note dated 10/17/2022 Resident #1 stated they did not feel themselves and had outburst of cursing and yelling. Physician was notified and Resident #1's representative was then notified of the gradual reduction of psychotropic medication. Review of Physician Order dated 10/19/2022 documented Resident #1 had Clonazepam and Risperdal increased gradually until discharge. There was no progress note prior to gradual reduction from physician about a discussion with Resident #1. Review of Physician memo dated 3/21/2024 documented Resident #1 was seen on 9/9/2022 and Resident #1 stated they no longer on Clonazepam and Risperdal and did not want to continue, and that Resident #1 agreed to gradual reduction of medication. During an interview with the Assistant Director of Nursing on 3/20/2024 at 2:35 PM they stated Resident #1 was on psychotropic medication and the medications were tapered off by the physician. After a few days off the medications, they noticed behaviors and orders were placed to restart Clozapine and Risperdal by physician on 10/17/2022. During an interview with the Administrator on 3/20/2024 at 3:50 PM they stated that at admission Resident #1's psychotropic medication was gradually reduced by the physician. The Administrator stated that they were sure the physician informed Resident #1 about gradual reduction. The Administrator stated there was no note documenting resident and/resident representative informed of change. During a telephone interview with the family representative on 3/25/2024 at 1:19 PM, they stated that the facility gradually reduced Clozapine and Risperdal on 9/9/2022 without their knowledge and staff stated they were following the guidelines of Department of Health New York for psychotropic medication reduction. Family representative stated that without their medication, Resident #1 began hearing voices and had outbursts. Family representative stated that Resident #1 would not be able to make rational decisions and they were concerned for their well-being in the facility. Family representative wanted medication to be re-initiated as Resident #1 had been on medication since they were [AGE] years old and needed their medication to be mentally stable. During telephone interview with Psychiatric Nurse Practitioner on 4/22/2024 at 1:08 PM they stated they did not have any interaction with Resident #1, however they could refer to the notes written by the psychaitrist that stated there was no recommendation for change in Resident #1's psychotropic medications. During an interview with Primary Care Physician on 4/22/2024 at 2:29 PM stated the admitting Physician placed the order for the gradual dose reduction of Resident #1's psychotropic medications and they were not aware the medications were being reduced gradually. The Primary Care Physician stated Resident #1 was stable on the psychotropic medications with no behaviors. The Primary Care Physician stated medication was reconciled at admission by the admitting Physician and there was no recommendation to taper off the psychotropic medications. 10NYRCC 415.3

Based on interview and record review during an abbreviated survey (NY00301820), the facility did not ensure that a resident was free of significant medication errors. Specifically, 1 of 3 residents (Resident #1) reviewed for medication administration did not receive significant medications including anticoagulant, cardiovascular, and insulin medications. The findings are: The facility undated policy titled, Medication Administration documented medications shall be administered in a safe and timely manner as prescribed within one hour of the prescribed time. If a medication is not available from the pharmacy for the scheduled time, the E-Box or First Dose Machine should be utilized, and the practitioner will be contacted for further instructions. The resident was admitted to the facility on [DATE] with diagnoses including but not limited to Orthopedic aftercare following surgical amputation, Diastolic Heart Failure, Hypertension, Non-ST Segment Elevation Myocardial Infarction (NSTEMI), Diabetes and Pulmonary Vascular Disease (PVD). The resident was discharged home on 8/18/22. The Admission Minimum Data Set (MDS; a resident assessment tool) dated 8/08/22 documented that the resident had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 15/15, associated with intact cognition. The resident required extensive assistance for bed mobility, transfers, locomotion, dressing, and toilet use, required limited assistance for hygiene, and was independent for eating. A review of the Physician's orders initiated on 8/2/2022 documented the following medications: Xarelto 2.5 