Every finding on record at The Grand Rehabilitation and Nursing at Barnwell

Based on interviews and record review, the facility failed to ensure residents were free from abuse, neglect, misappropriation of resident property and exploitation for one out of three residents reviewed for abuse. Specifically, the Facility Incident Report documented on 05/26/2026, Resident #1 became combative during the provision of care and Resident #1 struck Certified Nurse Aide #1 in the face. Certified Nurse Aide #2 reported that Certified Nurse Aide #1 then struck Resident #1 in the face in response. Care continued to be provided to the resident, and it was documented the resident had a bloody nose. The resident was not reapproached or redirected after striking Certified Nurse Aide #1. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy.Findings include:Facility policy titled Abuse-Prohibition Protocol, Types of Abuse/Reporting last reviewed 01/2026 documented every resident had the right to be free from abuse, mistreatment, neglect, misappropriation of property and to be free from abuse facilitated or caused by the facility's staff. All personnel must attempt to immediately stop the abuse, then promptly report any incident or suspected incident of resident abuse. Regular in-service training and education would include working with difficult and abusive residents. Emotional and psychological abuse was defined as the infliction of anguish, pain, or distress through verbal or nonverbal acts. Signs and symptoms included being emotionally upset or agitated. Facility policy titled Behavioral Assessment, Intervention and Monitoring, last revised 01/2022, documented interventions will be individualized and part of an overall care environment that supports physical, functional, and psychosocial needs, and strives to understand, prevent, or relieve the resident's distress or loss of abilities. Resident #1 was admitted to the facility with diagnoses of Alzheimer's disease (a progressive, irreversible brain disorder and the most common cause of dementia), neurocognitive disorder with Lewy bodies (a progressive brain disorder caused by the abnormal buildup of proteins in the brain), and atrial fibrillation (common, irregular heart rhythm where the heart's upper chambers beat chaotically). The Minimum Data Set (a resident assessment tool) dated 03/27/2026 documented the resident was usually understood, sometimes understood others, and was severely cognitively impaired. Comprehensive Care Plan with focus refuses medications/treatments/blood tests/consultations, activities of daily living care, out of bed initiated 03/03/2026 documented as an intervention: reapproach, offer alternative choices. Comprehensive Care Plan with focus, Resident exhibits behavior symptoms such as socially inappropriate/verbally aggressive/abusive; physically aggressive/abusive, irritability and anger initiated 01/29/2026 documented as an intervention: redirect negative behavior as needed.Facility incident report documented on 05/26/2026 at approximately 9:05 AM, Certified Nurse Aide #2 reported to Assistant Director of Nursing #1 an allegation of staff abuse involving a resident. Certified Nurse Aide #2 reported they were providing care to Resident #1 with Certified Nurse Aide #1. During the provision of care, Resident #1 became combative and struck Certified Nurse Aide #1. They stated Certified Nurse Aide #1 then struck Resident #1 in the face in response. Per the facility investigative report, Certified Nurse Aide #1 acknowledged Resident #1 struck them during care and they denied striking the resident back. Certified Nurse Aide #1 stated they continued to provide care as usual to Resident #1 after the incident. Certified Nurse Aide #1 reported Resident #1 had a bloody nose, but they did not know the cause of the bloody nose. Pending the outcome of the investigation, Certified Nurse Aide #1 was placed on indefinite suspension.Witness statement from Certified Nurse Aide #2 dated 05/26/2026 documented at 6:30 AM, they asked Certified Nurse Aide #1 to assist them with getting Resident #1 out of bed and warned Certified Nurse Aide #1 the resident was combative and would swing. The resident ended up swinging; they hit Certified Nurse Aide #1 in the face and Certified Nurse Aide #1 swung back at the resident in the face and Resident #1 had a bloody nose for about 30 seconds.Witness statement from Certified Nurse Aide #1 dated 05/26/2026 documented at 6:00 AM that day, Certified Nurse Aide #2 asked them for help with providing care for Resident #1. Both certified nurse aides were attempting to change the resident and Certified Nurse Aide #2 warned Certified Nurse Aide #1 the resident may swing so they should be careful. As they were rolling the resident towards Certified Nurse Aide #2, the resident threw their left hand up which hit Certified Nurse Aide #1 in the face, causing their glasses to fall off their face. They stated Certified Nurse Aide #2 handed their glasses back to them, and they continued to provide care to Resident #1. Certified Nurse Aide #2 asked Certified Nurse Aide #1 if they needed a break and they stated they did not need a break and should continue to provide care to Resident #1. They continued to clean the resident and get them dressed. When they transferred the resident into a wheelchair, they noticed Resident #1's right nostril was bleeding.Witness statement of events documented by Assistant Director of Nursing #1 on 05/26/2026 collected during a phone interview (time unknown) with Certified Nurse Aide #1 documented after Certified Nurse Aide #2 handed them their glasses, they continued to change the resident. They transferred the resident to a wheelchair and that was tough as Resident #1 was holding onto the certified nurse aides and they struggled to sit in the wheelchair. Resident #1's nose started to bleed after being transferred into the wheelchair.Nursing Progress Note dated 05/26/2026 at 1:56 PM by Assistant Director of Nursing #1 documented Resident #1 was reportedly involved in an altercation with a certified nurse aide during the 11:00 PM to 7:00 AM shift. Small amount of dried blood noted to Resident #1's right nostril. New orders were received to obtain facial x-rays. Resident #1's family and sheriff's office were notified.During a telephone interview on 06/29/2026 at 11:33 AM, Certified Nurse Aide #2 stated if a resident was being aggressive or combative during care, if the resident could be left in a safe setting, they would reapproach the situation. They stated on the day of this incident; they told Certified Nurse Aide #1 to be careful when providing care as the resident will punch somebody. They stated Resident #1 punched Certified Nurse Aide #1 and then Certified Nurse Aide #1 hit Resident #1. Certified Nurse Aide #2 stated to Certified Nurse Aide #1 they could come back and reapproach the resident, but Certified Nurse Aide #1 said No, let's get it done and over with. During a telephone interview on 06/29/2026 at 1:00 PM, Director of Nursing #1 stated when handling a resident that may be combative or aggressive, certified nurse aides were expected to use deescalating techniques which included speaking to the resident in a calm manner, explaining what they were doing and why they were doing it, and to use redirection and other things they knew would calm the resident down. If a resident was at harm to their self or others, certified nurse aides should call for help. In this instance there were two certified nurse aides providing care to Resident #1. They would expect one aide to step out and let a nurse know the resident was having behaviors. During a telephone interview on 06/30/2026 at 3:32 PM, Administrator #1 stated during orientation, staff received behavioral and mental health training in which appropriate interventions used with residents who were combative/aggressive were discussed. Interventions needed to be resident specific. Certified nurse aides should not be alone if they were providing care for a resident with a history of combative or aggressive behavior. If a resident was exhibiting combative or aggressive behavior during care, the certified nurse aide should step out of the situation and reapproach the resident. They should not continue providing care to the resident if the resident was being combative or aggressive. 10 New York Code, Rules, and Regulations 415.4(b)(1)(i)

Based on record reviews and interviews, the facility failed to ensure that all allegations of abuse or neglect were reported immediately to the facility administrator. Specifically, Certified Nurse Aide #2 stated they witnessed Certified Nurse Aide #1 strike Resident #1 in the face and did not report it until two and a half hours later. The findings include: Resident #1 Resident #1 was admitted to the facility with diagnoses of Alzheimer's disease (a progressive, irreversible brain disorder and the most common cause of dementia), neurocognitive disorder with Lewy bodies (a progressive brain disorder caused by the abnormal buildup of proteins in the brain), and atrial fibrillation (common, irregular heart rhythm where the heart's upper chambers beat chaotically). The Minimum Data Set (an assessment tool) dated 03/27/2026 documented the resident was usually understood, sometimes understood others, and was severely cognitively impaired. The policy and procedure titled Abuse - Prohibition, Protocol, Type of Abuse, Response/Reporting, last reviewed 01/2026, stated persons observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to their immediate supervisor or administrative staff. The Progress Note dated 05/26/2026 at 1:56 PM documented that Assistant Director of Nursing #1 was informed of an altercation between Resident #1 and Certified Nurse Aide #1 during the overnight (11:00 PM to 7:00 AM) shift at 09:10 AM. They then informed the family, medical provider, and started an investigation. In the Incident and Accident Statement Form Witness Statement dated 05/26/2026. Certified Nurse Aide #2 documented they had witnessed abuse at 06:30 AM and did not report it until 09:10 AM to Assistant Director of Nursing #1. During an interview on 06/03/2026 at 12:07 PM, Certified Nurse Aide #2 stated they did not want to report it to the shift supervisor because of an incident they knew of that happened at another facility, so they waited for Assistant Director of Nursing #1 to come in. During an interview on 06/03/2026 at 01:28 PM, Director of Nursing #1 stated the incident should have been reported immediately. They stated education on abuse and abuse reporting was given to all employees upon hire and annually. Past non-compliance has been identified for F609. Findings include facility education on abuse and abuse reporting that began on 05/26/2026 and completed on 06/01/2026. This education was provided to approximately 200 employees all employees of the facility. 10 New York Codes, Rules, and Regulations 415.4 (b) (4)

Based on observations, record review, and interviews, the facility failed to ensure correct installation, use, and maintenance of bed rails (side rails, safety rails, grab bars, assist bars, enabler bars) to ensure there was no gap between the bed rail and mattress wide enough to entrap a resident's head or body for four of four residents (Residents #3, #10, #12, #101, and #112) reviewed. Specifically, Resident #10's bed rail failed the entrapment zone test in Zone 3 (space between the mattress and the bed rail); Resident #101's bed rail failed the entrapment zone test in Zone 1 (space within the bed rail itself); and Residents #3, #10, #12, #101, and #112 did not have routine inspections of their mattress and/or bed rails for areas of possible entrapment. The facility did not evaluate alternatives to bed rails, failed to review the risks and benefits of bed rails with the residents or resident representatives, and failed to obtain informed consent prior to the installation of bed rails. This resulted in no actual harm with likelihood of serious harm, serious injury, serious impairment, or death that is Immediate Jeopardy and Substandard Quality of Care for all 77 residents with bed rails.Findings include: The facility policy and procedure Proper use of Side Rails, revised 01/2026 documented side rails were only used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. An assessment was made to determine the residents' symptoms, risk of entrapment and reason for using side rails. When used for mobility of transfer, an assessment included a review of the resident's bed mobility, ability to change positions, transfer to and from bed or chair, and to stand and toilet; and risk of entrapment from the use of side rails and the bed's dimensions are appropriate for the resident's size and weight. Consent for the use of restrictive device was obtained from the resident or legal representative and less restrictive interventions were incorporated in care planning. Risk and benefits were considered for each resident and consent for side rail use was obtained from the resident or legal representative, after potential benefits and risks were presented. Manufacturer instructions for the operation of side rails were adhered to. Residents were checked periodically for safety related to side rail use and the facility assessed the space between the mattress and side rails to reduce risk for entrapment. The 2006 United States Food and Drug Administration Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment documented dimensional limits for entrapment in Zones 1-4 to reduce the risk for entrapment. Zone 1 was any open space within the perimeter of the rail. Openings in the rail should be small enough to prevent the head from entering. A loosened bar or rail can change the size of the space; the recommended space was less than 120 millimeters, representing head breadth. Zone 3 was the space between the inside surface of the rail and the mattress compressed by the weight of a patient's head. The space should be small enough to prevent head entrapment when taking into account the mattress compressibility, any lateral shift of the mattress or rail, and the degree of play from loosened rails. The recommendations were for a dimension of less than 4 3/4 inches because the head was presumed to enter the space before the neck.During observations on 05/13/2026 between 9:42 AM and 10:30 AM, bed entrapment zones were measured as identified by the United States Food and Drug Administration Hospital Bed Safety Workgroup Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities, and Home Care Settings using the facility's bed system measurement tool. A total of five beds were sampled (Residents #3, #10, #12, #101, and #112). One bed was out of compliance with Zone 3 entrapment guidelines (the space between the mattress and the side rail should be no greater than 4 and 3/4 inches) and one bed was out of compliance with Zone 1 entrapment guidelines (the perimeter of the side rail with a space less than 120 millimeters). During observations and record review on 05/14/2026, 77 residents had bed rails on their beds.1) Resident #10 had diagnoses including fractured vertebrae and hemiplegia (paralysis on one side of the body). The 03/06/2026 Minimum Data Set (a resident assessment tool) documented the resident had moderate cognitive impairment, required supervision for rolling, partial to substantial assistance for all other transfers and mobility, had two or more falls since last admission, and did not use side rails.The comprehensive care plan, initiated 12/19/2025 and revised 03/25/2026, documented Resident #10 had an actual fall related to cognitive deficits and gait/balance problems. Interventions included the bed against the wall on the right side and side rails placed to the left side of the bed. There was no documented evidence of a physician order for the use of side rails; physical therapy assessments to determine how the resident used side rails; if alternatives to a bed rail were attempted; a side rail assessment was completed prior to installation; risks and benefits of the side rails were explained to the resident or their representative; consent was obtained prior to side rail installation; or of ongoing monitoring of entrapment zones.During an observation on 05/11/2026 at 4:11 PM, Resident #10 was not in their room. The resident's bed was not against the wall, there was one side rail on the right side of the bed, and a border mattress (elevated edges) in place. There was a large gap between the mattress and the side rail. During an observation and on 05/13/2026 at 9:42 AM, the resident's bed had a side rail on the right side and a border mattress in place. The Director of Maintenance and the Director of Rehabilitation measured entrapment zones with the facility side rail measuring tool as outlined in the Food and Drug Administration guidelines. The bed and side rail were out of compliance with Zone 3 entrapment guidelines (the space between the mattress and the side rail was greater than 4 3/4 inches). 2) Resident #101 had diagnoses including Alzheimer's disease and history of falls. The 02/26/2026 Minimum Data Set documented the resident had severe cognitive impairment, required partial to substantial assistance for most transfers and mobility, and did not use a bed rail.The Comprehensive Care Plan, initiated 01/06/2026 and revised 03/06/2026, documented Resident #101 had an actual fall related to limited mobility, gait/balance issues, poor safety awareness, history of falls and cognitive impairment. Interventions included the bed against the wall with side rails for bed mobility. There was no documented evidence that alternatives to a bed rail were attempted; a bed rail assessment was completed prior to bed rail installation; risks and benefits of the bed rails were explained to the resident or their representative; consent was obtained prior to bed rail installation; and of ongoing monitoring of entrapment zones. During an observation and interview on 05/11/2026 at 3:09 PM, Resident #101's bed had a side rail on the right side with a large gap between the top of the rail and the top of the mattress. The resident stated they used the rail to pull themselves up and to get out of bed. During an observation on 05/13/2026 at 10:30 AM, Resident #101's bed had a side rail on the right side of the bed. The Director of Maintenance and the Director of Rehabilitation measured entrapment zones with the facility side rail measuring tool as outlined in the Food and Drug Administration guidelines. The bed was out of compliance with Zone 1 entrapment guidelines (Zone 1 within the rail itself, was greater than 4 3/4 inches). 3) Resident #3 had diagnoses including paraplegia (inability to control/move lower parts of the body), lack of coordination, and muscle weakness. The 03/18/2026 Minimum Data Set documented the resident had intact cognition, was dependent or required substantial/maximal assistance for most transfers and mobility and did not have side rails. The 03/12/2026 Comprehensive Care Plan, revised 04/20/2026, documented the resident was at risk for functional decline in mobility and self-care related to polyneuropathy (nerve damage), chronic kidney disease, and wounds. Interventions included side rails to assist with turning and positioning in bed and engage, encourage, educate and regularly assess the resident's ability to use call bell and appropriate assistive/adaptive devices to improve, maintain, and reduce risk of decline in function, injury and falls. There was no documented evidence of a physician order for the use of side rails; physical therapy assessments to determine how the resident used side rails; if alternatives to a bed rail were attempted; a side rail assessment was completed prior to installation; risks and benefits of the side rails were explained to the resident or their representative; consent was obtained prior to side rail installation; or of ongoing monitoring of entrapment zones. During an observation on 05/11/2026 at 3:15 PM, Resident #3 was in their chair and bilateral side rails were on their bed. They stated the bars were too high up on the bed for them to use to help with bed mobility. During an interview on 05/13/2026 at 9:42 AM, the Director of Rehabilitation stated side rails could not be more than 4 3/4 inches away from the mattress. Resident #10's bed failed Zone 3 entrapment guidelines, using the side rail measuring tool. They were unsure when the resident had an assessment with therapy for side rails as the resident had not been taking part in physical therapy for a while. They were unsure how often resident assessments or side rail assessments needed to be done. They were unsure if they needed to get consent for side rails but believed that they had never gotten one. Side rail use was placed in the care plan, and the provider had to be okay with putting them on. They were not sure if side rails required an order. The therapy department identified where side rails were in the building quarterly, but did not perform risk assessments for them. To place them on beds, an email or maintenance ticket was placed and maintenance attached the bar to the bed. They were unsure if maintenance assessed the risk of entrapment. During an interview on 05/13/2026 at 9:45 AM, the Director of Maintenance stated they installed the side rails on the beds. They get an email or a maintenance request and then attach side rails to the bed. They never conducted an entrapment assessment on any of the beds that had side rails on them. They were not sure how to perform the assessment or how to use the side rail measuring tool. During an interview on 05/13/2026 at 4:06 PM, Registered Nurse Unit Manager #20 stated when a resident wanted a side rail, physical therapy assessed the resident. If therapy felt it was beneficial, they would let the provider know. They stated they did not know if maintenance or therapy placed the side rails on the bed. If they noticed a resident was no longer using the side rail or if they thought the resident would benefit from a side rail, they placed a referral for physical therapy. There were no routine assessments, just occasional changes. Side rails were used to help residents with independence and increase mobility. They were not sure what other interventions there were to help with bed mobility. They believed that side rails needed a provider order and were unsure if consents were needed. Risks of side rails included the resident sliding, getting hurt, getting pinched, the side rail unscrewing and the resident falling. They were not sure if maintenance performed any checks on the side rails. During a follow up interview on 05/13/2026 at 4:17 PM, the Director of Maintenance stated no side rail was placed on a bed without rehabilitation's approval. Therapy placed a work order with a specific side rail type, but would take any bar that was available and attach it to the bed the resident was in. The side rails were bolted on. The side rails they had available would not be able to fit every bed. Not all side rails were universal to fit all beds. Beds were checked once a year to ensure the bar was tight, but they did not do any assessments with the side rail measuring tool to identify entrapment zones. They never checked beds for risk for entrapment. During a follow up interview on 05/13/2026 at 4:44 PM, the Director of Rehabilitation stated they did not know where side rail assessments were documented. When they were asked by nursing to assess a resident for side rails, it should be in a physical therapy screen. When requested by rehabilitation, maintenance would put the side rail on the bed. They were unaware of other interventions for bed mobility other than a trapeze bar for paraplegic residents. They tried to educate residents to become confident to go without side rails on their bed. They stated they decided what side rail was needed by resident weight, if they needed a regular side rail or a bariatric side rail. If maintenance could not get the side rail to attach to the bed, they let therapy know, but that has not happened in a while. They did not know if risks and benefits of side rails were discussed with residents or resident representatives or where it would be documented. During an interview on 05/13/2026 at 5:58 PM, the Director of Nursing stated therapy saw all residents on admission and anyone who they deemed needed a side rail was discussed at their morning interdisciplinary team meeting. Physical therapy performed quarterly assessments or as needed with referrals or change in condition. Therapy determined the need for a side rail, but if they thought something else would help mobility, they tried that intervention first. Some residents asked for side rails for peace of mind. They needed approval from a provider for side rails. They would have a discussion with the resident or resident representative about side rails, but consents were never obtained. Side rails were added to resident care plans and were used as a fall intervention if they determined a fall happened because the resident was trying to move around in bed. Maintenance attached side rails to the bed. They stated they believed risk for entrapment assessments were done on admission. During an interview on 05/13/2026 at 10:11 AM, the Administrator stated they were not aware beds were not assessed for risk of entrapment. They stated they just found out beds were supposed to be checked regularly and residents required assessments regularly. They stated this was new territory for them. During a follow up interview on 05/13/2026 at 4:02 PM, Administrator stated side rail referrals were sent to rehabilitation for maneuvering issues. Rehabilitation evaluated for appropriateness and nursing was made aware to get a provider order and update the care plan. They were unsure how therapy determined other appropriate interventions prior to using side rails. The side rails and beds were not audited, and they were not aware of the measuring device or its use until 05/13/2026 when the beds were measured.During an interview on 05/14/2026 at 10:56 AM, Nurse Practitioner #22 stated they did not know that side rails required assessments, a provider order, and consents. They were never asked to place a side rail order. They stated they did not know the risks associated with side rails. Side rails should be used by cognitively intact residents working with physical therapy/occupational therapy for bed mobility. They believed a resident with cognitive impairment had poor safety awareness and could get a body part stuck in the rail. There was a possibility for significant risk or death. Repeated efforts were made to contact the Medical Director on 05/14/2026, but a response was not received. 10 New York Code Rules and Regulations 415.12(h)(1)(2)***********************************************************************************************The facility was notified of the Immediate Jeopardy on 05/14/2026 at 12:00 PM. The Immediate Jeopardy was removed on 05/15/2026 prior to the completion of the survey.The facility implemented the following to remove the immediacy:- The facility removed all bed rails from resident beds, except for two residents who refused to have them removed. They provided proof of risk of entrapment assessment, an assessment from physical therapy and a consent that included a discussion of the risk versus benefit. - The facility provided in-service education to 100% of staff as of 05/14/2026 at 9:01 AM, with plans for ongoing education of staff prior to the start of their next shift for those not currently on the schedule.- The survey team interviewed 19 staff members from various disciplines. All staff demonstrated knowledge of the education provided regarding bed rails.

Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety and to prevent an outbreak of food borne illness in one (1) of one (1) main kitchen. Specifically, the 3-bay sink chemical sanitizer concentration was not within manufacturer range and subsequently the Food Service Director did not monitor chemical sanitizing; Dietary Aide #32 was reusing trays and plate covers without sanitizing them; Cooks #55 and #56 improperly cooled potentially hazardous food on the kitchen counter; Dietary Aide #57 stacked pans that were not air dried; and there were unlabeled items and staff food in the kitchen reach in refrigerator. Findings include:The facility policy Temperatures Cooking and Cooling, revised 04/2024, documented food would be cooled from 140 degrees Fahrenheit to 70 degrees Fahrenheit within 2 hours. Acceptable and safe cooling methods were ice bath, ice paddle, dividing food into small and shallow pans placed in the refrigerator, or in a blast chiller. The undated facility policy Dishwashing Down, documented when the dish machine was down, no tray, pan, or food contact surface would be reused until it was properly sanitized and air dried. The facility policy Foodborne Illnesses, revised 01/2025, documented potentially hazardous foods included meat and eggs, and leading cause of foodborne illness was improperly cooled foods. The facility policy HACCP (Hazard Analysis Critical Control Points) Guidelines for Food Safety, updated 01/2025, documented food must be cooled rapidly to 41 degrees Fahrenheit by dividing into small, shallow pans in an ice bath or refrigerate on the top shelf and stir every 15 minutes to 60 minutes. Food Storage During an observation and interview on 05/11/2026 at 11:49 AM, the reach-in refrigerator on the cookline was 47 degrees Fahrenheit and contained a pan of unlabeled and undated rice for resident consumption. There were several staff food items. The Food Service Director stated it was not an issue to combine staff and resident food in the refrigerator if staff food was limited to a certain shelf. During an observation on 05/13/2026 at 9:50 AM, the reach-in refrigerator on the cook line contained several resident food items and a staff member's partially consumed soda on the same shelf. During an interview on 5/18/26 at 12:50 PM, the Food Service Director stated they did not use the reach in refrigerator on the cook line for resident food because they did not trust the temperature of it, and it was used for staff food only. They did not realize it was used for residents' food, but it was not an issue to mix the two if staff food was only in one corner. Sanitation The April 2026 and May 2026 Dish Machine Ware Washing Log documented the dish machine was working through dinner on 04/30/2026 and was out of order on 05/01/2026 at breakfast. During an observation and interview in the main kitchen on 05/12/2026 at 10:50 AM, Dietary Aide #32 sprayed down the dirty breakfast trays and plate covers with the hose in the dish machine area. They wiped them off with a cloth that was sitting in a metal bowl containing brown water. No suds were visible in the water. They stated the bowl contained soapy water. No sanitizer was present in the area. They stacked the trays and plate lids upright on a cart after wiping them off and brought them to the tray line for use at lunch. During an observation and interview on 05/12/26 at 11:56 AM, Dietary Aide #57 was washing pots and pans at the 3-bay sink. They stated they did not wash any trays, or insulated plate covers that day, only pots. Those were usually cleaned in the dish washer, which was broken. They stated staff were cleaning them in the dishwasher area still. During an interview on 05/12/2026 at 12:03 PM, the Food Service Director stated the dish machine had been down for about 2 weeks because it was not heating correctly, and parts would arrive that day. They were washing the trays and plate covers by spraying them with cold water, washing with detergent, then soaking in a bucket of sanitizer. The correct method for washing them when the dish machine was down was in the 3-bay sink by washing, sanitizing, then drying them on a rack. They were not using any adaptive equipment currently because they could not properly sanitize them without hot water. The unit staff were washing the adaptive mugs and lids up on the units but did not know how or what they were using to do that. They could not be sure the mugs and lids had been properly washed or sanitized. The dishwasher was reported to maintenance and the Administrator at the time it broke. During an interview on 05/12/2026 at 12:16 PM, Maintenance Secretary #59 stated they were notified by electronic mail that the dishwasher went out of service on 04/22/2026 and shared the information with the Administrator. During an interview on 05/12/2026 at 12:23 PM, the Administrator stated the vendor received their check and would be in by tomorrow with the parts to complete the dishwasher repair. They came in a couple weeks ago, but the parts were not available yet. They did not notify the Department of Health of the dishwasher being down because they thought it would be a quick repair. The facility was using disposable dishware and followed the normal sanitizing process in the kitchen for trays, plate covers, and pans. They had residents with illnesses that could be transmitted on unclean dishes. There were residents who still received their adaptive feeding equipment as needed. They stated therapy should take all adaptive feeding equipment down to the main kitchen to be adequately cleaned and sanitized. They were not aware the kitchen staff were not properly washing and sanitizing the reused trays and insulated lids. During an interview on 05/12/2026 at 12:29 PM, the Director of Rehabilitation stated they were using a modified built-up grip with residents and wiped them off with a sanitizer wipe. Adaptive mugs with lids were brought back to the therapy department and washed with soap and water in the sink in the bathroom. The process was to let hot water run for 20 seconds then wash with soap and water. During an observation in the main kitchen on 05/12/26 at 2:33 PM, Dietary Aide #32 had three separate bins to clean, rinse, and sanitize the dirty trays and plate covers from lunch. All bins were visibly cloudy and soiled. Dietary Aide #32 placed some visibly soiled lids into the rinse bin, then placed them onto the rack for the next meal without washing or sanitizing them. Stacks of four trays were rinsed at one time, not submerged individually, then stacked together on a rack without air drying. During an observation of the main kitchen 3-bay sink on 05/12/26 at 2:46 PM, the sanitizer concentration measured over 500 parts per million (high). The water was dark red color, and the test strip turned a dark blue. The Food Service Director tested the sanitizer concentration, and it again measured over 500 parts per million. They started to add water to dilute the sanitizer but were unsure how much to add or what the water temperature should be. During an observation and interview on 05/12/26 at 3:58 PM, the 3-bay sink sanitizer measured over 500 parts per million. The Food Service Director stated the acceptable sanitizer level for their product was 200-400 parts per million and 500 parts per million was not acceptable. They used a vendor-maintained dispenser but had to adjust the sanitizer concentration manually. They did not know why, it was just how it was, and they adjusted the strength of sanitizer each time they set up the sanitizer sink. During an interview on 05/13/2026 at 11:00 AM, the Food Service Director stated dishware was sanitized to kill harmful germs, and they were still waiting on a dishwasher part to come in. When the dish machine was down, therapy cleaned the special adaptive mugs and lids in the rehabilitation department. They did not know how or what they were using to do that. They were aware that the facility had Clostridium Difficile (highly contagious spore resistant to many sanitizers) positive residents in the facility but stated the quaternary sanitizer they used in the main kitchen killed that organism. During an observation and interview on 05/13/2026 at 11:08 AM, the following residents required specific adaptive feeding equipment. The equipment was observed on the tray line near the dishware for lunch meal service. -Resident #50: 2-handled mug with lid, plate guard, regular metal silverware (no plastic);-Resident #52: regular silverware (no plastic);-Resident #123: 2-handled mug with lid;-Resident #183: 2-handled mug with lid, built up grip with metal silverware;-Resident #197: 2-handled mug with lid, scoop dish;-Resident #215: 2-handled mugs, built up grip with metal silverware. The Chemical Sanitation Record log had entries 3 times a day for 05/13/2026, 05/14/2026, and 05/15/2026 and then stopped. The log did not record any actual sanitizer concentration results and only recorded the recommended manufacturer range of 200-400 parts per million repeatedly. During an observation and interview on 5/18/26 at 12:50 PM, the Food Service Director stated the 3-bay sanitizer dispenser was serviced 05/13/2026 by the vendor and was sometimes working correctly. The water in the sanitizer bay was bright red and tested over 500 parts per million. They stated sometimes the water was pink in color and tested at 400 parts per million. The chemical level in the sink was too high because the dispenser was still broken, had still to adjust the concentration manually, and the sink was just filled. The sinks were changed at least every 2 hours. During an interview on 05/19/2026 at 9:15 AM Vendor Representative #60 stated they were in the facility on 05/13/2026 and adjusted the sanitizer level in the 3-bay sink to dispense at 400 parts per million. They found it was running at 500 parts per million when they arrived. The facility used Knoxville, which was a quaternary sanitizer and the manufacturers recommendation was 200-400 parts per million concentration. They were coming back to the facility, but it did not make sense the dispensed sanitizer mix was red in color and tested over 500 parts per million one time, then a pink color and tested 400 parts per million another time. Cooling The Cooks Time Temperature Cooling Log documented the date, the food item to be cooled, the time and temperature the cooling process started at, the time and temperature after 2 hours of cooling, and the time and temperature after 4 hours of cooling. None of the entries on the log recorded start times with temperatures and the last entry was 05/12/2026. During an observation and interview on 05/13/2026 at 10:08 AM, four pans of food were sitting on a rack at room temperature and were identified by the Food Service Director as sausage, scrambled eggs, hard boiled eggs, and pureed scrambled eggs left over from the breakfast tray line. They stated their cooling procedure was to pull the food from the tray line and leave it on the rack or counter at room temperature for 2 hours, then check the temperature. If it was 70 degrees Fahrenheit or less, they left it out for 2 more hours and rechecked the temperature. If it was 41 degrees Fahrenheit or less, they put the pan in the refrigerator. They never cooled food in the refrigerator. None of the items were listed on the cooks cooling log and they could not determine exactly when the items were taken off the tray line to start cooling. At 10:50 AM the following temperatures were recorded; -scrambled eggs 84 degrees Fahrenheit;-sausage 129 degrees Fahrenheit;-hard boiled eggs 97.5 degrees Fahrenheit;-pureed scrambled eggs 90.2 degrees Fahrenheit. During an interview on 05/13/2026 at 11:00 AM, the Food Service Director stated the cooks should utilize the cooks cooling log every time they cooled cooked food, including leftovers from the tray line. They did not know why the cooks were not following this, they had been in-serviced on the form, and it could be hazardous to residents and cause foodborne illness if the food did not reach a safe temperature quickly. During an interview on 05/13/2026 at 11:10 AM, [NAME] #55 stated they were only instructed to use the cook cooling log for items they cooked then immediately chilled as part of a recipe, such as the pasta they made for a cold pasta salad. They were never instructed on how the log was supposed to be used, it was just posted on the wall one day without explanation. During an interview on 5/18/26 at 12:50 PM, the Food Service Director stated the current cooling process was the same as last week, they still put leftover food from the steamtable on the rolling cart or the prep table to cool for 2 hours then checked the temperature. If the results were 70 degrees Fahrenheit or less, it was put in the cooler. Their cooling practices were based on facility cooling policies. They used cooling at room temperature despite that method not listed in their cooling policy as an acceptable method because they did not have time for ice baths. During an interview on 05/18/2026 at 3:45 PM, [NAME] #56 stated when cooling food left over from the steam table, they followed the posted policy on the wall by the cook area. They put it on the counter for 2 hours, then checked the temperature. If it was 70 degrees Fahrenheit or higher, they threw it out. 10 New York Codes, Rules and Regulations 415.14(h)

Based on observations and interviews, the facility failed to ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for two (2) of two (2) test trays (05/13/2026 breakfast meal and 05/19/2026 lunch meal). Specifically, food was not served at palatable and appetizing temperatures during the breakfast meal on 05/13/2026 and lunch meal on 05/19/2026.Findings include: The facility policy Dining and Meal Service Policy and Procedure, dated 04/19/2026, documented individuals would be provided with nourishing, palatable, attractive meals that meet daily nutritional and special dietary needs. The facility policy Food Temperature and Test Tray Audits Policy and Procedure, dated 04/19/2026, documented hot food would be served at 135 degrees Fahrenheit or above, cold beverages and puddings would be served at 55 degrees Fahrenheit or below, and milk or milk products would be served at 45 degrees Fahrenheit or below. During an observation on 05/13/2026 at 8:45 AM, Resident #154's meal tray was tested, and a replacement was provided. Food temperatures were measured as follows: eggs (not listed on ticket) were 106.9 degrees Fahrenheit, breakfast sausage was114.6 degrees Fahrenheit, milk was 48.2 degrees Fahrenheit, and cinnamon oatmeal was 97 degrees Fahrenheit. All food was served on paper plates and coffee was missing from the tray. The eggs were cold, and the oatmeal was cold and pasty. During an interview on 05/13/2026 at 11:00 AM, Food Service Director #58 stated they used to get complaints of cold food but that resolved when they started using the new delivery carts last week. The dietitian did test trays a few times a week and checked tray temperatures on the floor but did not taste or evaluate the food. During an interview on 05/14/2026 at 10:27 AM, Licensed Practical Nurse #38 stated residents complained the food did not taste good, was tough, or was cold. During an interview on 05/18/2026 at 11:42 AM, Registered Nurse Unit Manager #35 stated some residents complained about the food; it did not taste good and was cold. During a lunch meal observation on 05/19/2026 at 11:49 AM, Resident #51's meal tray was tested in the presence of Certified Nurse Aide #7, and a replacement was provided. The super pudding was 66.7 degrees Fahrenheit, brown sugar glazed ham was 112.3 degrees Fahrenheit, candied yams was 132.4 degrees Fahrenheit, and green beans was 122.4 degrees Fahrenheit. All food was served on paper plates. During an interview on 05/19/2026 at 12:51 PM, Food Service Director #58 stated the temperature range of food items was not sufficient. The milk and pudding should not have been served above 40 degrees Fahrenheit, and the hot food should have been at least 135 degrees Fahrenheit. They felt the low temperatures for hot foods were due to using paper plates for dining. 10 New York Codes, Rules and Regulations 415.14(d)(1)(2)

Based on observations, record review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (3) of six (6) residents (Residents #2, #5 and #62) reviewed. Specifically, Resident #5's urinary catheter drainage bag was placed directly on the floor; Resident #2 was on enhanced barrier precautions and Licensed Practical Nurse #38 provided medications via a feeding tube without wearing required personal protective equipment; and Resident #62 was on contact precautions for clostridium difficile (a highly infectious bacteria) and Certified Nurse Aide #39 entered and exited their room, removed a food tray wearing only gloves and without performing hand hygiene. Findings include: The facility policy Enhanced Barrier Precautions, last reviewed 01/2026, documented nursing home residents with wounds and indwelling medical devices were at high risk of both acquisition of and colonization of multi-drug-resistant organisms. The use of gowns and gloves were used only for high contact resident care activities; a sign was placed outside the residents' room and was intended to be in place for the duration of the wound or discontinuation of the indwelling device that placed them at a higher risk. High contact resident care activities included device care or use. The facility policy Contact Precautions, last reviewed 01/2026, documented all personnel, including visitors, that had direct contact with a resident on contact precautions were required to follow all procedures outlined in the policy. When precautions were implemented, a sign was placed on the resident's door and remained in place until precaution procedures had been discontinued. The Contact Precaution sign documented that everyone must clean their hands, including before entering, and when leaving the room. Staff must put gloves on before room entry and discard gloves before room exit; put on gown before room entry and discard gown before room exit; and use dedicated or disposable equipment, clean and disinfect reusable equipment before use on another person. 1) Resident #62 had diagnoses including clostridium difficile. The 04/30/2026 Minimum Data Set assessment documented the resident had intact cognition and was not on isolation precautions. The 04/28/2026 Comprehensive Care Plan documented the resident was at risk for infection related to immunocompromise related to multiple myeloma, and history of methicillin resistant staphylococcus aureus and vancomycin-resistant enterococcus. Interventions included educating the resident or significant other regarding proper hand washing and handing of secretions, monitor labs, and monitor vital signs as ordered. The 04/28/2026 physician order documented strict contact precaution/isolation every shift for clostridium difficile, norovirus, vancomycin-resistant enterococcus, and methicillin resistant staphylococcus aureus. The 05/14/2026 Licensed Practical Nurse #38 progress note documented to monitor labs and vital signs, ensure resident safety, medication and treatments as ordered and enforce and follow contact precautions. During an observation and interview on 05/14/2026 at 9:24 AM Certified Nurse Aide #39 exited Resident #62's room with a meal tray and did not wear personal protective equipment or perform hand hygiene. Certified Nurse Aide #39 handed the food tray to another certified nurse aide and did not perform hand hygiene with soap and water prior to collecting a food tray from a different resident room. Certified Nurse Aide #39 stated they received infection control training in orientation. The white stop sign on the resident's door meant they had to look at the yellow sign to see what precautions the resident was on. When they performed care, they sometimes had to wear a gown and gloves. They were unsure why Resident #62 was on precautions. They stated they did not have to wear a gown in Resident #62's room because they were just collecting the meal tray and not performing care. During an interview on 05/14/2026 at 10:27 Licensed Practical Nurse #38 stated Resident #62 was on contact precautions for clostridium difficile and norovirus. Staff should wear a gown in the room, even when picking up a meal tray. Any time staff entered a contact or droplet precaution room they had to wear a gown and gloves. The infection control signage should be followed to protect residents and staff from spreading the virus. 2) Resident #2 had diagnoses including a gastrostomy (a feeding tube). The 05/07/2026 Minimum Data Set assessment documented the resident had moderately impaired cognition and had a gastrostomy tube. The 04/10/2026 Comprehensive Care Plan documented the resident had impaired skin integrity related to tube feeding and incontinence of bowel. Interventions included enhanced barrier precautions. The 04/10/2026 physician order documented to maintain enhanced barrier precautions every shift for indwelling medical device. During an observation on 05/13/2026 at 8:15 AM there was a sign outside the room documenting enhanced barrier precautions and to wear gown and gloves when performing resident care. Licensed Practical Nurse #38 checked the resident's gastrostomy tube site, checked for placement and proceeded to administer crushed medications through the gastrostomy tube and did not wear a gown. During an interview on 05/13/2026 at 1:49 PM Licensed Practical Nurse #38 stated Resident #2 was on enhanced barrier precautions and when doing high contact care activities, they had to wear a gown and gloves. Resident #2 had a gastrostomy tube, which meant when administering medication through the tube a gown and gloves needed to be worn. They did not wear a gown earlier when they administered medication to Resident #2. They did not wear a gown because they forgot. 3) Resident #5 had diagnoses that included stroke and urinary bladder dysfunction. The 12/29/2025 Minimum Data Set assessment documented the resident had severe cognitive impairment and had an indwelling urinary catheter. The 05/13/2021 Comprehensive Care Plan, revised 08/07/2025 documented the resident was at risk for infection related to environmental exposure, indwelling catheter, incontinence, open skin areas, and history of methicillin resistant staphylococcus aureus and extended-spectrum beta-lactamases (drug resistant organisms). Interventions included maintaining transmission-based precautions and performing hand hygiene before and after contact with the resident. The resident had an indwelling catheter related to bladder disorder/disease. Interventions included to change indwelling catheter as needed and change the urine collection bag per orders. The goal was for the resident to show no signs or symptoms of urinary infection. During an observation on 05/11/2026 at 4:17 PM Resident #5 was lying on their back in bed. The urine collection bag was sitting directly on the floor without a barrier. During an observation on 05/12/2026 at 9:33 AM the resident's urine collection bag was sitting directly on the floor without a barrier. During an observation on 05/12/2026 at 2:00 PM the resident's urine collection bag was sitting directly on the floor without a barrier. During an observation and interview on 05/12/2026 at 2:55 PM Certified Nurse Aide #19 stated they were Resident #5's aide that day. They made sure urinary collection bags were in a privacy bag, below the level of the bladder and off the floor. The resident's bag was hooked to the frame of the bed, but the resident had a low bed. They did not know how they were supposed to keep the bag from touching the floor when the resident had a low bed. If the resident had a normal bed the catheter bag would not touch the floor. During an interview on 05/12/2026 at 3:01 PM Licensed Practical Nurse #17 stated residents with low beds should have a barrier between the floor and the collection bag. They used clean disposable bed pads as a barrier. Resident #5 had a catheter and had a low bed. They should have a barrier between the collection bag and the floor. They did not know why they did not notice that the collection bag was on the ground. During an interview on 05/13/2026 at 9:12 AM Licensed Practical Nurse Unit Manager #19 stated special considerations for catheters placing the collection bag in a privacy bag when the resident was out of their room, keeping the bag below the level of the bladder and keeping the collection bag off the ground. They had to keep the bag from touching the ground to decrease the risk of infection. There needed to be a barrier between the bag and the ground if a resident had a low bed. Resident #5 had a catheter and a low bed. There should be a barrier between their collection bag and the ground. The facility used to have privacy bags that covered the whole entirety of the collection bag, so it worked as a barrier. The current privacy covers had an open bottom, so now they had to remember to put down a barrier. During an interview on 05/15/2026 at 11:03 AM Infection Control Registered Nurse #50 stated a catheter bag on the floor could introduce bacteria into the system and cause a urinary tract infection. Residents in low beds should have a barrier between the catheter bag and the floor. They could use a clean disposable bed pad as a barrier and change regularly to reduce infection risk. When orders were placed for a resident to be on transmission-based precautions they went to the floor and put up signage and reviewed with staff present. They reviewed donning and doffing personal protective equipment, depending on type of precaution. They should follow what was on the signage, it told them everything they needed to know. Contact precautions required personal protective equipment every time they went into the room and hands washed at a sink after doffing gloves. Enhanced barrier precautions were different; if answering a call bell or dropping off a meal tray, gown and gloves were not required. If staff needed to empty a catheter bag, reposition the resident or medication administration with tube feeding, they should wear personal protective equipment. During a follow up interview on 05/19/2026 at 9:14 AM Infection Control Registered Nurse #50 stated administering medications through tube feed required personal protective equipment. Staff did not need to wear gowns when medications were administered orally, only if they were through the feeding tube as this was high contact. Any time staff entered a room with clostridium difficile or any contact room they should wear personal protective equipment, even if they were just picking up a pen. Staff were required to wear gowns and gloves when delivering or removing a meal tray from a resident room with clostridium difficile or contact precautions. 10 New York Code Rules and Regulations 415.19(a)(b)