mg, I tablet by mouth once daily at 9AM for anticoagulant therapy; Torsemide 20 mg, give 2 tablets by mouth once daily at 9AM for increase in the amount of urine produced; Carvedilol 25 mg twice daily at 9AM and 6PM for Hypertension; Ranozaline ER 1000 mg Extended Release twice daily at 9AM and 6PM for Angina Pectoris; Admelog Insulin (Insulin Lispro), inject 2 units at bedtime for Diabetes; Admelog Insulin (Insulin Lispro), inject 2 units three times a day for Diabetes; Semglee Insulin Glargine, inject 5 units at bedtime for Diabetes A review of the resident's Medication Administration Record (MAR) dated August 2022 documented Xarelto 2.5 mg, I tablet by mouth once daily at 9AM for anticoagulant therapy was not administered on 8/3/22 at 9AM. The MAR was signed and dated by LPN #6, documented with Chart Code 9(denoting medication not delivered yet), and there was no check mark to document that the medications were administered per Physician's order. A review of the resident's Medication Administration Record (MAR) dated August 2022 documented Torsemide 20 mg, give 2 tablets by mouth once daily at 9AM for increase in the amount of urine produced was not administered on 8/3/22 at 9AM. The MAR was signed and dated by LPN #6, documented with Chart Code 9, and there was no check mark to document that the medications were administered per Physician's order. A review of the resident's Medication Administration Record (MAR) dated August 2022 documented Carvedilol 25 mg twice daily at 9AM and 6PM for Hypertension was not administered on 8/2/22 at 6PM or on 8/3/22 at 9AM or at 6PM. The MAR was signed and dated by LPN #6, documented with Chart Code 9, and there was no check mark to document that the medications were administered per Physician's order. A review of the resident's Medication Administration Record (MAR) dated August 2022 documented Ranozaline ER 1000 mg Extended Release twice daily at 9AM and 6PM for Angina Pectoris was not administered on 8/2/22 at 6PM or on 8/3/22 at 9AM or at 6PM. The MAR was signed and dated by LPN #6, documented with Chart Code 9, and there was no check mark to document that the medication was administered per Physician's order. A review of the resident's Medication Administration Record (MAR) dated August 2022 documented Admelog Insulin (Insulin Lispro), inject 2 units at bedtime for Diabetes, was not administered on 8/2/22 at 9PM. The MAR was signed and dated by LPN #6, documented with Chart Code 9, and there was no check mark to document that the medications were administered per Physician's order. A review of the resident's Medication Administration Record (MAR) dated August 2022 documented Admelog Insulin (Insulin Lispro), inject 2 units three times a day at 8AM 12PM, 5PM for Diabetes, was not administered on 8/2/22 at 5PM or on 8/3/22 at 8AM. The MAR was signed and dated by LPN #6, documented with Chart Code 9, and there was no check mark to document that the medications were administered per Physician's order. A review of the resident's Medication Administration Record (MAR) dated August 2022 documented Semglee Insulin Glargine, inject 5 units at bedtime for Diabetes, was not administered on 8/2/22 at 9PM. The MAR was signed and dated by LPN #6, documented with Chart Code 9, and there was no check mark to document that the medications were administered per Physician's order. A review of the resident's Weights and Vitals Summary documented blood pressure value and a Warning documented Systolic High of 139 exceeded on the following dates and times: 8/2/22 17:49 blood pressure result 148/66; 8/3/22 04:15 blood pressure result 150/73; 8/3/22 16:09 blood pressure result 142/74; 8/4/22 06:21 blood pressure result 170/80; 8/4/22 11:44 blood pressure result 140/76; and 8/4/22 22:35 blood pressure result 142/62. A review of the resident's Weights and Vitals Summary documented blood sugar result on 8/3/22 at 21:00 was 375. On 11/17/22 at 1:05 PM, an interview was conducted with Licensed Practical Nurse (LPN #6) regarding medication administration on 8/2/22 and 8/3/22. The LPN stated s/he didn't write any notes to document his/her leaving a message for the Physician or calling the pharmacy or contacting the supervisor, other than documenting in the MAR notes, that the medication was not available, or on its way from pharmacy. On 11/17/22 at 3:10 PM, an interview was conducted with the Registered Nurse Supervisor (RNS#1) regarding the resident's medication administration on 8/2/22 and 8/3/22. The RNS stated there were so many opportunities for resolution of the issues if the LPN had made him/her aware. The RNS stated that usually the LPNs call him/her for assistance as