Based on observations, record review, and interviews, the facility failed to promote and facilitate resident self-determination including the resident's right to make choices about aspects of daily life that are significant to the resident for one (1) of five (5) residents (Resident #198) reviewed. Specifically, Resident #198 requested to be transferred back into bed and was not assisted timely after their request. Findings include:The facility policy Resident Rights, last reviewed 01/2026, documented all residents had the right to be treated with kindness, respect, and dignity as well as the right to self-determination. Resident #198 had diagnoses including muscle weakness and difficulty walking or moving around. The 04/14/2026 Minimum Data Set assessment (a health status assessment tool) documented the resident had moderate cognitive impairment and required substantial/ maximum assistance with chair/ bed-to-chair transfers. The comprehensive care plan initiated 11/27/2024, documented the resident was at risk for being a victim due to dependence on others for activities of daily living. Interventions included signs and symptoms of abuse and/ or neglect were assessed and reported. Resident #198 was observed at the following times:-On 05/11/2026 at 12:17 PM sitting in their wheelchair outside their room. Licensed Practical Nurse #10 was in the hallway with the medication cart. The resident told Licensed Practical Nurse #10 they wanted to get back in bed because their back hurt. The nurse wheeled their medication cart away and told the resident someone would come to help them. At 12:28 PM, the resident was still sitting in their wheelchair outside of their room and stated to the surveyor the staff was ignoring them and that was why they did not like to go to therapy because staff did not assist them back to bed when they returned. They stated their back and legs were hurting. At 1:03 PM Certified Nurse Aides #11 and #12 wheeled the resident and the mechanical lift into the room to put them back into bed (46 minutes after their initial request).- On 05/14/2026 at 11:22 AM, sitting in their wheelchair in the dining room eating pizza. At 11:30 AM they told Certified Nurse Aide #13 they wanted to get back in bed and the resident was told they had to until after lunch. At 1:31 PM they were assisted back to bed with the mechanical lift (121 minutes after their initial request). During an interview on 05/14/2026 at 1:34 PM, Resident #198 stated they were just put back in bed. They stated staff kept them up for so long and it was not right. That was the reason they did not like to attend physical therapy. It took two certified nurse aides to put them back to bed with the mechanical lift. Staff always told them they would put them back in bed after lunch but look at the time, they just left me in the hallway, and it was not right. During a telephone interview on 05/15/2026 at 1:03 PM, Certified Nurse Aide #11 stated if residents wanted to get back in bed during lunch, it was dependent on the number of staff available. If there were only one or two certified nurse aides, they could not do it because they had four residents who required feeding assistance and had to pass out meal trays. If the resident needed a mechanical lift for transfers, they would have to wait. Resident wishes should be honored because this was their home, and they were there for help with care. Resident #198 usually asked to go back to bed immediately after they returned from physical therapy and that was always around lunch time. The lunch trays arrived on the unit around 11:30 AM. They stated the certified nurse aides typically took their breaks before lunch which also decreased the number of staff to assist the resident back to bed. During an observation on 05/15/2026 at 1:34 PM, the resident was sitting in their wheelchair in the hallway outside of their room. They stated to the surveyor, see they are doing it again. During an interview on 05/15/2026 at 1:35 PM, Licensed Practical Nurse #10 stated when Resident #198 returned from therapy, they immediately requested to get back in bed. It was usually lunchtime, so they asked them to wait until after lunch. They should honor the resident's wishes to the best of their ability because this was their home, and they should get what they wanted and what they needed. During an observation on 05/15/2026 at 1:44 PM, Resident #198 asked the surveyor if they knew when the staff would assist them back to bed. At 1:45 PM, Licensed Practical Nurse #10 stated to the resident they had just told them that they wanted to get back to bed. Registered Nurse Unit Manager #9 and Certified Nurse Aide #14 wheeled the resident into their room with the mechanical lift. During an interview on 05/18/2026 at 1:38 PM, Registered Nurse Unit Manager #9 stated the residents had rights to have certain choices and preferences. If it was lunchtime, the resident still had the right to get back in bed. It was challenging to meet all requests based on staffing. The resident was participating in physical therapy and wanted to get back in bed as soon as they returned to the unit. If the resident was not assisted back to bed timely, they may not want to get up out of bed anymore. 10 New York Codes, Rules, and Regulations 415.5(b)(1-3)

Based on observations, record review, and interviews (iQIES intake 2961519), the facility failed to ensure a safe, clean, comfortable, and homelike environment for one (1) of six (six) resident units (Unit 3) and one (1) of six (6) unit dining rooms (Unit 3 dining room). Specifically, room [ROOM NUMBER] on Unit 3 had an unpainted patched wall, a wall with several long areas of scratched sheetrock, and missing and chipped paint on the bathroom door; the Unit 3 main dining room ice dispenser was not working and the basin that caught water was unclean. Findings include:The facility policy Quality of Life, Home Like Environment, last reviewed 1/26, documented residents were provided with a safe, clean, comfortable, and homelike environment. Characteristics of a homelike environment included, clean, sanitary, homelike setting, inviting colors and decor, comfortable noise levels, and comfortable lighting.The facility policy Work Orders, revised 7/22/2026, documented when there was a need for repairs or general maintenance, enter the request into the maintenance logs located at the nurse's station. Any repairs that took more than one day to complete were evaluated by the Director of Plan Operations and/or the Administrator to determine if the repairs needed to be outsourced for completion that it is scheduled in a timely manner. Unit 3The 11/26/2025 room [ROOM NUMBER] audit completed by Maintenance Technician #65 documented the doors and doors jams were unsatisfactory and needed painting, the window glass, sill, and tracks were unsatisfactory and needed cleaning, and the walls were unsatisfactory and needed painting.The 02/13/2026 room [ROOM NUMBER] unsigned audit documented the doors, door jams, and walls were unsatisfactory. There were no comments on pending repairs. The maintenance log dated 12/11/2025 to 05/18/2026 did not document any repairs to walls or doors in room [ROOM NUMBER].During observations on 05/12/2026 at 9:47 AM, 05/12/2026 at 2:40 PM, 05/14/2026 at 10:25 AM, and 05/15/2026 at 10:58 AM room [ROOM NUMBER]'s bathroom door had chipped and missing paint, a wall to the left was patched and not painted, and a wall to the left above the baseboard had multiple areas of scratched and missing sheetrock. During an interview on 05/14/2026 at 10:27 AM, Licensed Practical Nurse # 38 stated the resident in room [ROOM NUMBER] was on contact precautions and isolated to their room. If they noticed scratches in the sheetrock, unpainted patching of walls, or paint missing or chipped on a bathroom door, they notified maintenance by completing a work order in the computer. They stated they were in room [ROOM NUMBER] earlier in the day and did not notice the walls or bathroom door. They observed room [ROOM NUMBER] with the surveyor and stated the area was not homelike for the resident. During an interview on 05/15/2026 at 11:18 AM, Maintenance Technician # 64 stated their department was responsible for building maintenance including plumbing, electrical work, drywall, and painting. Nursing staff notified them of maintenance issues electronically by completing a work order. Work orders were prioritized and distributed amongst the department for completion. When a wall was damaged, they patched it the same day and painted it a few hours after the patch dried. If a patch was not painted, it was not homelike. Environmental rounds were completed daily by Maintenance Technician #65 and when repairs were necessary, the department was notified, and the repairs were completed. There were no outstanding work orders for room [ROOM NUMBER]. After observing the walls and bathroom doors in room [ROOM NUMBER], they stated the room was not homelike and the door and walls needed repairs. Ice Machine During observations on 05/11/2026 at 1:33 PM, 05/12/2026 at 10:25 AM, 05/13/2026 at 7:56 AM, and 05/18/2026 at 11:38 AM the Unit 3 main dining room ice machine did not dispense ice, and the drain rack was covered with white and brown debris. All maintenance requests and emails regarding the third-floor ice machine were requested. On 05/19/2026 at 3:30 PM the Administrator stated all information regarding the ice machine was forward electronically. The only information received was an invoice for the ice machine dated 04/29/2026. During an interview on 05/13/2026 at 8:01 AM, Certified Nurse Aide #7 stated the Unit 3 ice machine was broken for at least 6 months. They stated the debris in the catch basin looked like mold. Most days Unit Secretary #66 filled up a bucket with ice for residents because they were always asking for ice. When the ice in the bucket was used, they went to another floor to get ice for residents. During an interview on 05/18/2026 at 11:42 AM, Registered Nurse Unit Manager #35 stated when things needed repair, they completed a work order for maintenance to address. The ice machine was broken for at least 6 months. They put in a work order at that time and when they did not get a replacement or hear about a replacement, they sent a follow-up email to the Maintenance Director. They looked in the computer and the date of the email to the Maintenance Director was 04/01/2026. Since the ice machine was broken, they had a round thermal container filled with ice that residents accessed because it was a rehab floor and residents often asked for ice. The container had a metal scoop residents used to scoop the ice into their water pitchers. During an interview on 05/18/2026 at 12:06 PM, the Maintenance Director stated they requested a replacement for the Unit 3 broken ice machine one year ago and still did not have administrative approval. During an interview on 05/19/2026 at 8:22 AM, Unit Secretary #66 stated they worked Monday through Friday, and they started every workday by taking the thermal container to the kitchen and filling it with ice. They stated several months ago the Maintenance Director took the machine apart, ordered parts, and 2 days later put it back together and it still did not work. The Maintenance Director tried to order a new machine and corporate would not approve a new machine at the time. Many residents asked for ice every day and there were not enough certified nurse aides to leave the unit to get ice, so they filled the thermal bucket every day. Many residents on the unit filled their ice pitchers with ice daily. During an interview on 05/19/2026 at 8:31 AM, Resident #211 stated they asked for ice several times throughout the day. They liked a pitcher of ice first thing so as it melted, they had cold water. They wore oxygen and their mouth was always dry. They stated the ice machine was broken and had been for a while. There were many times the ice bucket was empty, and staff said they were out of ice, and they were directed to the fourth floor for ice. During an interview on 05/19/2026 at 8:35 AM, Resident #83 stated they went to the nurses every morning and filled their pitcher with ice using the metal scoop. Usually, they ran out of ice by the change of shift and there was not always staff available to refill the bucket. 10 New York Codes Regulations and Rules 415.29(j)(1)

Based on observations, record review, and interviews (IQIES intake 3011442), the facility failed to ensure all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated for one (1) of two (2) residents (Resident #46) reviewed. Specifically, Resident #46 was observed with a large bruise covering the left side of their face and there was no documented evidence the injury was thoroughly investigated to rule out abuse. Findings include:The facility policy Abuse-Prohibition Protocol, Type, of Abuse, Response/Reporting, last reviewed 01/2026, documented all reports of alleged mistreatment, neglect, abuse, or misappropriation of resident property or exploitation will be responded to immediately and intervention shall be initiated. Events to be investigated include but not limited to suspicious bruising. If the investigation involves an employee, the employee is suspended pending outcome of the investigation. The facility must report, to the New York State Department of Health, any suspected resident abuse immediately and no later than two hours after the allegation if the incident resulted in physical injury. Resident #46 had diagnoses including dementia, aphasia (difficulty speaking), and seizure disorder. The 03/18/2026 Minimum Data Set assessment documented the resident had severely impaired cognition and was dependent on staff for all activities of daily living. The comprehensive care plan dated 04/02/2026 documented the resident was at risk of being a victim of abuse due to the inability to understand their surroundings related to cognitive impairment. Interventions included assess for signs and symptoms of abuse, provide assistance with activities of daily living, ensure the resident was free from abuse, and offer food or activities of interest to keep the resident occupied. The undated care instructions documented the resident required the use of a mechanical lift with assistance of two for transfers in and out of bed, was dependent on staff for all care, and was on 30-minute safety checks. The video on call Consultant report dated 05/10/2026 at 12:39 AM documented Resident #46 was evaluated by Physician Assistant #37 for extensive ecchymosis (bruising) to the left side of the face. The exact mechanism of injury was unclear, and nursing was uncertain whether the resident experienced an unwitnessed fall. The resident was unable to provide a history. The diagnosis was facial ecchymosis of unclear etiology and possible unwitnessed fall. The plan was to continue monitoring for pain and discomfort, increased swelling or bruising, changes in responsiveness, notify provider of acute clinical changes or controlled discomfort, and notify family per protocol. The undated Accident and Incident Report completed by the Director of Nursing documented Resident #46 was observed with a dark purple discoloration mark located to the left side of their face. The resident was unable to give a description of events. The provider was notified, and they would update the significant other at a more appropriate time. There were no injuries observed at time of the incident. The remainder of the report was blank including level of consciousness, mobility, and injury type. There were three witness statements attached: -05/10/2026 witness statement completed by Certified Nurse Aide #40 documented they completed care on Resident #46 between 7:00 PM and 7:30 PM on 05/09/2026.They washed and changed the resident and made sure safety measures were in place including floor mats and booster pillows. They completed rounds before leaving at 9:00 PM and the resident was safe in their bed. Licensed Practical Nurse #42 administered medication around the time they were leaving at 9:00 PM. -05/10/2026 witness statement completed by Certified Nurse Aide #41 documented they did not assist with Resident #46's care on 05/09/2026. The last time they observed the resident was at approximately 8:00 PM when the resident was in the common area. They did not observe the resident or give care to the resident after that time. -05/11/2026 witness statement completed by Licensed Practical Nurse #42 documented they were assigned to the unit where Resident #46 was located on 05/09/2026 and arrived on the unit around 8:00 PM. At approximately 9:00 PM they entered Resident #46's room and administered medications. They left the room and did not notice a bruise because the left side of the resident's face was turned away from them. The 05/09/2026 3:00 PM-11:00 PM schedule for Unit 3 was documented the following staff were assigned:-Licensed Practical Nurse #42 at 8:00 PM-Certified Nurse Aide #40-Certified Nurse Aide #41-Certified Nurse Aide #43 There was no documented evidence of a witness statement from Certified Nurse Aide #43 included in the Accident and Incident Report. During an observation on 05/12/2026 at 1:30 PM, Resident #46 was in bed on their back with a large bruise covering the entire left side of their face. During an interview on 05/14/2026 at 5:53 PM Licensed Practical Nurse #42 stated they worked on 05/09/2026 and was assigned to the Unit 3 medication cart from 8:00 PM until 11:00 PM, then floated to Unit 5 from 11:00 PM until 8:00 AM shift. At approximately 9:00 PM they prepared medications for Resident #46 who was in their room in bed. The light in the room was off, and the resident was sleeping. They did not notice a bruise because the left side of the resident's face was away from them. Staff did not report a bruise or an incident. When they left on 05/10/2026 at approximately 8:00 AM, Registered Nurse Supervisor #36 stated Resident #46 had a bruise on their face, they completed the incident report and notified the Director of Nursing. During an interview on 05/14/2026 at 6:51 PM, Certified Nurse Aide #40 on 05/09/2026 they worked the 3:00 PM shift and was scheduled to leave at 9:00 PM. They floated to Unit 3 and was assigned to Resident #46. They were not sure of the names of the other two certified nurse aides or the licensed practical nurse, because it was not their normal unit. Around 7:00 PM to 7:30 PM they wheeled Resident #46 from the day room area to their room to get them ready for bed. They asked another staff to assist with transferring the resident back to bed because the resident required use of a mechanical lift. They were not sure of the name of the certified nurse aide that assisted them with the transfer. They left the unit at 9:00 PM and did not see a bruise on the resident prior to leaving. At approximately 4:00 AM they were awoken to several calls from the facility and when they answered they were told they were suspended until the investigation was completed. During an interview on 05/19/2026 at 1:31 PM, Certified Nurse Aide #41 stated they worked on 05/09/2026 from 3:00 PM until 11:00 PM with Certified Nurse Aides #40 and #43. They observed Resident #46 in the common area around the television around 8:00 PM. Resident #46 required the use of a mechanical lift to transfer back to bed. Certified Nurse Aide #40 was assigned to the resident and transferred the resident back to bed before they left at 9:00 PM. They did not assist with transferring the resident back to bed as they had their own assignment and was busy. They did not see anyone assisting Certified Nurse Aide #40 transfer the resident to bed. They worked on 05/10/2026 at 7:00 AM and between 9:00 AM and 10:00 AM the registered nurse supervisor sent them home and said they were suspended until the investigation regarding Resident #46 was completed. During an interview on 05/19/2026 at 1:44 PM, Certified Nurse Aide #43 stated they worked on Unit 3 on 05/09/2026 from 3:00 PM until 11:00 PM. They observed Resident #46 in the dining room for dinner and in the day room after dinner. The resident was assigned to Certified Nurse Aide #40 who put the resident to bed before leaving for the evening at 9:00 PM. They did not assist with the transfer and did not observe anyone assisting with the transfer. They worked 05/10/2026 and received a call from the Director of Nursing who stated they were suspended because of the incident. After speaking to the Director of Nursing and explaining they did not assist with the transfer, they were allowed to work. The Director of Nursing then reached out again on 05/12/2026 and explained they were suspended until the investigation regarding the incident with Resident #46 was completed. During an interview on 05/19/2026 at 11:45 AM, the Director of Nursing stated Resident #46 had an incident on 05/09/2026 that they investigated. Registered Nurse Supervisor #36 reported Certified Nurse Aide #44 found the resident around 11:30 PM with a large bruise to their face and notified Licensed Practical Nurse #34. The only staff that remained in the building from the 3:00 PM to 11:00 PM shift was Licensed Practical Nurse #42, and their witness statement was obtained. Registered Nurse Supervisor #36 obtained witness statements from Licensed Practical Nurse #42 who did not observe the bruise, and Certified Nurse Aide #43 who reported Certified Nurse Aide #40 and Certified Nurse Aide #41 put the resident to bed that evening. That witness statement was not attached to the accident and incident report with the other witness statements and they were not sure where that statement was located. The Director of Nursing obtained the witness statement from Certified Nurse Aide #41 who documented they did not participate in the care for Resident #46, and the resident was assigned to Certified Nurse Aide #40. When they asked Certified Nurse Aide #40 to describe the person that assisted them with transferring the resident to bed, they stated the staff was not working on the unit and came to Unit 3 looking for an adult brief when they asked for help transferring the resident. After the incident was discovered, the physician was notified, there were no new orders, and they told the supervisor to call the significant other in the morning. Certified Nurse Aide #40 and Certified Nurse Aide #41 were both suspended. When assisting with staffing on 05/10/2026 around 8:00 AM they were notified Certified Nurse Aide #41 was working and they directed the Registered Nurse Supervisor to notify Certified Nurse Aide #41 they were suspended pending investigation and had to leave until the investigation was completed. They observed the injury for the first time on 05/11/2026 in the early morning and observed patterns of bruising and a hole in the resident's bottom right lip. After reviewing the witness statements they concluded Resident #46 hit their head on the bar of the mechanical lift when being put to bed by Certified Nurse Aide #40 and Certified Nurse Aide #41 even though Certified Nurse Aide #40 stated the staff that assisted them was from another unit and Certified Nurse Aide #41 stated they did not participate in the residents care that evening. Since there was not a care plan violation and neglect was ruled out within two hours, it did not meet the requirements of reporting to the Department of Health. 10 New York Codes Rules Regulations 415.4(b)(3)