needed. On 11/16/22 at 2:05 PM, an interview was conducted with the Registered Nurse Unit Manager (RNUM # 3) regarding medication administration on 8/3/22. The RNUM stated s/he was unaware that the resident's medications were unavailable. The RNUM stated the LPN should have reported to him/her, and should have called the Physician and the pharmacy, and s/he would have assisted the LPN to address the issue immediately. On 11/16/22 at 2:10 PM, an interview was conducted with the Previous Director of Nursing (DON), s/he stated the LPN is responsible to contact the Physician and write a note to document any new orders and place any new orders into the resident's EMR. The Previous DON stated the LPN should have asked the RNS and/or the RNUM for assistance if needed. On 11/16/22 at 2:20 PM, an interview was conducted with the Admitting Physician (MD#3). The Physician stated that s/he was not made aware that the resident did not receive medications on 8/2/22 and on 8/3/22. On 11/17/22 at 5:45PM, an interview was conducted with the Primary Physician (MD#2) regarding medications that were not administered per Physician's orders on 8/2/22 and 8/3/22. The Physician stated they were not made aware that there were issues with receiving the resident's medications. The Physician stated the admission orders are taken from the hospital discharge medication list, and the resident should have received his medications as ordered. The Physician stated they can't be sure of what adverse effects might have occurred from not receiving the medications on 8/2/22 and 8/3/22. The Physician stated that the resident's blood sugar of 375 on 8/2/22 at 9PM could also have been the result of something the resident ate that evening, perhaps something from home, but s/he can't be sure. MD#2 stated that medications could be held if resident is undergoing a procedure or if parameters for administration are not met. 415.12(m)(2)

Based on interviews and record review during an abbreviated survey (NY00298790), the facility did not implement a comprehensive person-centered care plan for 1 of 3 residents reviewed for Neglect. Specifically, the resident required 2-person assistance for bed mobility, however bed mobility was provided with one person assistance. The resident was injured sustaining head trauma and laceration to the left forehead during bed mobility performed with the physical assistance of 1 person. The findings are: A review of the undated facility Policy and Procedure titled, Activities of Daily Living (ADL) support documented that appropriate care and services will be provided for residents unable to carry out ADLs independently in accordance with their plan of care including appropriate support and assistance with hygiene, elimination, and mobility. A review of the undated facility Policy and Procedure titled, Care Plans documented the care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being provided by qualified persons. The resident was admitted to the facility on [DATE] with diagnoses including but not limited to Dementia, Alzheimer's Disease, and depression. The Quarterly Minimum Data Set (MDS - a resident assessment tool) dated 5/13/22 documented that the resident had a severe cognition impairment. The assessment documented that the resident required extensive assistance of two staff for bed mobility, dependent assistance of two staff for transfers, dependent of one staff for dressing and toilet use and hygiene, and extensive assistance of one staff for eating. A review of the facility Accident / Incident Investigation dated 7/7/22 includes the TNA's statement which documented that the TNA was caring for the resident, rolled her over to get the brief from under her, and the resident's upper body slipped out of the bed, and she fell to the floor. A review of the Care Plan titled; Activities of Daily Living (ADLs) dated 5/14/21 revised 5/15/22 documented interventions including Dependent Assistance of 2 staff for Bed Mobility. A review of the resident's C.N.A. Documentation Survey Report dated June 22 documented to provide 'total assist of 2 staff for bed mobility'. On 11/02/22 at 2:40 PM, an interview was conducted with Licensed Practical Nurse (LPN #5), who stated the resident required 2 staff for bed mobility and 1 staff to assist for toilet use/check and change in bed. The LPN stated that means that 2 staff should provide assistance, the first person to wash and change the resident's brief and the second person should be on the other side of the bed to hold the resident on her side and keep the resident from rolling off the bed. The LPN stated that on 7/07/22, the T.N.A. called him/her to the room and s/he saw the resident lying on the floor with a bleeding head injury bleeding from the top right side of the forehead. The L.P.N. stated that the T.N.A. stated s/he had provided care to turn and position the resident without assistance and the resident slipped off the bed. The LPN stated s/he didn't verbally tell the TNA that the resident required 2 staff for bed mobility when the LPN gave the TNA their assignment, for the reason that the TNA had cared for the resident in the past and the resident had not had any changes to her plan of care. The LPN stated that s/he had recently spoken with all the C.N.A.s and T.N.A.s regarding the importance of using 2 staff for assistance when required, but not specifically for that resident. On 11/02/22 at 3:45 PM, an interview was conducted with the Temporary Nursing Assistant T.N.A. (TNA) who stated s/he had cared for the resident previously and had always cared for the resident without assistance. The TNA stated s/he did not know that the resident required 2 staff for bed mobility. The TNA stated the Kardex was confusing because it said the resident required 1 staff for toilet use. The TNA stated that s/he did not look at the instructions in the Kardex. The TNA stated that the other C.N.A.s gave him/her instructions to provide assistance to the resident without another staff to assist. The TNA stated that when s/he got his/her assignment, the nurse did not explain that the resident required 2 staff for bed mobility. On 11/02/22 at 2:35 PM, an interview was conducted with Registered Nurse Unit Manager (RNUM#3), who stated s/he was the RNUM on the second floor unit and they called from the second-floor unit to assess the resident on the third floor. The RNUM stated s/he found the resident on the floor to the left side of the bed, lying on her left side. The resident was bleeding from a small laceration about 1 cm to the left forehead, and s/he applied a pressure dressing and ice to the affected area. The RNUM stated s/he completed a full assessment and reported to the Director of Nursing, told the Physician, wrote the assessment note and took orders to transfer the resident to the hospital. The RNUM stated that the TNA stated s/he provided care to the resident without any other staff to assist. The RNUM stated s/he asked the T.N.A., if s/he was aware that the resident required 2 staff to assist with bed mobility and the TNA didn't seem to know, although the TNA had cared for the resident in the past. The RNUM told the TNA that the resident doesn't move in the bed without assistance and requires 2 staff for turning and positioning in bed. The RNUM stated it is the TNA's responsibility to check the Kardex prior to cares and the LPN on the unit is responsible for the TNA's and C.N.A.s on the unit. The RNUM stated that the nurse who makes the assignment gives report to any new staff and of any changes to the residents. On 11/15/22 at 2:00PM, an interview was conducted with the previous Director of Nursing who was the DON at the time of the incident (Previous DON) who stated that the RNUM on the 2nd floor was responsible for any assistance the 3rd floor unit required from a Registered Nurse and the LPN was responsible for the TNAs and CNAs on the unit. The previous DON stated the resident was dependent on 2 staff for bed mobility and did not participate in bed mobility. The previous DON stated that the resident's bed grab bars had been previously removes on 7/1/22 due to a decline in bed mobility, but the resident had required 2 staff assistance with bed mobility prior to that date On 11/15/22 at 2:15 PM, an interview was conducted with the Physician who stated the resident was dependent for all care and required 2-person assistance for care. The Physician stated the resident did not participate in bed mobility and had some contractures of the hands and wrists. 415.11 (c) (1)

Based on record review and interviews conducted during an abbreviated survey (NY00298790), the facility did not ensure that a resident was free from accidents for 1 of 3 residents (Resident # 1) reviewed for Neglect. Specifically, the facility did not provide adequate care and supervision for a resident requiring total dependence with 2-person physical assistance for bed mobility due to decreased mobility and left-hand contracture. The resident sustained a laceration/ head trauma during bed mobility performed with 1 person physical assistance instead of 2 people. The findings are: A review of the undated facility Policy and Procedure titled, Falls and Fall Risk, Managing documented resident conditions that may contribute to the risk of falls includes poor grip strength and functional