Based on record review, and interviews (iQIES 2579030), the facility failed to ensure that it provided sufficient preparation to residents to ensure a safe and orderly transfer or discharge from the facility for one (1) of three (3) residents (Resident #240) reviewed. Specifically, Resident #240 was discharged from the facility without notification to the receiving social services department, without safe/secure housing, and without ensuring the resident had access to outside services.Findings include:The facility policy Discharge Planning, last reviewed 01/2026, documented the facility was to maintain a coordinated program to ensure each resident had a plan of continuing care that met the resident's post discharge needs.The facility policy Discharge Summary and Plan, last reviewed 01/2026, documented the post-discharge plan would include where the resident planned to reside and arrangements for follow-up care and services.Resident #240 had diagnoses including schizophrenia (a serious mental illness), bilateral below knee amputations, and a history of psychoactive substance abuse. The 01/28/25 admission Minimum Data Set assessment documented the resident had was cognitively intact, had disorganized thinking, depression symptoms, required set-up assistance with eating, supervision with oral hygiene/upper body dressing/personal hygiene/bed positioning/wheelchair use, moderate assistance with toilet hygiene/shower/bath/lower body dressing/transfers/picking up objects, was on a therapeutic diet, was receiving occupational and physical therapy, and received an antipsychotic/antibiotic/opioids.The 01/28/2025 comprehensive care plan documented the resident's placement was short-term with a plan to reside with Unity House upon discharge to the community. The resident's discharge status was uncertain at the time of admission, and the resident and/or designated representative would be involved in discharge planning. Interventions included facilitating discharge planning with all disciplines via comprehensive care plan meeting and making appropriate referrals such as home care as needed. The 04/16/2025 at 10:46 AM Social Worker #33 progress note documented they reached out to a supportive living facility (half-way house) previously used by the resident. The supportive living facility refused to take the resident back unless specific conditions were met as the resident had caused damage and the local police were contacted. The 04/25/2025 quarterly Minimum Data Set assessment documented the resident had intact cognition, was independent for eating/oral hygiene/upper and lower body dressing/personal hygiene/bed positioning/wheelchair use/toilet hygiene/transfers/picking up objects, required moderate assistance with a shower/bath, and was receiving an antipsychotic.The 04/28/2025 at 09:16 AM Social Worker #33 progress note documented an assisted living facility referral was declined as the resident was not age appropriate.The 05/02/2025 at 12:23 PM, 05/29/2025 at 4:28 PM, and 06/26/2025 at 9:34 AM Social Worker #33 progress notes documented more assisted living referrals were sent to various facilities.The 05/30/2025 at 10:23 PM Social Worker #33 progress note documented the resident was cleared as independent and medically stable. The facility issued a 30-day discharge notice with a tentative discharge date of 07/01/2025 to a local Department of Social Services listed to assist with appropriate housing. The Ombudsman was notified via facsimile. The social worker continued to assist with possible assisted living arrangements.The 05/30/2025 Transfer/Discharge Notice documented the resident would be discharged on 7/1/2025 to a local Department of Social Services and it was appropriate because the resident's health had improved sufficiently so that the resident no longer needed facility services.The 06/30/2025 at 2:01 PM Social Worker #33 progress note documented discharge planning was finalized. The resident was set to be discharged on 07/01/2025 to the County Department of Social Services via medical transport. A primary care provider follow-up appointment was scheduled, and the resident was made aware of the situation. There were no additional social services progress notes addressing the resident's discharge. The 07/01/2025 at 12:21 PM Licensed Practical Nurse #38 nursing note documented the resident was discharged . There was no documentation where the resident was discharged to, how the resident was transported, and if discharge instructions or medication reconciliation information was provided to the resident. There was no documentation of a physician order to discharge the resident.The 07/01/2025 discharge Minimum Data Set assessment documented the resident was discharged to home/community (e.g., private home/apartment, board/care/ assisted living, group home, transitional living, other residential care arrangements). The section Provision of Current Reconciled Medication List to Subsequent Provider at Discharge was not completed. Functional abilities at the time of discharge was independent for all activities of daily living. There was no documented evidence of a post-discharge summary indicating where the resident planned to reside, any arrangements for follow-up care, and any post-discharge medical and non-medical services. There was no documented evidence of a medical provider discharge summary with a recapitulation of the resident's stay that included, but not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. During an interview on 05/18/2026 at 1:26 PM, Licensed Practical Nurse #34 stated the facility's social services department and the unit manager were involved in discharge planning. The facility had some residents that were homeless prior to admission and were sent to a shelter or the appropriate county's Department of Social Services when discharged . They stated they were aware Resident #240 was homeless prior to their discharge. The resident was transferred to another unit prior to being discharged from the facility.During an interview on 05/19/2026 at 10:37 AM, the Director of Social Services #33 stated discharge planning started when the resident was admitted to the facility. That planning was entered into a progress admission note. Residents with pending discharges were discussed at weekly interdisciplinary team meetings. The facility moved ahead with those plans of meeting home needs to ensure a safe discharge. Those residents that were homeless were educated about community services and subsidized housing. Assisted living referrals were also sent. The facility would also assist with group home living. If there were no other options for the resident, a 30-day notice of discharge was given to the resident and they were taken to the Department of Social Services office in the county they were last known to come from, unless the resident gave the facility another county to go to. The facility contacted the Ombudsman regarding Resident #240's discharge. The facility did not notify the county Department of Social Services prior to sending the resident there. Each resident should be discharged with a discharge packet outlining the situation and care received from the facility. If the resident was going to another facility, the receiving facility was contacted prior to the discharge. They stated the facility tried to find a suitable housing arrangement for Resident #240 but was unable to do so prior to the planned discharge date as no one would accept the resident. The resident was sent to the county Department of Social Services with a discharge packet that included medical follow ups and a list of medications.During an interview on 05/19/2026 at 10:56 AM, the Director of Nursing stated medication prescriptions were sent to the pharmacy prior to the resident leaving the facility. The social work department discussed any assistance the resident needed and accompanied the resident out of the building. They should also call the receiving facility and notify the county Department of Social Services if appropriate.During an interview on 05/19/2026 at 11:01 AM, the Administrator stated discharge communication should occur with the receiving facility when discharge planning started. A potential receiving facility needed to confirm they would accept the resident. Every attempt should be made to ensure a safe discharge and ensure the receiving facility was able to meet the resident's needs. There was a concern with the facility's previous Director of Social Services, but that had been rectified regarding the receiving facility's notification. A progress note should be written when the facility notified the receiving facility of the pending discharge. 10 New York Codes, Rules, and Regulations 415.2(v) and 415.3(i)(vi)(vii)

Based on observations, record review, and interviews, the facility failed to implement a comprehensive person-centered care plan to meet a resident's needs one (1) of two (2) residents (Resident #11) reviewed. Specifically, Resident #11 was not provided with 1:1 assistance with meals as planned. Findings include: The facility policy Resident Care with Activities of Daily Living, last reviewed 1/2025, documented the facility was to assist residents with the need and support for activities of daily living.Resident #11 had diagnoses including stroke, malnutrition, and gastro-esophageal reflux disease. The 03/18/2026 Minimum Data Set assessment documented the resident had moderately impaired cognition and required moderate assistance with eating.The 3/6/2026 at 3:06 PM Registered Dietitian #5 progress note documented the resident weighed 179 pounds and the reweight was 182 pounds. The resident had an unplanned significant weight loss due to hospitalization, variable intakes, selective eating habits and distraction during meals. The 03/13/2026 at12:47 PM Registered Nurse Unit Manager #25 progress note documented the care team discussed the resident's lack of interest in meals with diminished appetite. The team decided to make the resident 1:1 at meals to see if it would result in better engagement at meals. The 03/14/2026 comprehensive care plan documented the resident was at risk for functional decline in self-care related to syncope (fainting) and collapse. Interventions included partial/moderate assistance with eating. The 5/13/2026 care instructions documented the resident was 1:1 feeding for all meals due to lack of interest.During an observation and interview on 05/13/2026 from 8:58 AM until 9:04 AM, the resident was in the unit dining room feeding themself. There were no staff feeding or assisting the resident. The resident ate most of the meal. At 8:58 AM, Certified Nurse Aide #7 stated the night shift was to get the resident up in the morning so they could eat breakfast in the unit dining room. During an observation on 05/13/2026 at 1:09 PM, the resident only ate their ice cream and pineapple tidbits at lunch. No staff was engaged with the resident during the meal. During an interview on 05/13/2026 at 1:14 PM, Certified Nurse Aide #15 stated they knew which resident required feeding assistance by looking at the care instructions. A resident who was 1:1 feeding meant a staff member only fed that 1 resident until they were done eating. They stated they did not believe Resident #11 was 1:1 because they ate independently.During an observation on 05/14/2026 at 8:49 AM, the resident was feeding themselves in the unit dining room with no staff assistance or engagement as planned. During an observation and interview on 05/15/2026 at 12:43 PM, the resident was sitting in a wheelchair in the unit dining room. At 12:47 PM, the resident began wheeling themself out of the dining room while staff were passing meal trays. Staff redirected the resident to the dining room and the resident wheeled out a different exit. The resident did not eat anything on their meal tray. During an interview on 05/15/2026 at 1:45 PM, Licensed Practical Nurse #21 stated 1:1 for feeding meant staff had to sit and feed the resident. Resident #11 was not on a 1:1 feeding program. During an interview on 05/15/2026 at 2:05 PM, Certified Occupational Therapy Assistant #24 stated nursing staff were expected to look at the care plan or care instructions to see if a resident was 1:1. Resident #11 was 1:1 with feeding and would eat well when fed. The resident needed reminders to eat, was hungry, and ate when they were provided with 1:1 assistance. During an interview on 05/19/2026 at 10:34 AM, Registered Dietitian #5 stated Resident #11 was made 1:1 feeding on 3/14/2026 due to significant weight loss. The resident tended to wander during the meal and did not actively eat. During an interview on 05/19/2026 at 2:03 PM, Registered Nurse Manager #35 stated Resident #11 was 1:1 feeding for meals as they had difficulties remaining engaged while eating and also had significant weight loss. A resident who was 1:1 for feeding meant that a staff member was to feed only that specific resident, and it should be documented in the resident's care instructions. 10NYCRR 415.11(c)(1)

Based on observations, record review, and interviews (iQIES intakes 2697750, 2747995, 279049, 2961519, and 2970887), the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, personal and oral hygiene for two (2) of nine (9) residents (Residents #4 and #46) reviewed. Specifically, Resident #4 was not provided with a shower as planned and was not assisted with shaving per the resident's preference; and Resident #46 was not assisted with feeding as planned.Findings include: The facility policy Resident Care with Activities of Daily Living, last reviewed 01/2025, documented the purpose was to accurately assist with the residents' need for support for basic activities of daily living function. When residents were assisted with personal skin care and cleanliness staff reviewed the resident's care plan and assessed any special needs of the resident. Shaving the residents was included with personal skin care and cleanliness. Staff notified the supervisor if residents refused the procedure. The purpose of the procedure was to promote cleanliness, provide comfort to the residents and to observe the condition of the resident's skin 1) Resident #4 had diagnoses including dementia and schizophrenia (a serious mental health disorder). The 02/28/2026 Minimum Data Set assessment documented the resident had severely impaired cognition, did not refuse care, and required partial/moderate assistance for personal hygiene and substantial/maximum assistance for bathing. The 09/14/2022 comprehensive care plan, revised 01/24/2026, documented Resident #4 required assistance with activities of daily living related to dementia and limited mobility. Interventions included encourage the resident to fully participate possible; encourage the use of the call bell for assistance; monitor for changes in status; notify interdisciplinary team as needed; inspect the skin to monitor for redness open areas, scratches, cuts, bruises and report changes to the nurse. There was no documented evidence of the resident's preference for facial hair. The undated care instructions (Kardex) documented the resident required substantial/maximum assistance for showering and bathing. Their shower was scheduled on Tuesday during the day shift. There was no documented evidence of the resident's preference for shaving and facial hair. During an observation on 05/11/2026 at 4:04 PM Resident #4 was sitting in the lounge area. Their hair appeared greasy and brushed back. They had long, white hairs on their chin and upper lip. The resident stated they did not like the hair on their face and wanted it off. The May 2026 Certified Nurse Aide tasks documented the resident did not receive a shower on Tuesday 05/12/2026. During an observation on 05/13/2026 at 9:16 AM the resident was sitting in the dining area waiting for breakfast. Their hair appeared greasy, and they had long white hairs on their chin and upper lip. During an observation and interview on 05/14/2026 at 9:20 AM Certified Nurse Aide #16 stated they were responsible for giving residents their showers. If needed they shaved both men and women on their shower days. They stated Resident #4 had long white hair on their face. They were supposed to give the resident a shower on Tuesday, but there were two certified nurse aides on, and they did not have enough time to get to it. They did not tell the next shift the shower was not done and should have. They intended to do it the next day but did not get to it again because they were busy. They should have told the nurse Resident #4 did not get their shower. During an interview on 05/14/2026 at 9:24 AM Licensed Practical Nurse #17 stated certified nurse aides gave the residents showers. They were not told that Resident #4 did not get their shower, or that the certified nurse aides were too busy to give them one. They did not know the resident wanted to be shaved but Resident #4 could tell them they wanted to be shaved if they asked. During an interview on 05/14/2026 at 9:27 AM Licensed Practical Nurse Unit Manager #18 stated certified nurse aides were primarily responsible for providing showers to the residents. They expected the certified nurse aide to fully wash the resident from head to toe, which included shaving. If the day was busy, they expected the next shift to perform the shower. They were not aware Resident #4 did not receive their shower on their care planned shower day. The next shift should have given the resident their shower and shaved them. Razors were kept in the medication room; a nurse would have to retrieve the razor for the certified nurse aide. They did not know the resident wanted to be shaved. 2) Resident #46 had diagnoses including dementia, protein calorie malnutrition, and seizure disorder. The 03/18/2026 Minimum Data Set assessment documented the resident had severely impaired cognition, was dependent on eating, weighed 188 pounds, and was on a mechanically altered diet. The Comprehensive Care Plan initiated 03/11/2026 documented the resident was at risk for functional decline in self-care related to dementia with aphasia (difficulty speaking). Interventions included the resident was dependent on feeding. The undated care instructions documented the resident required 1:1 feeding, was dependent on feeding, and was on a regular ground texture diet. During an observation and interview on 05/11/2026 at 12:18 PM, Resident #46 was in bed being fed by their significant other. They stated they visited the resident every day at lunch because the resident was unable to feed themselves. During an observation on 05/12/2026 at 1:30 PM, Resident #46 was observed in bed being fed by their significant other. During a constant observation on 5/13/2026 starting at 7:26 AM Resident #46 was in bed. At 8:40 AM Certified Nurse Aide #7 entered the resident's room with their breakfast tray, prepared the tray by opening lids and putting straws in liquids. They greeted the resident, said they had breakfast, and would return to feed them. After leaving the tray on a table at the foot of the bed they passed trays from a green cart they were pushing from room to room. Certified Nurse Aide #7 did not return to the resident's room to feed the resident. At 9:09 AM Certified Nurse Aide #8 pushed a green cart from room to room placing finished breakfast trays in the cart. Outside of Resident #46's room they asked Certified Nurse Aide #15 if anyone fed the resident. Certified Nurse #15 stated Certified Nurse Aide #7 fed the resident. Certified Nurse Aide #8 entered the room, took the resident's uneaten tray and placed it on the green cart with other trays. During an observation and interview on 05/14/2026 at 9:07 AM, Certified Nurse Aide #6 entered Resident #46 room. At 9:14 AM they were observed leaving the room with the residents' breakfast tray. The items on the resident's tray were untouched. Certified Nurse Aide #6 stated the resident refused to open their mouth when they attempted to feed the resident. The resident did not eat anything on their breakfast tray There was no documented evidence on the Certified Nurse Aide survey report for May 2026 the resident was fed: -05/12/2026 7-3 shift -05/13/2026 7-3 or 3-11 shift -05/14/2026 3-11 shift During an interview on 05/15/2026 at 1:45 PM, Licensed Practical Nurse #21 stated Resident #46 was 1:1 for meals because they were unable to feed themselves. When the certified nurse aide was done feeding the resident, they documented the percentage of food the resident consumed in the electronic medical record. If there was no documentation in the electronic medical record for meal intake, they would not know what percentage of the meal was consumed. If a resident did not eat, they should be offered something from the refrigerator stocked with sandwiches and juice. The certified nurse aide should notify the nurse, who should document a progress note. They were not notified Resident #46 refused any meals. During an interview on 05/18/2026 at 12:15 PM, Certified Nurse Aide #7 stated if a resident refused to eat, they notified the licensed practical nurse and the nurse document in the progress note. Resident #46 required 1:1 assistance when being fed and they were not fed on 05/13/2026 because they dropped the tray off and prepared the tray for the resident. They had to pass trays for the remaining residents, so food was not cold. They got busy, thought another staff member fed the resident, and never returned to Resident #46 to feed them. During an interview on 05/19/2026 at 9:33 AM, Certified Nurse Aide #6 stated they were responsible for feeding residents. When a resent refused a meal, they reapproached the resident later in the day. If they continued to refuse, they notified the nurse on the medication cart. Resident #46 refused their breakfast on 05/14/2026 and they reapproached the resident later in the morning when the yogurt arrived in the unit. They did not notify the nurse because the resident had refused meals in the past, so they were aware the resident refused meals. They should notify the nurse every time the resident refused meals to ensure the resident was getting the nutrients and calories they needed and were not losing weight. During an interview on 05/19/2026 at 10:34 AM, Dietitian #5 stated occupational therapy determined the level of assistance each resident required, and nursing documented the recommendation in the care plan. When a resident was 1:1 for feeding they expected staff to sit with the resident and feed them. When a resident refused a meal, they should be reapproached and the nurse on duty should be notified. When the meal intake percentage was not documented in the electronic medical record, they relied on the certified nurse aides to recall the meal intake percentage. During an interview on 05/19/2026 at 2:03 PM, Unit Manager #35 stated when a resident required 1:1 assistance with meals they expected staff to be with the resident and feed the resident. Resident #46 could not feed themselves and was dependent on for eating. When a resident refused a meal, they should be offered an alternative, and the refusal should be reported to the nurse. The certified nurse aides documented the percentage of food and fluids consumed in the electronic medical record. They looked in the electronic medical record for Resident #46 and stated they could not say how much the resident ate on 05/08/20206, 05/09/2025, or 05/13/2026 as there was no intake documented on those days and on many other days there was only one or two meals documented. They expected the resident to be fed as soon as the tray entered the room. Staff should not leave the tray in the room to pass trays to other residents. 10 New York Code Rules and Regulations 415.12(a)(3)

Based on record review and interviews (iQIES Intakes 2747995, 2961519, 2976530), the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one of 12 residents (Resident #56) reviewed. Specifically, Resident #56 had a fall that was not immediately reported, and diagnostic imaging was not completed as ordered to rule out fracture. Findings include:The facility policy Change in a Resident's Condition or Status, last reviewed 01/2026, documented the facility notified the resident, attending physician, and resident representative of changes in the resident's medical condition and/or status including an accident or incident that involved the resident.The facility policy Lab and Diagnostic Test Results-Clinical Protocol, reviewed 01/2026, documented the physician identified and ordered diagnostic testing based on diagnostic and monitoring needs. Staff processed test requisitions and arranged tests. The nurse reviewed and communicated to the physician all results. The facility policy Communication Policy-Nursing to Provider, revised 01/2026 documented the facility maintained a process for communication between nursing staff and providers regarding resident's changes, treatment needs, orders, and follow up care. Communication was timely, documented and supported continuity of care. Resident #56 had diagnoses including dementia, difficulty walking or moving around, and muscle weakness. The 10/13/2025 Minimum Data Set assessment (a health status assessment tool) documented the resident had moderately impaired cognition, required supervision with bed mobility and transfers, and did not have any falls. The comprehensive care plan initiated 08/12/2025 and revised 01/19/2026 documented the resident was at risk for falls related to abnormalities of gait and mobility. Interventions included anticipate needs; call light within reach and use was encouraged; and bed was in lowest position. On 12/19/2025 the resident had an actual unwitnessed fall, and additional interventions included enabler bars were placed, and a bariatric (large size) bed was requested. The 12/19/2025 at 2:48 PM Fall Incident Report initiated by Registered Nurse Unit Manager #9 documented the resident's spouse received a telephone call from the resident they fell at approximately 10:45 PM the prior evening. Immediate actions included nurse and medical doctor assessments, placement of enabler bars, and staff were educated. The resident had three bruised areas to the left rib cage/ abdomen area. The conclusion of the investigation by Assistant Director of Nursing #30 was that the resident had an unwitnessed fall the night before. There was an undated or signed handwritten statement by Certified Nurse Aide #43 documenting they witnessed the resident slip out of bed. There was education on fall reporting with Certified Nurse Aide's #43 name at the top of the posttest. There was no documented evidence Certified Nurse Aide #43 reported the resident's fall on 12/18/2025 or the resident was assessed by a qualified individual immediately after the fall. The 12/19/2025 at 3:01 PM, Registered Nurse Unit Manager #9 progress note documented the resident reported that day they fell out of bed on 12/18/2025 at 10:45 PM. Upon skin check the resident had bruising to the left rib area. The resident requested a larger bed with enabler bars. The medical provider and physical therapy were made aware. The 12/19/2025 at 2:47 PM Physician #53 progress note documented the resident was seen for follow up after a fall. The resident had an unwitnessed fall last night when rolling in bed to change position. The resident struck their chest and sustained three bruises to the left lower chest, the resident denied head strike and was not on anticoagulation. The plan was for a chest x-ray to exclude rib fracture and Tylenol 500 milligrams 3 times daily for 3 days. The 12/19/2025 Physician #53 order documented a diagnostic test for ribs-bilateral with chest x-ray one time only. The order was discontinued and removed on 12/19/2025. There was no documented evidence that an x-ray was completed to rule out rib fracture, or that the diagnostic testing was no longer needed. During a telephone interview on 05/14/2026 at 11:47 AM, Certified Nurse Aide #43 stated if a resident falls, they were supposed to notify a nurse or supervisor right away. They did not recall Resident #56's fall on 12/18/2025. During a telephone interview on 05/15/2026 at 1:47 AM, Licensed Practical Nurse #54 stated if a certified nurse aide witnessed a fall or found a resident on the floor, they should report it to a nurse or supervisor. The supervisor then completed an incident report, the certified nurse aide completed a statement, and the provider and family were updated. They did not recall if they were notified of Resident #56's fall on 12/18/2025. If they were made aware, they would have documented in a nursing note. During a telephone interview on 05/18/2026 at 1:09 PM, Assistant Director of Nursing #52 stated in 12/2025 they were a supervisor for the evening shift. If they were notified of a resident fall, they completed an assessment. If there were any injuries, they called the physician and the family and documented in the electronic record. They did not recall if they were notified of Resident #56's fall on 12/18/2025. If there were no documented progress notes, it meant they were not notified. During an interview on 05/18/2026 at 1:38 PM, Registered Nurse Unit Manager #9 stated in the event of a fall the certified nurse aide notified a nurse. A registered nurse and a provider assessed the resident. A certified nurse aide needed to report the fall because it was not in their scope to determine if there were any injuries. Family was also notified. If a provider wanted an x-ray there was an order and the order went directly to the imaging company. They completed an incident/accident report for Resident #56 on 12/19/2025. The resident self-reported a fall to their spouse who then notified them. Physician #53's note indicated they wanted an x-ray. They did not see the order or the results of the x-ray. After the fall, they updated the resident's care plan to include enabler bars. If statements were obtained, the Assistant Director of Nursing #30 would have them. During a telephone interview on 05/19/2026 at 11:37 AM, Physician #53 stated they no longer worked at the facility. They did not recall Resident #56's fall, but if there was bruising to the left ribcage and pain, they would have ordered an x-ray to rule out fracture. If they ordered an x-ray they told the registered nurse manager. Results were followed up after they were listed as pending results in the electronic record. They were on the dashboard and nursing saw pending results as well. This was all discussed in morning meeting. They stated they were responsible for ensuring orders were completed and results were reviewed but they relied on the nurse manager and the Director of Nursing to check if they missed something. During an interview on 05/19/2026 at 1:17 PM, Assistant Director of Nursing #30 stated when Resident #56 fell on [DATE] it was reported to Registered Nurse Unit Manager #9 the next day by the resident's spouse. When nothing was documented in the chart, they initiated the fall protocol. They questioned staff from the night before and Certified Nurse Aide #43 had witnessed the fall and did not report it to a nurse. Certified Nurse Aide #43re-educated, and a statement was obtained. The statement should have had a date and signature so there was proof of who was spoken to and the date they did so. During a follow up telephone interview on 05/19/2026 at 1:47 PM, Certified Nurse Aide #43 stated they now remembered Resident #56's fall. They helped the resident back into bed. The resident's spouse called the unit about the fall and then nursing questioned them about what happened. They stated the night was busy, and they forgot to report the fall to anyone. They did not recall being re-educated. 10 New York Codes, Rules, and Regulations 415.12