impairments, and includes that the staff with input from the Physician will implement a resident centered fall prevention plan. The resident was admitted to the facility on [DATE] with diagnoses including but not limited to Dementia, Alzheimer's Disease, and Depression. The Quarterly Minimum Data Set (MDS) (Minimum Data Set; a resident assessment tool) dated 5/13/22 documented that the resident had severe cognition impairment. The resident required 2-person extensive assistance for bed mobility, 2-person total dependence for transfers, 1-person total dependence for dressing, toilet use and hygiene, and 1-person extensive assistance for eating. A review of the facility investigation dated 7/07/2022 documented a thorough investigation which included notification of the RN, DON, MD, Administrator, suspension of the TNA, RN assessment of the resident, staff statements, the resident was started on neuro-checks and sent to the ER for further evaluation, the care plan was reviewed and updated, re-education of the TNA, PT/OT referral. The resident sustained a 1 cm laceration to the left forehead, was sent to the ER for evaluation, CAT scans revealed negative findings, the resident required no sutures or steri-strips, and received an order for bacitracin. A review of the facility Accident / Incident Investigation dated 7/7/22 includes the TNA's statement which documented that the TNA was caring for the resident, rolled her over to get the brief from under her, and the resident's upper body slipped out of the bed and she fell to the floor. A review of the Care Plan titled, Resident is at Risk for Falls dated 8/21/14 revised 2/25/22 documented the resident is at risk for falls, interventions include anticipate and meet the resident's needs. A review of the Activities of Daily Living (ADLs) Care Plan dated 5/14/21 revised 5/15/22 documented interventions including Dependent Assistance of 2 staff for Bed Mobility. A review of the resident's CNA Documentation Survey Report dated June 22 documented to provide 'total assist of 2 staff for bed mobility'. A review of the Occupational Therapy Evaluation and Plan of Treatment dated 5/9/22 documented right-hand postures in flexed resting position, left hand flexion contracture, left-hand roll to be worn at all times, right and left upper extremities range of motion is impaired, and functional limitations as a result of contractures including grasp/release. On 11/02/22 at 4:00 PM, an interview was conducted with the Temporary Nursing Assistant T.N.A. (TNA) who stated s/he had cared for the resident previously and had always cared for the resident without assistance. The TNA stated s/he did not know that the resident required 2 staff for bed mobility. The TNA stated the Kardex was confusing because it said the resident required 1 staff for toilet use. The TNA stated that s/he did not look at the instructions in the Kardex. The TNA stated that the other CNAs gave him/her instructions to provide assistance to the resident without another staff to assist. The TNA stated that when s/he got his/her assignment, the nurse did not explain that the resident required 2 staff for bed mobility. On 11/02/22 at 2:40 PM, an interview was conducted with Licensed Practical Nurse (LPN #5), who stated the resident required 2 staff for bed mobility and 1 staff to assist for toilet use/check and change in bed. The LPN stated that means that 2 staff should provide assistance, the first person to wash and change the resident's brief and the second person should be on the other side of the bed to hold the resident on her side and keep the resident from rolling off the bed. The LPN stated that on 7/07/22, the T.N.A. called him/her to the room and s/he saw the resident lying on the floor with a bleeding head injury bleeding from the top right side of the forehead. The L.P.N. stated that the T.N.A. stated s/he had provided care to turn and position the resident without assistance and the resident slipped off the bed. The LPN stated s/he didn't verbally tell the TNA that the resident required 2 staff for bed mobility when the LPN gave the TNA their assignment, for the reason that the TNA had cared for the resident in the past and the resident had not had any changes to her plan of care. The LPN stated that s/he had recently spoken with all the C.N.A.s and T.N.A.s regarding the importance of using 2 staff for assistance when required, but not specifically for that resident. On 11/02/22 at 2:35 PM, an interview was conducted with Registered Nurse Unit Manager (RNUM#3), who stated s/he was the RNUM on the second floor unit and s/he was called from the second-floor unit to assess the resident on