Based on observations, record review, and interviews, the facility failed to ensure that residents who required dialysis services (a process that filters blood when the kidneys do not work efficiently) received such services consistent with professional standards of practice for one (1) of one (1) resident (Resident #122) reviewed. Specifically, Resident #122 received dialysis, had a dialysis access and there was no documented evidence pre and post dialysis evaluations were consistently completed. Findings Include:The facility policy Dialysis Communication, last reviewed 01/2026, documented on the days of dialysis the nurse will take vital signs and document relevant labs and pre-dialysis weight in the dialysis communication book. An evaluation of the resident's access site will be completed and all findings documented in the communication book as well as the resident's medical chart. Resident #122 had diagnoses including end stage kidney disease and dependence on dialysis. The 04/16/2026 Minimum Data Set assessment documented the resident had intact cognition and required dialysis treatment.The comprehensive care plan initiated 04/12/2024 and revised on 04/29/2026, documented the resident had fluid overload or potential for fluid volume overload related to end stage dialysis and required dialysis. The interventions and goals listed did not include the resident's type of dialysis, monitoring vital signs, weights, nutritional and fluid needs or restrictions, lab results, and type of access site and the care required for the access site.The 08/25/2025 physician orders documented:-Hemodialysis three times a week, and as needed per the dialysis center plan, every Tuesday, Thursday and Saturday for end stage renal disease.-Hold the once-a-day blood pressure medications on dialysis day and give upon return from dialysis.-Complete pre and post dialysis assessment on dialysis days.- Right femoral perma-catheter site (dialysis access site), keep dry, monitor for infection; and monitor site for bleeding and report changes to the provider-Resident has a temporary dialysis catheter in place in right groin area near hip. Resident #122's dialysis intercommunication pre-dialysis form notes documented the following:-On 04/02/2026, 04/14/2026, 04/16/2026, the resident went to dialysis. -On 04/18/2026, the resident went to dialysis. The access dressing site was documented as n/a and a positive symbol (+) documented for access condition, bruit and thrill (used to determine blood flow with a fistula). The resident did not have a fistula.-On 04/21/2026, 04/23/206 and 04/28/2026 the resident went to dialysis. There was no documentation the access site was assessed. -On 04/30/2026 and 05/05/2026, the resident went to dialysis. The access site was documented with an X, and the bruit and thrill were documented with symbol (+) for positive.-On 05/07/2026, the resident went to dialysis.-On 05/09/2026, the resident went to dialysis. The staff documented the symbol (+) positive for bruit and thrill.-On 05/12/2026, the resident went to dialysis. The staff documented there was no dressing intact, and site condition was positive.There was no documentation that a pre-dialysis assessment/progress note was completed on the days the resident went to dialysis. Resident #122's post-dialysis dialysis intercommunication forms documented the following:-On 04/02/2026, the resident returned from dialysis. Their access site was not addressed.-On 04/14/2026 and 04/16/2026, the resident returned from dialysis and the vital signs were documented.-On 04/18/2026, the resident returned from dialysis and staff documented, the dressing was not intact with a line through the word no.-On 04/21/2026 and 04/23/2026, the resident returned from dialysis. The access site was not addressed. -On 04/28/2026 and 04/20/3036 the resident returned from dialysis and the access site was documented with dressing intact.-On 05/05/2026, 05/07/2026 and 05/0/2026 the resident returned from dialysis. The vital signs were completed.-On 05/12/2026, the resident returned from dialysis. The access site dressing was intact, and there were positive bruit and thrill.There was no documentation that post dialysis assessment/progress notes were completed on the days the resident returned from their dialysis treatment.The May 2026 treatment administration record did not include monitoring of the resident's right femoral artery perma-catheter access site.During an interview on 05/13/2026 at 9:09 AM, Resident #122 stated they received dialysis treatments for four years and had a catheter for their dialysis access. The catheter dressing was intact and located on the upper right hip. They stated the nursing staff at the facility never looked at their dialysis access site. When they returned from dialysis in the evening, they did not usually see a nurse. They were tired, they ate the food left in their room and then slept.During an interview on 05/15/2026 at 11:05 AM, Dialysis Clinic Registered Nurse Manager #28 stated the resident had frequent catheter access site infections in the past. The infections were usually related to resident hygiene issues. The resident was non-compliant and would deny staff assistance with their care. The resident received dialysis three times a week and had a catheter in their groin tunneled into the femoral vein. The resident had been on dialysis for a long time and was very sick. The nursing home nursing staff should be assessing the dressing, to ensure it was clean, dry and intact, and without signs of infection.During a telephone interview on 05/18/2026 at 10:40 AM, Licensed Practical Nurse Unit Manager #29 stated the resident went to dialysis three times a week. The resident had a catheter in their right groin for treatment access. The nursing staff did not touch the dressing, as dialysis nurses did the dressing. Nurses should let the Registered Nurse Supervisor know if the dressing was leaking or saturated. Prior to dialysis and upon return from dialysis treatments, the licensed practical nurse should take vital signs, weigh the resident, and observe the access site. The registered nurse would not assess the resident unless there was an issue reported pre or post dialysis treatment.During a telephone interview on 05/18/2026 at 11:46 AM, Assistant Director of Nursing #30 stated they thought the nurses on the unit observed the dialysis access site, but any dressing changes or issues with the perma-catheter were addressed by the dialysis nurses. The licensed practical nurse on the unit should collect the resident's vital signs and weight, and if there were any abnormalities they would reach out to the registered nurse to assess. The registered nurse did not routinely assess the resident pre and post dialysis. They would only assess the resident if they were called to the unit for something outside of the resident's routine observation. 10 New York State Codes Rules and Regulations 415.11(a)(5)

Based on observation, record review, and interviews, the facility failed to ensure a resident who displayed or was diagnosed with a mental disorder received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychological well-being for one (1) of five (5) residents (Resident #145) reviewed. Specifically, Resident #145 had a history of anxiety and depression, expressed worsening depression symptoms and there was not consistent or timely support provided by the facility addressing the resident's psychosocial well-being. Findings include: The facility policy Behavioral Assessment, Intervention and Monitoring, last reviewed 01/2026, documented the facility provided and residents received behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Behavioral health services were provided by qualified staff who had the competencies and skills necessary to provide appropriate services for the residents. Resident #145 had diagnoses including insomnia (difficulty sleeping), depression, and anxiety. The 03/13/2026 Minimum Data Set assessment (a health status assessment tool) documented the resident was cognitively intact; had little interest or pleasure in doing things several days; felt down, depressed, or hopeless nearly every day; had trouble falling or staying asleep, or sleeping too much several days; felt tired or had little energy half of more of the days; poor appetite or overeating nearly every day; felt bad about self-or that they were a failure or had let themselves or their family down half or more of the days; and received antianxiety and antidepressant medications. The comprehensive care plan initiated 10/16/2025 documented the resident had a mood state of depression and anxiety. Interventions included the resident was assessed for suicidal ideation and family involvement was encouraged. Physician orders documented: -On 12/12/2025 psychiatry and psychology consultation, treatment, and follow-up per recommendation, and mirtazapine 30 milligrams at bedtime for depression.-On 01/24/2026 Lamictal 200 milligrams daily for anxiety.-On 05/07/2026 lorazepam 0.5 milligrams every 24 hours as needed for anxiety.-On 05/08/2026 trazodone 100 milligrams at bedtime for depression. The 01/28/2026 Psychiatric Nurse Practitioner #48 initial evaluation progress note documented the resident had a history of depression and anxiety and reported increased depression over the past month and ongoing anxiety. The resident suffered quite a bit of depression in the past month and endorsed current anxiety symptoms. Their motivation was low, and they did not feel like doing anything and had to make themselves do things. The plan was to follow up in 6 weeks. The 02/16/2026 Social Worker #46 progress note documented the resident discussed depressive symptoms with them and they would contact the psychiatric nurse for follow up. On 02/16/2026 at 2:00 PM an electronic mail communication was sent from Social Worker #46 to psychiatric Registered Nurse #47. Registered Nurse Unit Manager #9 and the Director of Social Work were copied on the communication. The communication documented the resident scored a 12 (moderate depression) on the PHQ-9 test (a screening tool used to measure the severity of depressive symptoms) and asked if they could meet with the resident to assess depression. There was no documented evidence the resident was seen by psychiatric Registered Nurse #47. The 03/10/2026 Interdisciplinary Team note completed by Registered Nurse Unit Manager #9 documented the resident was requesting a psych follow up. There was no documented evidence the resident had a psych follow up. The 04/14/2026 Registered Nurse Unit Manager #9 progress note documented the resident would like to be added to the psych list. The 04/21/2026 Psychiatric Nurse Practitioner #48 progress note documented the resident was seen for follow up psychiatric evaluation (12 weeks after initial evaluation). The resident reported increased anxiety and increased grogginess in the morning. There were medication changes. Continued psychiatric care for medication management and symptom assessment as well as supportive therapy as needed. Follow up in one month. During an observation and interview on 05/11/2026 at 1:06 PM, Resident #145 was lying in bed dressed. The room was quiet, and they were looking off into the distance with an unfocused, blank expression. They stated they were depressed and nothing was being done. Prior to being in the facility, they spoke with a therapist once a week. They stated the psychologist came to see them once and they would see them weekly, but it took over 10 weeks. The last time they were seen was 3-4 weeks ago and the practitioner told them they must have fallen through the cracks. Today they felt extremely depressed and did not even want to get out of bed. They needed to see a therapist but did not think it was offered at the facility. Sometimes they wanted to go the psych ward just to talk to someone. They told the facility at the beginning of the year and again a month later they were going through a great depression, and the staff had not done anything about it. At 3:48 PM, they were still lying in bed, dressed, room quiet, without expression on their face. During an interview on 05/14/2026 at 11:53 AM, Certified Nurse Aide #11 stated Resident #145 did seem down sometimes and seemed tired lately. During an interview on 05/14/2026 at 12:20 PM, Licensed Practical Nurse #10 stated there were psychiatric nurses and nurse practitioner, but they did not know their names or how often they came to the facility. If a resident was feeling down, they should check on them. Resident #145 seemed more anxious and had verbally expressed depression. During an interview on 05/18/2026 at 1:38 PM, Registered Nurse Unit Manager #9 stated the facility used the services of Psychiatric Nurse Practitioner #48 and psychiatric Registered Nurse #49. If the resident displayed depression or anxiety, they let Registered Nurse #49 and social work know by sending an email. They had not noticed any changes with Resident #145; they got out of bed, ambulated, talked, and were not withdrawn. During an interview on 05/18/2026 at 2:43 PM, the Director of Social Work stated nursing submitted a psychiatric referral in an email that went to psychiatric Registered Nurse #49, and they were copied on it. Registered Nurse #49 was in the facility Monday-Friday, and they met with residents all throughout the day. They had not noticed any big mood changes with Resident #145. Depression symptoms should be taken very seriously and should not be brushed off because they can [NAME]. During an interview on 05/19/2026 at 10:00 AM, psychiatric Registered Nurse #49 stated they covered the whole facility. They mainly managed the list of residents to be seen by the Psychiatric Nurse Practitioner #48 when they came once a week. They saw the residents if there were medication changes. If the resident requested to speak with Psychiatric Nurse Practitioner #48, they would see them first. Psychiatric Nurse Practitioner #48 told them when they wanted to see a resident again and they kept a list for them of who needed to be seen. They were in the facility to provide emotional supportive therapy to anyone if they just wanted to talk. They only had one resident that they saw weekly. They were not familiar with Resident #145, but Psychiatric Nurse Practitioner #48 had seen them. During a telephone interview on 05/19/2026 at 10:54 AM, Psychiatric Nurse Practitioner #48 stated residents were evaluated at facility request. Registered Nurse #49 was available for emotional support and had residents they saw weekly. Resident #145 was depressed and anxious last week and had been every time they had seen them. They completed the resident's initial evaluation when they were just starting at the facility. They were trying to manage their case load 3 months went by before they had a follow up. The facility had not asked for the resident to be seen again, or they would have seen them sooner. They were now seeing the resident monthly as the resident would benefit from regular emotional support. The resident was highly anxious and very depressed with issues getting motivated. They had a history of deep depression, but they did not have the details off hand and did not have access to the electronic medical record at the time. 10 New York Codes, Rules, and Regulations 483.40(b)(1)

Based on observations and interviews the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional standards and principles for one (1) of six medication carts (Unit 5 B Medication cart) reviewed. Specifically, the Unit 5 B Medication Cart had one (1) undated Humalog insulin vial and one (1) expired Trelogy Inhaler cartridge.Findings include:The facility policy Storage of Medications, last reviewed 01/2026, documented the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Drug containers that had missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing; the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.During an observation on 05/12/2026 at 1:37 PM with Licensed Practical Nurse #23, the Unit 5 B Medication Cart top drawer contained one undated vial of Humalog insulin and one expired Trelogy inhaler cartridge dated 03/25/2026. During an interview 05/19/2026 at 12:21 PM, Registered Nurse Unit Manager #20 stated if a vial of medication was not dated when opened there was no way of knowing when the medication expired and it should be discarded. There should be no expired medications in the cart.During an interview on 05/19/2026 at 1:31 PM, Licensed Practical Nurse #23 (assigned to Unit 5 B Medication Cart) stated open vials of insulin should have a date it was opened with the nurse's initials. Expiration dates of medications should be checked before administration and any medication without a label was discarded. Licensed Practical Nurse #23 stated that the nurse who opened the medication should have written the date when it was opened. 10 New York Codes, Rules and Regulations 415.18(d)

Based on observation, record review, and interview the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for one (1) of one (1) resident (Resident #3) reviewed. Specifically, Resident #3 was observed with a BiPAP (bilevel positive airway pressure) machine in their room and did not have a physician order or care plan for the device, and the mask was unclean. Findings include: The facility policy CPAP/BiPAP, revised 01/2026, documented the facility provided continuous positive airway pressure with or without supplemental oxygen to the spontaneous breathing resident to improve arterial oxygenation in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. The physician ordered the oxygen concentration and flow and the positive end expiratory pressure for the machine. The humidifier chamber was filled with distilled water only and cleaned weekly, disinfecting with vinegar-water solution (1:3) in clean humidifier, soaking for 30 minutes and rinsing thoroughly. The filter was cleaned with running water weekly and replaced annually. The masks, nasal pillows, and tubing were cleaned daily using soap and water. The time of application and machine settings were documented in the electronic medical record. Resident #3 was admitted to the facility with diagnoses including stroke with paraplegia (paralysis of lower half of body) and muscle weakness. The 03/18/2026 Minimum Data Set assessment documented the resident had intact cognition, did not use oxygen therapy, and did not utilize bilevel positive airway pressure therapy. The 03/10/2026 hospital discharge summary documented the resident had diagnoses including acute respiratory failure and aspiration pneumonia (lung infection where food or liquids enter the lungs). The 04/10/2026 Respiratory Therapist #61 progress note documented the resident was ordered BiPAP (bilevel positive airway pressure) at night and the resident stated it was worn most nights. Bronchial breath sounds were clear, and respiratory distress was not observed. There was no documented evidence of a physician order or comprehensive care plan addressing the use of bilevel positive airway pressure therapy. During an observation and interview on 05/11/2026 at 1:36 PM, Resident #3 stated they used the BiPAP (bilevel positive airway pressure) every night. Staff never cleaned the tubing or mask, and the mask was dirty. They wanted the tubing and mask cleaned so they did not get sick. The BiPAP (bilevel positive airway pressure) mask was observed with a significant amount of white debris inside the mask: -on 05/11/2026 at 1:36 PM-on 05/11/2026 at 3:15 PM-on 05/12/2026 at 9:57 AM-on 05/12/2026 at 4:36 PM-on 05/15/2026 at 11:02 AM During an interview on 05/15/2026 at 11:02 AM, Licensed Practical Nurse #38 stated when a resident was transferred from the hospital and had a BiPAP (bilevel positive airway pressure) machine they contacted the pulmonologist to secure the resident specific settings for the machine and to ensure the settings were accurate for the resident. The physician wrote an order for the BiPAP (bilevel positive airway pressure) therapy, and the admission nurse documented use of the therapy on the care plan. The order generated the machine settings, the time of placement (usually at bedtime or when napping), and the cleaning schedule for the tubing and mask. The mask and tubing were cleaned daily, usually on the day shift. Resident #3 utilized a BiPAP at night and was on their assignment for the day. They did not clean the tubing or facemask as it was not on the treatment administration record. They stated the mask was dirty and required cleaning. During an interview on 05/18/2026 at 11:42 AM, Registered Nurse Unit Manager #35 stated Resident #3 was admitted with acute hypoxic respiratory failure and obstructive sleep apnea and used a bilevel positive airway pressure machine. They were not sure why the resident did not have a respiratory care plan or why there was no order and instructions for use of the bilevel positive airway pressure machine. The resident had been in the facility for a few months using the bilevel positive airway pressure machine and all nurses that cared for the resident, including themselves, should have noticed there were no orders, care plan, interventions, or a cleaning schedule for the machine. 10 New York Codes, Rules, and Regulations 415.25(a)(4)

Based on observations and interviews, the facility failed to ensure the daily current resident census, the total number, and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift was posted in a prominent location readily accessible to residents and visitors for three 3 of 4 days reviewed. Specifically, daily nurse staffing was not posted daily at the beginning of each shift and in a prominent location on 5/9/2026, 5/10/2026, and 5/11/2026 as required. Findings include: There was no documented evidence of a facility policy for Posted Nursing Staffing Information. The daily nurse staffing and resident census information was not posted in the main lobby, on the main entrance doors, or on the reception desk during the following observations:- on 5/11/2026 at 11:19 AM.- on 5/11/2026 at 1:49 PM. During an interview on 05/13/2026 at 2:42 PM, Human Resources Director #25 stated staffing, and the resident census should be posted in an accessible area for visitors to view so they can know how many staff are in the building caring for residents. They were not responsible for posting the staffing daily, Staffing Coordinator #26 was responsible for posting staffing. During an interview on 05/15/2025 at 1:32 PM, Staffing Coordinator #26 stated they were aware staffing should be posted daily. The resident census and daily staffing for licensed and unlicensed staff was posted in the main lobby at the front desk and in the back hallway outside their office. They posted the staffing everyday Monday through Friday, and the Registered Nurse supervisor posted the staffing on the weekend. When they arrived at work on Monday 5/11/2026, they noticed the posted staffing was dated Friday 5/8/2026 and was not updated over the weekend, or for Monday. They were not sure why it was not posted on the weekend or what time it was posted on Monday 5/11/2026. They stated it should have been done first thing in the morning, and it was not. 10 New York Codes, Rules, and Regulations 415.13

Based on record review and interviews during an abbreviated survey (Case #s NY00376223 and NY00377464), the facility did not ensure it established a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and that it determined that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. Specifically, (a) the facility did not ensure narcotics were counted by two (2) licensed staff members on the B-side of unit two (2), on 2/23/2025 at the end of the 3:00 PM to 11:00 PM shift. On 2/24/2025, the 7:00 AM - 3:00 PM nurse discovered twenty (20) Oxycontin extended release 10 milligram (extended-release narcotic pain medication) prescribed for Resident #1 were missing. During the facility's investigation it was determined that narcotic counts were not done by the required two (2) nurses. The physician reordered the medication on 2/24/2025 and was received in the facility on 2/25/2025. On 2/25/2025 at 9:00 PM, the medication administration record documented the medication was given, when the controlled medication record did not indicate a pill was administered, and (b) the facility did not document nursing unit narcotics as having been counted by two licensed staff members and signed as appropriate on the facility-provided narcotic record sheets for six (6) of six (6) nursing units. This is evidenced by: The Policy and Procedure titled, Controlled Substance/Narcotic Management Protocol, reviewed 1/2025, documented it was the facility's policy to prescribe, administer, store and destroy all controlled substances within accepted regulations of the responsible governing body. All controlled substances ordered would be ordered in accordance with best practice and regulations. With each administration, the nurse must document the date, time, prior count and post administration count of the remainder of the medication and sign in the controlled substance logbook in addition to the medication administration record. All narcotics would be counted and reconciled at the beginning of every shift with the outgoing and oncoming nurse. Both must sign the controlled substance log attesting to the presence of the narcotic as stated from the previous shift. Any discrepancies in the count must be reported to the unit manager or nursing supervisor immediately. Staff responsible for narcotic administration would not leave the shift until the narcotic count was reconciled. The facility's Lesson Plan for Controlled Substances & Narcotic Count, dated 2/20/2025, documented the objective was to ensure nurses were following the policy and procedure of narcotic handling and narcotic count. The Policy and Procedure, titled Controlled Substances/Narcotic Management Protocol, reviewed 1/2023 was referenced. Lesson Plan procedure documented nurses would count and reconcile all narcotics at the beginning of every shift with the outgoing and oncoming nurse. Both nurses would sign the controlled substance log attesting to the presence of the narcotic as stated from the previous shift. All nurses would follow the count in chronological order from the previous number stated. Any discrepancies in the count must be reported to the unit manager/nursing supervisor immediately. Resident #1: Resident #1 was admitted to the facility with diagnoses of fibromyalgia (long-term condition that involves widespread body pain), chronic pain syndrome (pain that lasts for over 3 months), and anxiety disorder (repeated episodes of sudden feelings of intense anxiety and fear or terror that reach a peak within minutes (panic attack). The Minimum Data Set (an assessment tool) dated 2/18/2025, documented the resident was cognitively intact. The resident was able to make themselves understood and usually understood others. Order Recap Report for order date 2/1/2025 to 4/25/2025, documented an order dated 2/14/2025 for Oxycontin Oral Tablet extended release 12 Hours Abuse-Deterrent 10 milligram (Oxycodone HCl), give one (1) tablet by mouth two (2) times a day for pain for 14 days. The order start date was 2/16/2025 and end date was 2/24/2025. Individual Controlled Medication Record for Resident #1 dated 2/14/2025, documented Oxycontin Oral Tablet 10 milligrams ER, give one (1) tablet by mouth two (2) times a day for pain for 14 days. The last documented administration was on 2/23/2025 at 10:18 PM by Licensed Practical Nurse #1, with 20 pills remaining. Medication Administration Record dated February 2025, documented Oxycontin Oral Tablet extended release 12 Hours Abuse-Deterrent 10 milligram (Oxycodone HCl) was scheduled to be given daily at 9:00 AM and 9:00 PM. The order start date was 2/16/2025 and was discontinued on 2/24/2025 at 8:59 PM. It documented the medication was administered on 2/23/2025 at 9:00 PM by Licensed Practical Nurse #1. Loss of Controlled Substances Report, date of incident 2/24/2025 at 10:00 AM on unit 2. Description documented: Oxycontin ten (10) milligrams extended release, twenty (20) pills discovered missing morning of 2/24/2025. Medication was last administered on 2/23/2025 at 10:18 PM by Licensed Practical Nurse #1. Licensed Practical Nurse #1 was relieved by Licensed Practical Nurse #2. Licensed Practical Nurse #1 stated they counted all narcotics at medication cart while oncoming nurse, Licensed Practical Nurse #2 was present at desk. Licensed Practical Nurse #2 told Licensed Practical Nurse #1 to lock medications back in the medication cart. Licensed Practical Nurse #2 stated they were not present when Licensed Practical Nurse #1 did the count, but did tell them to keep the medications in the lock box in the medication cart. Licensed Practical Nurse #2 stated they never removed medications from the lock box during their shift, as they did not need to administer the oxycontin to the resident on their 11:00 PM to 7:00 AM shift. The 7:00 AM to 3:00 PM nurse on 2/24/2025 discovered the count was off and 20 pills were missing. Review of the untitled narcotic count signature sheet by the on-coming and off-going nurse dated 2/23/2025 on unit two (2) (B-side), documented nurse signatures for all three (3) shifts, indicating the narcotic count was done on all shifts. Notice of Disciplinary Actions documented 2/24/2025, documented Licensed Practical Nurse #s 1, 2, and 3 were given a first and final warning for failure to perform narcotic count with two (2) nurses present at the beginning and end of the shift. General Statement dated 2/24/2025 written by the Director of Nursing #1, documented a phone interview with Licensed Practical Nurse #1. The nurse was asked if they counted the narcotics with their relief on 2/23/2025 at 11:00 PM and they stated yes and stated, 'everything was there.' The nurse was informed that a card of 20 pills of oxycodone was missing for Resident #1. Licensed Practical Nurse #1 stated they gave the resident their dose and it (the pill pack) was there when they left. The nurse suggested that pills may have gotten 'mixed up in other meds.' The nurse was asked where the narcotics were when they gave Licensed Practical Nurse #2 the keys and they stated they asked Licensed Practical Nurse #2 where they wanted the narcotics, and they stated the medication cart and Licensed Practical Nurse #1 put them back in the medication cart. Review of a written statement dated 2/25/2025 by Licensed Practical Nurse #1, documented they counted all the narcotics at the medication cart while Licensed Practical Nurse #2 was sitting at the desk. General Statement dated 2/24/2025 written by the Director of Nursing #1, documented a phone interview with Licensed Practical Nurse #2. Licensed Practical Nurse #2 stated Licensed Practical Nurse #1 called them after they (Licensed Practical Nurse #2) left on the morning of 2/24/2025 and told them the count was off. Licensed Practical Nurse #2 was asked if they counted with the 3:00 PM to 11:00 PM nurse (Licensed Practical Nurse #1) before taking the keys and they stated, 'Kind of. I didn't thoroughly count. They told me it was good.' Licensed Practical Nurse #2 stated they told Licensed Practical Nurse #1 to leave the narcotics in the medication cart and stated they administered narcotics on their shift to two (2) other residents but did not give any medications to Resident #1. Review of an email dated 2/26/2025 by Licensed Practical Nurse #3 and sent to Director of Nursing #1, documented they got to the unit at 7:00 AM and Licensed Practical Nurse #2 was there and handed them the keys stating they had to leave in a hurry. Licensed Practical Nurse #3 then began counting the narcotics on both sides of the unit and noticed the B side medication cart was missing the blister pack of Oxycontin. Licensed Practical Nurse #3 texted Licensed Practical Nurse #2 and asked them what happened. Licensed Practical Nurse #2 responded back and stated, 'They were going to be honest. They did not count the narcotics at all on their shift.' General Statement dated 2/26/2025 written by Director of Nursing #1, documented a phone interview with Trooper #1 and Licensed Practical Nurse #2. Licensed Practical Nurse #2 stated they did not count at all with Licensed Practical Nurse #1, who they were relieving. Licensed Practical Nurse #2 stated they took Licensed Practical Nurse #1's 'word that everything was good.' General Statement dated 2/27/2025 written by Licensed Practical Nurse #2, documented the off-going nurse (Licensed Practical Nurse #1) was at the medication cart finishing up their work and asked them if they wanted them to leave the medications in the medication cart, and they told them to leave them there. Licensed Practical Nurse #2 documented, 'at no point did they count the narcotics with [Licensed Practical Nurse #1].' The facility investigation report for missing narcotics dated 3/4/2025, for date of incident 2/24/2025, by Director of Nursing #1. Incident: missing narcotics on unit 2. Oxycontin extended release ten (10) milligrams, twenty (20) tablets missing. Last administration of Oxycontin was by Licensed Practical Nurse #1 at 10:18 PM. It documented: Licensed Practical Nurse #1 stated they counted all narcotics with Licensed Practical Nurse #2 and was instructed by them to place all narcotics back into the medication cart narcotic box. Licensed Practical Nurse #2 stated they were not present for the count but did tell the other nurse to keep the medications in the lock box in the medication cart. Licensed Practical Nurse #2 stated they never removed any medications from the lock box during their shift. Oxycontin extended release ten (10) milligrams was not scheduled to be administered on the 11:00 PM to 7:00 AM shift. The 7:00 AM to 3:00 PM nurse on 2/24/2025 discovered the count was not accurate and 20 pills were missing and notified the Director of Nursing. At time of narcotics reported missing, narcotic cabinets were inspected with no damage noted. All narcotics counted with no discrepancies. Medication carts searched. State police and Bureau of Narcotic Enforcement were notified of missing medications. Employees received disciplinary action regarding failure to perform appropriate narcotic count. Narcotic handling education to be completed for all nurses. Incident was reported to the New York State Department of Health. During an interview on 4/23/2025 at 3:09 PM, Licensed Practical Nurse #1 stated they had already met with the Department of Health in the Director of Nursing #1's office in February 2025 and gave a written statement. They stated they never signed anything about not doing a narcotic count and never had a verbal conversation with the Director of Nursing #1 or the Assistant Director of Nursing. During an interview on 4/23/2025 at 3:19 PM, Licensed Practical Nurse #2 stated they all got in trouble for not doing the narcotic count. They stated, 'that was a big thing for us. We were just taking the keys without counting.' They stated they all knew each other and trusted each other. They stated it was a 'big mistake' and they would never do it again. Order Recap Report for order date 2/1/2025 to 4/25/2025, documented an order dated 2/24/2025 for Oxycontin Oral Tablet extended release 12 Hours Abuse-Deterrent 10 milligram (Oxycodone HCl), give one (1) tablet by mouth two (2) times a day for pain for 14 days. The order start date was 2/24/2025 and end date was 3/10/2025. Documentation on the a) Individual Controlled Medication Record was inconsistent with documentation on the b) Medication Administration Record: Individual Controlled Medication Record for Resident #1 dated 2/25/2025, documented Oxycontin Oral Tablet ten (10) milligrams extended release, give one (1) tablet by mouth two (2) times a day for pain for 14 days. The medication was received 2/25/2025. Medication Administration Record dated February 2025, documented Oxycontin Oral Tablet extended release 12 Hours Abuse-Deterrent 10 milligram (Oxycodone HCl) was scheduled to be given daily at 9:00 AM and 9:00 PM. The order start date was 2/24/2025 at 9:00 PM. 2/25/2025 a) did not document any administrations. The first documented administration was on 2/26/2025 at 9:00 PM. 2/25/2025 b) Oxycontin extended release ten (10) milligrams was administered by Licensed Practical Nurse #6. During an interview on 4/25/2025 at 2:02 PM, Administrator #1 stated they would be starting education related to missed medications, failure to notify the provider, and documentation on the medication administration record. During an observation on 4/23/2025 at 10:56 AM on unit 6 (A-side), the untitled narcotic count signature sheets by the on-coming and off-going nurse dated April 2025 were reviewed. The sheets did not consistently document signatures by the on-coming and off-going nurse. For instance, 4/20/2025 days on, days off, evenings on, and evenings off did not document a signature for the nurse. During an interview with Licensed Practical Nurse #17 on 4/23/2025 at 11:02 AM, they stated they were aware of the ongoing investigation by the Bureau of Narcotic Enforcement. They stated they usually reviewed all the narcotic books and if they found a shift that was not signed, they would find the nurse who worked the shift on 4/20/2025 and would have them sign the book. Immediately following the interview, Licensed Practical Nurse #17 was observed reviewing the narcotic count sheets and was writing on them. Review of the Employee Education Attendance Record for Controlled Substances documented Licensed Practical Nurse #17 attended the training on 3/07/2025. During an observation on 4/23/2025 at 11:10 AM on unit 5 (A-side), the untitled narcotic count signature sheets by the on-coming and off-going nurse dated April 2025 were reviewed. The sheets did not consistently document signatures by the on-coming and off-going nurse. For instance, 4/20/2025 nights on, 4/21/2025 nights off, and 4/22/2025 days on and days off did not document a signature for the nurse. During an interview on 4/23/2025 at 11:16 AM, Licensed Practical Nurse #18 stated they had education on narcotics in late February/early March 2025 and stated narcotics were to be counted before and after each shift and discrepancies reported. During an observation on 4/23/2025 at 11:18 AM on unit 4 (A-side), the untitled narcotic count signature sheets by the on-coming and off-going nurse dated April 2025 were reviewed. The sheets did not consistently document signatures by the on-coming and off-going nurse. For instance, 4/1/2025 nights on, days off, evenings on, evenings off and nights on did not document a signature for the nurse. During the observation Licensed Practical Nurse #4 was observed writing in the unit's (B-side) narcotic count sheet book. During an interview on 4/23/2025 at 11:24 AM, Licensed Practical Nurse #4 stated they did not recall having any formal training about the narcotic counts and/or signing the narcotic count sheets. Review of the Employee Education Attendance Record for Controlled Substances documented Licensed Practical Nurse #4 attended the training on 3/04/2025. During an observation on 4/23/2025 at 11:18 AM on unit 3 (B-side), the untitled narcotic count signature sheets by the on-coming and off-going nurse dated April 2025 were reviewed. The sheets did not consistently document signatures by the on-coming and off-going nurse. For instance, 4/13/2025 nights on, days on, days off, and nights on did not document a signature for the nurse. During an interview on 4/23/2025 at 11:40 AM, Registered Nurse #2 stated they received education in March about the narcotic counts and signing the sheets. They stated they looked at the narcotic count books frequently and stated that sometimes 'staff do miss' and had to be told to sign it. They stated they would check to see who worked the shift on 4/20/2025 and would have them sign it. Review of the Employee Education Attendance Record for Controlled Substances documented Registered Nurse #2 attending the training on 3/4/2025. During an observation on 4/23/2025 at 11:55 AM on unit 2 (B-side), the untitled narcotic count signature sheets by the on-coming and off-going nurse dated April 2025 were reviewed. The sheets did not consistently document signatures by the on-coming and off-going nurse. For instance, 4/23/2025 nights off and days on did not document a signature for the nurse. During an interview on 4/23/2025 at 12:02 PM, Licensed Practical Nurse #1 stated they arrived on the unit after 9:00 AM. They stated the nurse working the unit prior to 9:00 AM, (Licensed Practical Nurse #6) should have counted the narcotics and signed the sheet. Surveyor asked if a count was done upon their arrival to the unit and they stated they counted for the B-side with Licensed Practical Nurse #6 and should have signed for 'days on.' They stated there should have been two (2) signatures on the line for 'days on,' theirs and Licensed Practical Nurse #6's. Review of the Employee Education Attendance Record for Controlled Substances documented Licensed Practical Nurse #1 attended the training on 2/27/2025. During an observation on 4/23/2025 at 2:18 PM on unit 1, the untitled narcotic count signature sheets by the on-coming and off-going nurse dated April 2025 were reviewed. The sheets did not consistently document signatures by the on-coming and off-going nurse. For instance, 4/20/2025 did not document any nurse signatures for the entire day on all three (3) shifts. During an interview on 4/23/2025 at 2:27 PM, Licensed Practical Nurse #19, stated they received education a while ago on counting narcotics and signing the narcotic sheet. During an interview on 4/24/2025 at 3:10 PM, Director of Nursing #1 stated there was house-wide education in February 2025, regarding counting narcotics with another nurse (on-coming and off-going) signing narcotic books and making sure control records were signed and dated. During an interview on 4/24/2025 at 2:02 PM, Administrator #1 stated they started education today, 4/24/2025, regarding narcotic count sign on/off with two (2) nurses. They stated the Educator would be auditing the narcotic sheets every sheet for the next two (2) weeks and then daily on the dayshift. They stated the Educator would audit the dayshift, 7:00 AM to 3:00 PM and the nursing supervisor would audit 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM. They stated that after that they would decide if the audits would be continued weekly or daily. 10 New York Code Rules and Regulations 415.18(a)