the third floor. The RNUM stated s/he found the resident on the floor to the left side of the bed, lying on her left side. The resident was bleeding from a small laceration about 1 cm to the left forehead, and s/he applied a pressure dressing and ice to the affected area. The RNUM stated s/he completed a full assessment and reported to the Director of Nursing, told the Physician, wrote the assessment note and took orders to transfer the resident to the hospital. The RNUM stated that the TNA stated s/he provided care to the resident without any other staff to assist. The RNUM stated s/he asked the T.N.A., if s/he was aware that the resident required 2 staff to assist with bed mobility and the TNA didn't seem to know, although the TNA had cared for the resident in the past. The RNUM told the TNA that the resident doesn't move in the bed without assistance and requires 2 staff for turning and positioning in bed. The RNUM stated it is the TNA's responsibility to check the Kardex prior to cares and the LPN on the unit is responsible for the TNA's and C.N.A.s on the unit. The RNUM stated that the nurse who makes the assignment gives report to any new staff and of any changes to the residents. On 11/15/22 at 2:00PM, an interview was conducted with the previous Director of Nursing who was the DON at the time of the incident (Previous DON) who stated that the RNUM on the 2nd floor was responsible for any assistance the 3rd floor unit required from a Registered Nurse and the LPN was responsible for the TNAs and CNAs on the unit. The previous DON stated the resident was dependent on 2 staff for bed mobility and did not participate in bed mobility. The previous DON stated that the resident's bed grab bars had been previously removes on 7/1/22 due to a decline in bed mobility, but the resident had required 2 staff assistance with bed mobility prior to that date. On 11/15/22 at 2:15 PM, an interview was conducted with the Physician who stated that the resident was dependent for all care and required 2-person assistance for care. The Physician stated the resident did not participate in bed mobility and had some contractures of the hands and wrists. 415.12 (h) (2)

Based on observations and interviews conducted during a recertification survey, the facility did not ensure food was stored in accordance with professional standards for food service safety in a manner to prevent contamination. Specifically, a 5-pound package of open cheese and 5-pound package of open boloney which were not dated to document date of having been opened were observed in the refrigerator in the kitchen, and 3 boxes frozen apple juice and 3 boxes frozen orange juice were observed sitting on a cart in the kitchen at room temperature. The findings are: The facility's policy and procedure regarding food storage dated 10/15/20, revised 12/14/21 documents that perishable foods must be frozen or stored in the refrigerator or freezer immediately after receipt to assure nutritive value and quality, and that leftover food should be clearly labeled and dated. During the initial tour of the kitchen on 12/14/21 at 9:30 AM, an opened 5-pound package of [NAME] cheese and an opened 5-pound package of boloney were observed in the fridge with no dates to document when they were opened. The Food Services Director (FSD) was interviewed on 12/14/21 at 9:30 AM, who stated that when food is opened, it should be documented with the date it was opened. During the initial tour of the kitchen on 12/14/21 at 9:45 AM, 3 boxes of frozen apple juice and 3 boxes of frozen orange were observed sitting out on a cart in the kitchen at room temperature. Observed the label on the orange juice box documenting store at 0 degrees, and the label on the apple juice box documented if frozen thaw in fridge overnight. The FSD was interviewed on 12/14/21 at 9:45 AM, who stated that the juices were delivered this morning at 7:00 am and should have been put in fridge. During a follow-up visit to the kitchen on 12/17/21, an interview was conducted at 8:05 am with the FSD who stated that s/he had observed boloney being opened on Monday 12/13/21 at lunch for a resident who had requested a boloney sandwich and thought the staff member would document the opening date. S/he stated all the dietary staff are responsible for checking the dates of food items that are delivered and dating foods when they are opened, and there are no logs to track the best before or use by dates. S/he stated the cook should check the fridges and freezers for dates on food, all dietary staff should also be checking dates, s/he is ultimately responsible for everything, but s/he can't see everything. 483.60(i)