Based on record review and interviews during an abbreviated survey (Case #s NY00376223 and NY00377464), the facility did not ensure residents were free from significant medication errors for seven (7) (Resident #s 2, 3, 4, 5, 6, 7, and 12) of seven (7) residents reviewed. Specifically, the facility did not ensure accurate medication administration and documentation of controlled substances for a) Clonazepam (treats anxiety) for Resident #s 2, 5, and 12, b) Clonazepam and Tramadol (narcotic pain medication) for Resident #3, c) Alprazolam (treats anxiety) for Resident #4, and d) Oxycodone (narcotic pain medication) for Resident #s 6 and 7. This is evidenced by: The Policy and Procedure titled, Controlled Substance/Narcotic Management Protocol, reviewed 1/2025, documented it was the facility's policy to prescribe, administer, store and destroy all controlled substances within accepted regulations of the responsible governing body. All controlled substances ordered would be ordered in accordance with best practice and regulations. With each administration, the nurse must document the date, time, prior count and post administration count of the remainder of the medication and sign in the controlled substance logbook in addition to the medication administration record. In the event a resident did not take a controlled substance that had already been removed from its package, the nurse must document the details of the failed administration and destroy the medication in the presence of another nurse. Destruction must render the substance irretrievable. Two (2) nurses must witness and sign for all narcotic wastage in the controlled substance binder on the unit and document the new count. The nursing supervisor or Unit Manager must be made aware of the destruction and circumstances regarding same immediately. Resident #5: Resident #5 was readmitted to the facility with diagnoses of unspecified depression (mental health disorder that affects how a person feels, thinks, and handles daily activities), anxiety disorder (mental health disorder that causes fear, dread and other symptoms that are out of proportion to the situation), and conduct disorder (a mental health condition that involves a persistent pattern of aggressive and antisocial behaviors). The Minimum Data Set (an assessment tool) dated [DATE], documented the resident had moderate cognitive impairment. The resident was able to make themselves understood and understood others. Care Plan for Resident #5 used Psychotropic Medications (drugs that affect a person's mental state) related to anxiety and depression, revised [DATE]. Interventions documented give medications ordered by the physician; monitor/document side effects and effectiveness. Medication Review Report for date range [DATE] to [DATE], documented an order dated [DATE] for Clonazepam oral tablet 0.5 milligram, give one (1) tablet by mouth in the morning for five (5) administrations. The order start date was [DATE]. Review of the a) Individual Controlled Medication Record and the b) electronic Medication Administration Record dated February 2025 documented: Individual Controlled Medication Record for Resident #5 dated [DATE], documented Clonazepam 0.5 milligram, give one (1) tablet by mouth in the morning for 5 administrations. Medication Administration Record dated February 2025, documented Clonazepam 0.5 milligram, give one (1) tablet by mouth in the morning for five (5) administrations. The medication was scheduled to be given at 10:00 AM. Documentation on the a) Individual Controlled Medication Record was inconsistent with documentation on the b) Medication Administration Record. For instance: a) Clonazepam 0.5 milligram was administered on [DATE] at 10:47 AM, [DATE] at 8:00 AM, [DATE] at an illegible time, [DATE] at 8:00 AM, and [DATE] at 9:00 AM, respectively, for a total of five (5) administrations. b) Clonazepam 0.5 milligram was administered at 10:00 AM on [DATE], [DATE], [DATE], and [DATE], for a total of four (4) administrations. Order Summary Report for order date range [DATE] to [DATE], documented an order dated [DATE] for Clonazepam oral tablet 1 milligram, give one (1) tablet by mouth at bedtime for anxiety for fourteen (14) days. The order was started on [DATE] and was to end on [DATE]. Review of the a) Individual Controlled Medication Record and the b) electronic Medication Administration Record dated [DATE] documented: Individual Controlled Medication Record for Resident #5 dated [DATE], documented Clonazepam 1 milligram, give one (1) tablet by mouth at bedtime for anxiety for fourteen (14) days. Medication Administration Record dated [DATE], documented Clonazepam 1 milligram, give one (1) tablet by mouth at bedtime for anxiety for fourteen (14) days. The medication was scheduled to be given at 9:00 PM. Documentation on the a) Individual Controlled Medication Record was inconsistent with documentation on the b) Medication Administration Record. For instance: [DATE] a) Clonazepam 1 milligram was administered at 9:00 AM by Licensed Practical Nurse #8, when it was scheduled for 9:00 PM. [DATE] b) Medication Administration Record did not document the administration. [DATE] a) Clonazepam 1 milligram was administered at 9:00 AM by Licensed Practical Nurse #8, when it was scheduled for 9:00 PM. [DATE] b) Medication Administration Record did not document the administration. [DATE] a) Clonazepam 1 milligram was administered at 9:00 AM by Licensed Practical Nurse #8, when it was scheduled for 9:00 PM. [DATE] b) Medication Administration Record did not document the administration. Medication Administration Incident Report for Resident #5, date of discovery [DATE] at 9:00 PM. Date of error: [DATE], [DATE], and [DATE] at 9:00 AM. Type of error: wrong medication administered. Description of medication error: [DATE], [DATE], and [DATE] clonazepam one (1) milligram was administered at 9:00 AM. The order was to administer at bedtime. The report was signed by Licensed Practical Nurse #8 on [DATE]. Notice of Disciplinary Action for Licensed Practical Nurse #8 dated [DATE], documented a first and final warning for a medication error. Licensed Practical Nurse #8 gave Klonopin (clonazepam) on [DATE], [DATE], and [DATE], without a physician order. Medication was signed out on the narcotic sheet. Loss of Controlled Substances Report dated [DATE] by Director of Nursing #1, documented Resident #5 had a standing order for Clonazepam one (1) milligram to be administered at bedtime. Licensed Practical Nurse #8 administered the medication at 9:00 AM on [DATE], [DATE], and [DATE], without a physician's order. Medication was signed out on the narcotic sheet by the nurse. Resident #3: Resident #3 was admitted to the facility with diagnoses of unspecified schizophrenia (a condition and a spectrum of disorders involving a disconnection from reality), anxiety disorder, and conduct disorder. The Minimum Data Set, dated [DATE], documented the resident was cognitively intact. The resident was able to make themselves understood and understood others. Care Plan for Resident Exhibits Behavior Symptoms such as anxious, agitated and refusal of care and medications; socially inappropriate/verbally aggressive/abusive; physically aggressive/abusive; hallucinations (seeing, hearing, feeling or smelling something that does not exist); delusions (an unshakable belief in something that is untrue), revised [DATE]. Interventions documented administer psychotropic medications as ordered. Order Summary Report for order date range [DATE] to [DATE], documented an order dated [DATE] for Clonazepam 0.5 milligram, give one (1) tablet by mouth two (2) times a day for anxiety for fourteen (14) days. The order was started on [DATE] and was to end on [DATE]. Review of the a) Individual Controlled Medication Record and the b) electronic Medication Administration Record dated February 2025 documented: Individual Controlled Medication Record for Resident #3 dated [DATE], documented Clonazepam 0.5 milligram, give one (1) tablet by mouth two times a day for anxiety for fourteen (14) days. Medication Administration Record dated February 2025, documented Clonazepam 0.5 milligram, give one (1) tablet by mouth two times a day for anxiety for fourteen (14) days. The medication was scheduled to be given at 9:00 AM and 9:00 PM. The order was to start on [DATE] at 9:00 PM and ended on [DATE] at 9:00 AM. Documentation on the a) Individual Controlled Medication Record was inconsistent with documentation on the a) Medication Administration Record. For instance: [DATE] a) Clonazepam 0.5 milligram was administered at 2:00 PM, when it was scheduled to be given at 9:00 AM and 9:00 PM, and was already given at 9:00 AM. [DATE] b) Medication Administration Record did not document the 2:00 PM administration. [DATE] a) Clonazepam 0.5 milligram was administered at 9:00 PM, when the order had expired after the 9:00 AM administration on [DATE], and there was no new order until [DATE] at 9:00 PM. [DATE] b) Medication Administration Record did not document the administration. [DATE] a) Clonazepam 0.5 milligram was administered at 9:00 AM, when there was no new order until [DATE] at 9:00 PM. [DATE] b) Medication Administration Record documented the order was to start on [DATE] at 9:00 PM and did not document the 9:00 AM administration. Order Summary Report for order date range [DATE] to [DATE], documented an order dated [DATE] for Clonazepam 0.5 milligram, give one (1) tablet by mouth two (2) times a day for anxiety for fourteen (14) days. The order was started on [DATE] and was to end on [DATE]. Review of the a) Individual Controlled Medication Record and the b) electronic Medication Administration Record dated March documented: Individual Controlled Medication Record for Resident #3 dated [DATE], documented Clonazepam 0.5 milligram, give one (1) tablet by mouth two (2) times a day for anxiety for fourteen (14) days. Medication Administration Record dated [DATE], documented Clonazepam 0.5 milligram, give one (1) tablet by mouth two (2) times a day for anxiety for fourteen (14) days. The medication was scheduled to be given at 9:00 AM and 9:00 PM. Documentation on the a) Individual Controlled Medication Record was inconsistent with documentation on the b) Medication Administration Record. For instance: [DATE] a) Clonazepam 0.5 milligram was administered at 9:00 AM and was documented as wasted. There was no documentation that another nurse witnessed the waste. A subsequent entry documented the medication was administered at 10:00 AM. [DATE] b) Medication Administration Record documented one (1) administration at 9:00 AM. Order Summary Report for order date range [DATE] to [DATE], documented an order dated [DATE] for Tramadol HCl oral tablet 50 milligrams, give one (1) tablet by mouth two (2) times a day for fourteen (14) days. The order was started on [DATE] and was to end on [DATE]. Review of the a) Individual Controlled Medication Record and the b) electronic Medication Administration Record dated February documented: Individual Controlled Medication Record for Resident #3 dated [DATE], documented Tramadol HCl oral tablet 50 milligrams, give one (1) tablet by mouth two (2) times a day for fourteen (14) days. Medication Administration Record dated February 2025, documented Tramadol HCl oral tablet 50 milligrams, give one (1) tablet by mouth two (2) times a day for fourteen (14) days. The medication was scheduled to be given at 9:00 AM and 9:00 PM. Documentation on the a) Individual Controlled Medication Record was inconsistent with documentation on the b) Medication Administration Record. For instance: [DATE] a) Tramadol 50 milligram was administered on [DATE] at 9:00 PM by Licensed Practical Nurse #3 and at 9:00 AM by Licensed Practical Nurse #7, respectively. [DATE] b) Medication Administration Record documented the medication was administered on [DATE] at 9:00 AM by Licensed Practical Nurse #5 and at 9:00 PM by Licensed Practical Nurse #3. [DATE] a) There were no documented administrations. [DATE] b) Medication Administration Record documented the medication was administered on [DATE] at 9:00 AM by Licensed Practical Nurse #7 and at 9:00 PM by Licensed Practical Nurse #9. Order Summary Report for order date range [DATE] to [DATE], documented an order dated [DATE] for Tramadol HCl oral tablet 50 milligrams, give one (1) tablet by mouth two (2) times a day for fourteen (14) days. The order was started on [DATE] and was to end on [DATE]. Review of the a) Individual Controlled Medication Record and the b) electronic Medication Administration Record dated [DATE] documented: Individual Controlled Medication Record for Resident #3, documented Tramadol HCl oral tablet 50 milligrams, give one (1) tablet by mouth two (2) times a day for fourteen (14) days. Medication Administration Record dated [DATE], documented Tramadol HCl oral tablet 50 milligrams, give one (1) tablet by mouth two (2) times a day for fourteen (14) days. The medication was scheduled to be given at 9:00 AM and 9:00 PM. Documentation on the a) Individual Controlled Medication Record was inconsistent with documentation on the b) Medication Administration Record. For instance: [DATE] a) Tramadol 50 milligram was administered at 9:00 AM, when the order ended on [DATE] at 9:00 PM and there was no new physician order until [DATE] at 9:00 AM. [DATE] b) Medication Administration Record did not document the administration. [DATE] a) Tramadol 50 milligram was administered at 9:00 AM, when there was no new physician order until [DATE] at 9:00 AM. [DATE] b) Medication Administration Record did not document the administration. Order Summary Report for order date range [DATE] to [DATE], documented an order dated [DATE] for Tramadol HCl oral tablet 50 milligrams, give one (1) tablet by mouth two (2) times a day for fourteen (14) days. The order was started on [DATE] and was to end on [DATE]. Review of the a) Individual Controlled Medication Record and the b) electronic Medication Administration Record dated [DATE] documented: Individual Controlled Medication Record for Resident #3 dated [DATE], documented Tramadol HCl oral tablet 50 milligrams, give one (1) tablet by mouth two (2) times a day for fourteen (14) days. Medication Administration Record dated March and [DATE], documented Tramadol HCl oral tablet 50 milligrams, give one (1) tablet by mouth two (2) times a day for fourteen (14) days. The medication was scheduled to be given at 9:00 AM and 9:00 PM. Documentation on the a) Individual Controlled Medication Record was inconsistent with documentation on the b) Medication Administration Record. For instance: [DATE] a) Tramadol 50 milligram was administered at 9:00 PM, when the order ended on [DATE] at 9:00 PM and there was no new physician order until [DATE] at 8:59 AM. [DATE] b) Medication Administration Record did not document the administration. [DATE] a) Tramadol 50 milligram was administered at 9:00 AM, when there was no new physician order until [DATE] at 8:59 AM. [DATE] b) Medication Administration Record did not document the administration. [DATE] a) Tramadol 50 milligram was administered at 9:00 AM and 9:00 PM, when there was no new physician order until [DATE] at 8:59 AM. [DATE] b) Medication Administration Record did not document the administrations. Resident #6: Resident #6 was readmitted to the facility with diagnoses of spinal stenosis lumbar region (narrowing of the spinal canal in the lower back) without neurogenic claudication (condition that causes pain, weakness, and heaviness in the legs when walking), sciatica unspecified side (pain that travels along the path of the sciatic nerve from the buttocks and down each leg) and other chronic pain. The Minimum Data Set, dated [DATE], documented the resident was cognitively intact. The resident was able to make themselves understood and understood others. Care Plan for Resident has Musculoskeletal Impairment related to spinal stenosis, vertebrae fracture (broken bone in spine), and osteoporosis (disease that weakens the bones), revised [DATE]. Intervention documented administer pain medications per physician orders. Order Summary Report for order date range [DATE] to [DATE], documented an order dated [DATE] for Oxycodone HCl oral tablet ten (10) milligrams, give one (1) tablet by mouth every six (6) hours as needed for pain for fourteen (14) days. Review of the a) Individual Controlled Medication Record and the b) electronic Medication Administration Record dated March and [DATE] documented: Individual Controlled Medication Record for Resident #6 dated [DATE], documented Oxycodone HCl oral tablet 10 milligrams, give one (1) tablet by mouth every six (6) hours as needed for pain for fourteen (14) days. Medication Administration Record dated [DATE], documented Oxycodone HCl oral tablet ten (10) milligrams, give one (1) tablet by mouth every six (6) hours as needed for pain for fourteen (14) days. Documentation on the Individual Controlled Medication Record was inconsistent with documentation on the Medication Administration Record. For instance: [DATE] a) Oxycodone ten (10) milligram was administered at 9:00 PM. [DATE] b) Medication Administration Record did not document the administration. [DATE] a) Oxycodone ten (10) milligram was administered at 8:00 AM and 2:00 PM. [DATE] b) Medication Administration Record did not document the administrations. [DATE] a) Oxycodone ten (10) milligram was administered at 10:00 PM, 8:00 AM, and 1:00 PM respectively. [DATE] b) Medication Administration Record documented one (1) administration on [DATE] at 2:18 PM. [DATE] a) Oxycodone ten (10) milligram was administered at 1:35 PM by Licensed Practical Nurse #10. [DATE] b) Medication Administration Record did not document the 1:35 PM administration. Also, there was documentation of an administration at 9:48 PM by Licensed Practical Nurse #10, that was not documented on the Individual Controlled Medication Record. [DATE] a) Oxycodone ten (10) milligram was administered at 7:00 PM. [DATE] b) Medication Administration Record did not document the administration. [DATE] a) did not document any administrations. [DATE] b) Medication Administration Record documented one (1) administration at 11:45 PM. [DATE] a) Oxycodone ten (10) milligram was administered at 5:00 PM, 11:30 PM, 7:00 AM, 3:00 PM, and 9:12 PM, respectively. [DATE] b) Medication Administration Record only documented one (1) administration on [DATE] at 9:12 PM administration. [DATE] a) Oxycodone ten (10) milligram was administered at 1:00 PM. [DATE] b) Medication Administration Record did not document the administration. Loss of Controlled Substances Report dated [DATE] by Director of Nursing #1, Lost/stolen controlled substance listing documented one (1) Oxycodone ten (10) milligram tablet. Date/time of incident was [DATE] at 1:30 PM. Name of suspect documented Licensed Practical Nurse #10. It documented Resident #6 requested prn (as needed) pain medication and was informed they already received it at 1:35 PM. Resident #6 stated they never requested pain medication at that time because they were in therapy. During an interview on [DATE] at 10:29 AM, Licensed Practical Nurse #4 stated they were aware of Resident #5's Clonazepam administration issues. They stated they noticed a problem with the medication administration on the evening shift of [DATE], when they went to give the 9:00 PM dose of clonazepam. They looked at the prior administration on the narcotic control sheet and saw it was given at 9:00 AM on [DATE] and [DATE] and reported the errors on [DATE] to the Director of Nursing #1. They stated the errors were made by Licensed Practical Nurse #8. They stated the narcotic count was correct, but they noticed that Licensed Practical Nurse #8 gave the medication at 9:00 AM. They told the Director of Nursing #1 they could not give the daily dose because it was already given, and Licensed Practical Nurse #4 was told they had to call the doctor. The Assistant Director of Nursing stated they would call the physician and then called the Nurse Practitioner. When they called, they said they had a resident who received their medication early and the Nurse Practitioner told them to hold the medication. Licensed Practical Nurse #4 asked Resident #5 if they got their Clonazepam in the morning and resident said they take that at night. They stated the resident knew the color of the pill and that they get the pill at bedtime. During an interview on [DATE] at 3:06 PM, Registered Nurse #1 stated they knew the 'rules' regarding narcotic medication administration. They stated when a narcotic was administered the narcotic control record, and the electronic medication administration record were to be signed/documented. They stated signing the narcotic control record but not signing the electronic medication record meant the nurse did not give the medication to the resident. They stated a nurse needed another nurse to witness the wasting of a narcotic medication and the witness needed to sign the narcotic control record that they witnessed the waste. During an interview on [DATE] at 3:10 PM, Director of Nursing #1 stated there was house-wide education in February 2025, regarding counting narcotics with another nurse (on-coming and off-going) signing narcotic books and making sure control records were signed and dated. When narcotics are administered, they need to be signed out on the control record and then documented in the electronic medication record once they are administered. They stated narcotics needed to be wasted with a second nurse and documented why it was wasted, with the second nurse signature on the narcotic control record. During an interview on [DATE] at 2:02 PM, Administrator #1 stated they started education today, [DATE], regarding narcotic count sign on/off with two (2) nurse, documentation and reason for wasting narcotics on the control record. They stated the Educator would be auditing the narcotic sheets every sheet for the next two (2) weeks and then daily on the dayshift. They stated the Educator would audit the dayshift, 7:00 AM to 3:00 PM and the nursing supervisor would audit 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM. They stated that after that they would decide if the audits would be continued weekly or daily. 10 New York Code of Rules and Regulations 415.12(m)(2)

Based on observation, record review, and interview during the recertification survey, the facility did not ensure a resident received adequate supervision and assistive device to prevent accidents for 1 (Resident #64) of 6 residents reviewed for accidents. Specifically, Resident #64, who was identified as high risk for falls on admission, had a witnessed fall on 7/01/2023 while ambulating without a walker. There were no interventions initiated or implemented following the fall to prevent further accidents. Subsequently, on 9/26/2023 Resident #64 fell and sustained a cervical 1 vertebrae fracture (broken neck). This resulted in actual harm for Resident #64 that is not immediate jeopardy. This is evidenced by: The Policy and Procedure titled Falls and Fall Risk management dated 10/1997, revision dates; 3/2022, 1/2023 and last revised on 1/2024 documented based on previous evaluations and current data, staff would identify interventions related to resident's specific risks and causes to try to prevent the resident from falling and minimize complications from falls. Staff, with the input of the attending physician, would identify appropriate interventions to reduce the risks of falls. It also documented if falls recur despite initial interventions, staff will implement additional or different interventions. If underlying causes could not be readily identified or corrected, staff would try various interventions, based on assessment of the nature or category of fall until falls were reduced or stopped. Staff would monitor and document each resident's response to intervention intended to reduce falls or the risk of falling. The Policy and Procedure titled Accidents or Incidents dated 1/2024, documented all accidents or incidents involving a residents would be investigated, and any corrective action taken would be documented. Incident/accident reports would be reviewed by the safety committee for trends related to accident or safety hazards in the facility and analyze any individual resident vulnerabilities. Resident #64 was admitted to the facility with diagnoses of unspecified displaced fracture of first cervical vertebra, metabolic encephalopathy (a brain disorder that occurs when a chemical imbalance in the blood caused by an illness or organ dysfunction impairs brain function), and depression. Minimum Data Set, dated dated dated (an assessment tool) dated 7/13/2023 documented resident had moderately impaired cognition, could be understood, and could understand others. The Comprehensive Care Plan Titled Actual fall related to increase agitation, cognitive deficit, decreased mobility, and gait problems last revised on 4/09/2024 documented actual falls on the following dates: -7/1/2023 witnessed fall. -9/26/2023- witnessed fall, head strike. -9/30/2023 unwitnessed fall, no injury. There was no documented evidence on the care plan that interventions were put in place after these actual falls to prevent further accidents. The facility's Incident and Accident Investigation Summary dated 7/01/2023 at 12:45 PM documented Resident #64 walked from unit 2 to reception without a walker, lost balance and fell . It documented contributing factors were loss of balance and repeated falls. It further documented fall risk assessment was completed and identified resident as high risk. Recommended steps to prevent recurrence was to remind the resident to use walker. There was no documented evidence on the care plan the intervention was put in place after this actual fall to prevent further accidents. The facility's Incident and Accident Investigation Summary dated 9/26/2023 documented Resident #64 tripped on an intravenous pole and fell striking the left side of head. Resident was transported to the hospital. It further documented Resident #64 returned from the hospital on 9/29/2023 with diagnosis of cervical 1 vertebra fracture with a cervical collar (a medical device used to support and immobilize a person's neck) in place. Recommended steps to prevent recurrence was to remove clutter from resident areas to prevent tripping. There was no documented evidence on the care plan the intervention was put in place after this actual fall to prevent further accidents. Resident #64's Fall Risk Evaluation dated 8/15/2023 at 4:13 PM, documented resident has had multiple falls within last six months. Resident #64's Fall Risk Evaluation dated 9/16/2023 at 8:30 PM, documented resident has had multiple falls within last six months. Health Status Note dated 9/16/2023 at 9:04 PM written by Licensed Practical Nurse #12 documented they were notified by assigned staff that Resident #64 was observed on the floor in the resident's room. It documented the resident stated they struck their head. Neuro checks were started and on call physician made aware. Health Status Note dated 9/26/2023 at 9:30 AM written by Registered Nurse #4 documented they were called to the unit for a witnessed fall for Resident #64. It documented on arrival resident was observed sitting on the floor alongside Licensed Practical Nurse #13 holding pressure on the left side of the head laceration with minimal bleeding. It further documented, per Licensed Practical Nurse #13, the resident tripped on an intravenous pole and struck the left side of their head on a desk chair. Resident was transported to the hospital. Nurse Practitioner Notes dated 9/26/2023 at 9:42 AM written by Nurse Practitioner #3 documented they were asked to assess resident for a fall while ambulating. Resident stated they tripped on an intravenous pole and fell forward and struck their head. It was documented the resident had a small laceration to their left eyebrow. Resident had complaint of headache. Resident was sent to the hospital for further examination and monitoring. Resident #64's History and Physical from the hospital dated 9/26/2023 documented resident presented from nursing home after sustaining a mechanical fall resulting with a cervical 1 vertebra fracture at the posterior arch (a break in the vertebra). Cervical collar on at all times. Resident #64's computed tomography angiogram (a diagnostic test) of the neck dated 9/26/2023 from the hospital documented there was a [NAME] fracture of the cervical 1 vertebral body (a bone fracture of the anterior and posterior arches of cervical 1 vertebra). Admission Note dated 9/29/2023 at 4:01 PM written by Registered Nurse #3 documented resident was admitted from the hospital. The reason for admission was resident had a mechanical fall from standing while using a walker. Resident #64 had a cervical collar due to cervical 1vertebra fracture. The was no documented evidence Resident #64's care plan for falls was updated with interventions after their return from the hospital. Physicians Progress Note dated 10/02/2023 at 10:54 AM, documented Resident #64 had a fall with head strike on 9/26/23. Resident was transferred to the emergency room for evaluation due to head strike, laceration, and the need for further evaluation. Resident found to have cervical 1 vertebra fracture bilateral posterior arch acute fractures, soft tissue hematoma (bruise) measuring 2.4 centimeters at the lateral left hip soft tissue without underlying osseous (bone) fracture. Patient returned to facility on 9/29/23 with cervical collar and recommendation for Ortho spine follow up. Resident did not have surgery. During an interview on 6/27/2024 at 11:55 AM, Assistant Director of Nursing #2 stated they were responsible for updating the fall Care plans after each fall. They stated every fall had to have an intervention and their main goal was for the resident not to get injured. They stated they did not see an intervention on the care plan for Resident #64 after the fall on 7/01/2023 and there should have been one on the care plan. They stated they did not know why interventions were not on the care plan. During an interview on 6/27/2024 at 12:07 PM, Director of Nursing #1 stated after a resident fall the Registered Nurse Supervisor would get notified and the resident would be assessed. The care plan would be updated with interventions after each fall and would be done at the time of the incident. They stated the Assistant Director of Nursing ensured the interventions were on the care plan after each fall. They stated they met with the Assistant Director of Nursing after falls and made sure interventions were discussed and put on the care plan after each fall to prevent it from happening again. They stated every actual fall had to have an intervention in place after the incident. They stated Resident #64 fell on [DATE] and was sent to the hospital. Resident #64 sustained cervical 1 vertebra fracture and returned with cervical collar. Director of Nursing #1 looked on Resident #64's fall care plan and could not find the interventions that were put in after the fall on 7/01/2023. They stated there should have been interventions in place for the 7/01/2023 fall. During an interview on 6/27/2024 at 12:10 PM, Regional Clinical Director of Nursing #1 stated there should be interventions on the care plan after each fall to prevent further accidents. On 6/28/2024 multiple attempts were made to get in contact with facility's physician for interview but no response. 10 New York Codes, Rules, and Regulations 415.12(h)(1)

Based on record review and interviews during an abbreviated survey (Case # NY00331916), the facility failed to protect residents' rights to be free from abuse for 2 (Resident #s 1 and 2) of 3 residents reviewed for abuse. Specifically, the facility failed to ensure the residents' safety and provide adequate supervision to prevent abuse on 1/21/2024, when Certified Nurse Aide #1 observed Residents #s 1 and 2, both of whom had severe cognitive impairment, sitting next to each other on Resident #1's bed. Resident #2 was not redirected out of the room and Certified Nurse Aide #1 left the room, with the residents unsupervised. Subsequently, Certified Nurse Aide #1 returned to the room [ROOM NUMBER] to 8 minutes later and observed Resident #s 1 and 2 engaging in inappropriate sexual behavior. Additionally, during an interview with Certified Nurse Aide #3 on 3/20/2024 at 1:51 PM, they reported they had observed Resident #s 1 and 2 engaging in inappropriate touching prior to the incident on 1/21/2024, it was reported to the Nurse Manager, and they could not recall when it happened or who they told. This resulted in, or had the likelihood for, psychosocial harm that is Immediate Jeopardy and Substandard Quality of Care for Resident #s1 and 2 and had the likelihood to affect 106 vulnerable residents in the facility who are cognitively impaired. This was evidenced by: The Policy and Procedure titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program reviewed 1/2024, documented residents had the right to be free from abuse. It documented this included but was not limited to freedom from sexual abuse. The resident abuse prevention program consisted of a facility-wide commitment and resource allocation to support the following objectives: protect residents from abuse by anyone including other residents, develop and implement policies and protocols to prevent and identify abuse of residents, and ensure adequate staffing and oversight/support to prevent burnout, stressful working situations and high turnover rates. The Policy and Procedure titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating reviewed 1/2024, documented all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property would be reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. It documented findings of all investigations were documented and reported. Upon receiving any allegations of abuse, the administrator was responsible for determining what actions (if any) were needed for the protection of the residents. The Incident and Accident Statement Form: Supervisor Statement/Summary of Investigation for Resident #s 1 and 2 dated 1/21/2024 at 3:45 PM, summary of investigation documented inappropriate sexual interaction. Contributing factors documented dementia and impaired decision making. Actions taken documented separated and 15-minute checks. Conclusion documented the incident was witnessed; a sexual interaction occurred between two cognitive deficit residents unable to give consent. The facility's investigation report dated 1/26/2024, for date of incident 1/21/2024 at 3:45 PM, documented a resident-to-resident altercation between Resident #s 1 and 2. It documented a Certified Nurse Aide observed Resident #2 naked from the waist down, standing in front of Resident #1, who was sitting on the bed with their clothes on. It documented a Certified Nurse Aide observed the residents engaging in inappropriate sexual behavior. Interventions documented the residents were immediately separated and both residents were placed on 15-minute checks until the room change was completed for Resident #2. The investigation conclusion documented sexual interaction occurred between two residents that due to cognitive deficits were unable to give consent. Resident #1: Resident #1 was admitted to the facility with diagnoses of dementia with psychotic disturbance, delusional disorders, and hallucinations. The Minimum Data Set (an assessment tool) dated 12/28/2023, documented the resident had severe cognitive impairment, usually could be understood, and sometimes understood others. The Comprehensive Care Plan for Exhibits Behavior Symptoms, initiated on 12/18/2023 and revised 1/23/2024, documented resident socially inappropriate/verbally aggressive/abusive; hallucinations; delusions; wandering behavior; belief that other residents were their husband and was easily redirected. A care plan intervention initiated 12/22/2023, documented all day hourly checks. The Comprehensive Care Plan for At Risk for Being a Victim, initiated 1/22/2024, documented resident's inability to understand their surroundings related to cognitive impairment and dementia. It documented a resident-to-resident altercation on 1/21/2024. The Nursing Progress Note dated 1/21/2024 at 3:45 PM written by Registered Nurse Supervisor #1, documented they were called to the unit and staff reported that Resident #1 was observed with Resident #2, performing inappropriate sexual interactions. The residents were immediately separated. It was documented Resident #1 stated they were spending time with their husband. The resident was placed on 15-minute checks and the on-call Nurse Practitioner #1, and the Director of Nursing were notified. The Physician's Progress Note dated 1/21/2024 at 5:34 PM by the Nurse Practitioner #1, documented a late entry note. They were notified by the nurse that Resident #1 and another resident were having inappropriate sexual relations with each other. It documented the nurse notified the Director of Nursing and facility protocols followed. The Physician's Progress Note dated 1/23/2024 at 10:53 AM by the Physician #1, documented the nurse notified them that Resident #1 and another resident were having inappropriate sexual relations with each other. It documented the nurse notified the Director of Nursing and facility protocols followed. It documented the resident was getting monitored for sexual behaviors. The assessment/plan documented to monitor for sexual behaviors. Resident #2: Resident #2 was admitted to the facility with diagnoses of sequelae of cerebral infarction (complications after a stroke), anxiety disorder, and recurrent major depressive disorder. The Minimum Data Set, dated dated dated [DATE], documented the resident had severe cognitive impairment, could be understood, and usually understood others. The Comprehensive Care Plan for Exhibits Behavior Symptoms, initiated 10/26/2023 and revised 2/9/2024 after the incident, documented socially inappropriate/verbally aggressive/abusive; physically aggressive/abusive; wandering behavior; wandered around the unit at times and easily redirected. A care plan intervention initiated on 10/26/2023, documented staff were to distract the resident from wandering by offering pleasant diversions. There was no documented evidence of new interventions, until 3/23/2024; staff were to intervene when the resident became agitated with the following interventions: coffee, snacks, enjoys reminiscing about their past. The Comprehensive Care Plan for At Risk for Being a Victim, initiated on 12/28/2023 and revised on 1/21/2024 after the incident, documented the inability to understand their surroundings related to cognitive impairment and dementia. It documented a resident-to-resident altercation on 1/21/2024. A care plan intervention initiated on 12/29/2023, documented for staff to provide support and ensure the resident was free from abuse. An intervention initiated on 1/22/2024, documented room change off unit. An intervention for 15-minute checks for safety was initiated on 3/22/2024. The Comprehensive Care Plan for Abuse, Neglect related to altered mental status, initiated 3/23/2024, after the incident, documented care plan interventions: 15-minute checks for safety and resident to be offered food and/or activities of interest while wandering to help keep the resident occupied. The Nursing Progress Note dated 1/21/2024 at 3:45 PM by Registered Nurse Supervisor #1, documented they were called to the unit. It documented staff stated Resident #2 was observed in Resident #1's room having inappropriate sexual interactions. Resident #2 was immediately removed from the room and taken to their room. Resident #2 was unable to state the incident and when asked if there was any incident with another resident they stated no. The Director of Nursing, the resident representative and the on-call Nurse Practitioner were notified. It documented the resident was placed on 15-minute checks. There was no documented evidence the care plan was updated to include 15-minute checks until 3/22/2024. The Physician's Progress Note dated 1/21/2024 at 5:36 PM by Nurse Practitioner #1, documented a late entry note. It documented they were notified by the nurse that Resident #2 and another resident were involved in inappropriate sexual behavior. It documented the residents were separated, the Director of Nursing was notified, and facility protocols were followed. During an interview on 3/20/2024 at 12:31 PM, Certified Nurse Aide #1 stated they saw Resident #s 1 and 2 sitting next to each other on Resident #1's bed on 1/21/2024. They stated the bathroom door was open and they could see feces on the floor. They stated they left Resident #1's room to gather cleaning supplies and returned approximately 7 to 8 minutes later. Certified Nurse Aide #1 stated when they returned the room, the door was closed, they knocked on the door and called out Resident #1's name. They stated no one said anything so they just walked in. They stated they saw Resident #1 sitting on the bed with their clothes on and Resident #2's pants were off and were placed on the sink, about 5 to 7 feet away from the bed. They stated Resident #2 was naked from the waist down and the Residents were engaged in an inappropriate sexual interaction. They stated they did not try to get Resident #2 out of the room earlier, because they were coming right back, and thought Resident #2 would be alright for those few seconds. They stated they were totally wrong on that note. and stated the supervisor asked them same thing. They stated they did not feel any cause for alarm because both residents wandered and would go in and out of other resident rooms. They stated they thought they would escort Resident #2 out of the room when they got back. They stated they had no knowledge of Resident #2 being sexually inappropriate with any other resident. They stated they called out for Certified Nurse Aide #3 to help them get Resident #2 out of the room. They stated Resident #1 told them they were going to prison because they interrupted their marital affairs. During an interview on 3/20/2024 at 1:51 PM, Certified Nurse Aide #3 stated they were familiar with the incident between Resident #s 1 and 2. They stated Resident #1 had been on the unit 1 for a couple of months. They stated they saw Resident #2 go into Resident #1's room on occasion and they stated it was a daily thing. When asked if the residents were ever sexually inappropriate prior to the incident, they stated there was one time when Resident #1 was sitting on their bed and Resident #2 was standing in front of them and Resident #1 was inappropriately touching Resident #2. They stated they removed Resident #2 from the room and told the manager. They stated they did not recall when it happened or who they told. They stated they had not received formal training about what to do for a wandering resident prior to or after the incident. They stated they had received abuse training and if they saw something related to abuse, they would report to the manager or a nurse on the unit. During an interview on 3/21/2024 at 11:22 AM, Licensed Practical Charge Nurse #1 stated they were aware of an incident of a sexual nature that occurred prior to Resident #2 coming to their unit 6. They stated they had not received any training after the incident. They stated Resident #2 was on 15-minute checks and was still being monitored. They stated male residents were not allowed in female resident rooms. They stated Certified Nurse Aide #1 should have removed the resident from the room before they left the room. They stated Resident #s 1 and 2 should never have been left in a room unsupervised. During an interview on 3/21/2024 at 2:05 PM, Director of Nursing #1 stated they personally trained Certified Nurse Aide #1 specifically for redirecting residents following the incident. They stated Certified Nurse Aide #1 observed Resident #s 1 and 2 sitting on Resident #1's bed. They stated Certified Nurse Aide #1 saw feces on the floor and went to get something to clean it up. They stated when Certified Nurse Aide #1 got back to the room, they saw Resident #2 was naked and Resident #1 was engaged in inappropriate sexual behavior with Resident #2. Director of Nursing #1 stated it was a dementia unit and residents wandered around and mingled with each other. They stated Certified Nurse Aide #1 received dementia training upon hire, annually, and as needed. They stated there was no abuse training following the incident. During an interview on 3/21/2024 at 2:14 PM, Staff Educator #1 stated they were not aware of an incident between Residents #1 and #2. They stated when there was stuff going on in the facility they were not informed about the details. They stated they would just be told to educate staff and was told what the need was. They stated they did abuse training for the facility in January 2024. They stated they did orientation for new staff coming in and stated dementia training was done at that time. They stated they provided no individual training for Certified Nurse Aide #1 following the incident. During an interview on 3/21/2024 at 2:34 PM, Registered Nurse Manager #1 stated they knew briefly about what happened over the weekend between Resident #s 1 and 2 by reading about it. They talked to Certified Nurse Aide #1 who had witnessed the incident and Certified Nurse Aide #1 said they were checking residents and walked by Resident #1's room. The Certified Nurse Aide then walked into the room and Resident #2 had their pants down and Resident #1 was engaged in a sexual act with Resident #2. Registered Nurse Manager #1 stated they were aware Certified Nurse Aide #1 was in Resident #1's room several minutes prior to the incident and that the aide saw both residents fully clothed and sitting on the bed together. They stated whenever they saw two residents in a room together, they would separate them immediately out of dignity and safety of the residents. Registered Nurse Manager #1 stated both residents had a diagnosis of dementia and were unable to give consent for sexual relations. They stated based on their the brief interview for mental status score, Resident #s 1 and 2 were not formally assessed to be unable to give consent. They stated they were responsible for the care planning on that unit. Registered Nurse Manager #1 stated it was on Resident #1's care plan that the resident believed other residents were their husband and stated Resident #1 would say that's my husband when referring to residents on the unit. They stated they would have to redirect Resident #1 constantly and remove them from the male residents' rooms. They stated there was no relationship between Residents #1 and #2. Registered Nurse Manager #1 stated Resident #2 looked like Resident #1's husband, who would visit the resident. They were not aware that Resident #2 was in Resident #1's room daily and stated Resident #2 wandered into everyone's room. Registered Nurse Manager #1 stated they were not aware that Resident #1 had touched Resident #2 inappropriately as was witnessed by Certified Nurse Aide #3. They stated all staff were to report any inappropriate contact between residents. Registered Nurse Manager #1 stated hourly checks meant staff needed to put their eyes on Resident #1 and try to keep them in the common area where they could see the resident. They stated that after the incident both residents were placed on 15-minute checks and now they were on hourly checks. The Registered Nurse Manager #1 stated they did not update the residents' care plan following the incident. They stated with any resident-to-resident altercation, they usually updated the care plan. They stated the Registered Nurse Supervisor should have updated the care plan at the time of the incident. They stated Resident #2 was moved to unit 6 on the Monday 1/22/2024 following the incident. They stated the facility had abuse training in January 2024, however, there was no specific training regarding the incident. Registered Nurse Manager #1 stated they were not sure if Certified Nurse Aide #1 was educated following the incident. During an interview on 3/22/2024 at 1:00 PM, Assistant Administrator #1 stated they were made aware of the incident with Resident #s 1 and 2 on Monday, following the allegation of sexual abuse incident. Assistant Administrator #1 stated the residents should have been separated when the Certified Nurse Aide saw Resident #2 in Resident #1's room sitting on the bed and documentation should have been placed in the record. Assistant Administrator #1 stated the facility addressed everything right away and reported it right away. Assistant Administrator #1 stated Resident #2 had been previously moved because the resident was wandering and disruptive and was care planned for this. They stated Resident #2 was moved to yet another unit after the incident and was kept on 15-minute checks. Assistant Administrator #1 stated there was documentation in the electronic medical record about Resident #1, but it was not placed in the care plan. During an interview on 3/25/2024 at 9:55 AM, Administrator #1 stated they were made aware of the incident with Resident #s 1 and 2 at the time it occurred by the Director of Nursing. They stated they were not aware that Certified Nurse Aide #1 left both residents in the room and was not aware that this incident was not the residents' first sexual encounter together. During an interview on 3/28/2024 at 2:50 PM, Medical Director #1 stated the incident with Resident #s 1 and 2 sounded familiar but were not familiar with the residents because Medical Director #1 only provided oversight to the providers for clinical issues. They stated that normally, the protocol was to put resident safety first and stated the Certified Nurse Aide should have never left Resident #s 1 and 2 unattended. They stated there was no going around this and the incident should never have happened. During an interview on 4/1/2024 at 2:15 PM, Certified Nurse Aide #2 stated it was around 3:00 PM or 4:00 PM on 1/21/2024, when Certified Nurse Aide #1 walked into Resident #1's room and started screaming their (Certified Nurse Aide #2's) name. They stated Resident #1 was on the bed and Resident #2 was standing with their pants down. They stated Resident #1 had their clothes on and Resident #2 was noted with an erect penis and was yelling and cursing at the Certified Nurse Aides, saying give me one more minute. They stated they gave both residents a shower that evening and in talking to the residents, Resident #2 had forgotten about the whole thing and Resident #2 thought they were having a marital incident. They stated they did not know the residents were seen by Certified Nurse Aide #1, sitting on Resident #1's bed together prior to the incident. They stated that if they had seen the residents together, they would have gotten Resident #2 out of the room. They stated they would have separated and redirected both residents. During an interview on 4/3/2024 at 1:43 PM, Registered Nurse Supervisor #1 stated the incident between Resident #s 1 and 2 was reported to them by the Certified Nurse Aides on the unit. They stated the Certified Nurse Aides described a sexual interaction, and the residents were separated. Registered Nurse Supervisor #1 stated when Resident #2 was asked about the incident, the resident was not understanding what was happening or what had occurred. When they questioned Resident #1, the resident told them it was something that they and their husband liked to do. They stated Resident #1 was upset because they were separated. They stated they asked Certified Nurse Aide #1 why they did not remove Resident #2 from Resident #1's room. Registered Nurse Supervisor #1 were told there was a mess in the room, the aide left to get cleaning supplies, and got distracted by helping another Certified Nurse Aide. During an interview on 4/8/2024 at 12:55 PM, Physician #1 stated the on-call provider was notified about the incident with Resident #s 1 and 2 on the day of the incident. They stated they were notified the day after the incident. They stated both residents had dementia and resided on a locked unit. They stated Resident #2 was only oriented to themselves, was confused all the time, and had an alcohol abuse disorder. They stated Resident #2 wandered into other resident rooms and was redirected out by staff. They stated Resident #1 was confused all the time and did not recognize other people. They stated they did not know that Resident #2 was seen in Resident #1's room prior to the incident. They stated Certified Nurse Aide #1 just thought they were talking and did not think it to be a problem. They stated the residents should have been separated when seen in the room together and stated that residents usually socialized in the dining room. They stated Resident #1 felt that they were doing this sexual act with their husband. 10 New York Codes, Rules, and Regulations 415.4(b)(1)(i)

Based on observation, record review, and interviews during an abbreviated survey (Case #NY 510), the facility did not ensure that each resident received adequate supervision to prevent accidents for 1 (Resident #1) of 3 residents reviewed for accidents. Specifically for Resident #1, the facility did not ensure they provided adequate supervision to maintain the safety of the resident who had a recent history of self-harm and hospitalization s for mental health issues. Resident #1 made suicide attempts on 7/5/2022 and 8/11/2022. This resulted in actual harm to Resident #1 that was not immediate jeopardy. This was evidenced by: Resident #1 Resident #1 was admitted to the facility with diagnoses of non-suicidal self-harm, [CONDITION(S)], and major depressive disorder. The Minimum Data Set (MDS-an assessment tool) dated 8/10/2022, documented the resident was cognitively intact, could be understood, and could understand others. The policy and procedure titled Suicide Threats dated 8/2022, documented resident suicide threats shall be taken seriously and addressed appropriately. The Hospital Discharge Summary dated 6/30/2022 at 9:12 AM, documented Resident #1 was admitted to the hospital on 6/6/2022 following an attempt to hurt themselves by cutting their arms with a plastic knife. The resident's family had a history of suicides and the resident stated they were afraid of doing the same. It documented Resident #1 needed the 1:1 sitter for 20 days until the 1:1 sitter was discontinued on 6/26/2022 when the resident was cleared psychologically. The initial Comprehensive Care Plan (CCP) dated 7/1/2022, documented Resident #1 exhibited behavior symptoms such as socially inappropriate, verbally aggressive/abusive, physically aggressive/abusive, hallucinations, delusions, and wandering behaviors. There was nothing in the care plan that documented the resident's recent history of self-harm. The CCP revised on 7/6/2022 for Behavior Symptoms/Provocative with Suicidal Ideation, documented that the resident was to receive paper products, plastic silverware, and no glass or metal utensils. There were no other interventions addressing suicidal ideation. The CCP for Major Depressive Disorder and Anxiety Disorder dated 7/19/2022, documented the resident had a history of several hospitalization s for mental illness. The care plan goal documented the resident would work with psychology and psychiatry services. The intervention dated 7/22/2022, documented the resident's stability and safety would be maintained. The certified nursing assistant (CNA) care card as of 8/15/2022, documented the resident was to receive paper products, plastic silverware and no metal or glass utensils. The Admission Note dated 6/30/2022 at 2:36 PM, documented the resident was admitted from the hospital for long term care. It documented the resident's mood/behavior concerns were sad/depression, anxiety, and potential for violence. The note did not document the resident had been admitted to the hospital because they harmed themselves by cutting themselves with a plastic knife. I added this because it does not document the resident's attempted self-harm that caused their hospitalization . A Health Status Note dated 7/5/2022 at 3:24 AM, written by a Licensed Practical Nurse (LPN), documented that at 2:15 AM, blood was observed on the resident's floor. On assessment by the RN, it was documented the resident was lying in their bed with a large amount of blood on the floor and a 5 cm laceration to their left ankle. The resident stated they had intentionally cut themselves with a piece of glass and wanted to die. They did not want to die a slow death in a nursing home and that they would do better next time. The resident was transported to the hospital via ambulance. A Health Status Note dated 7/6/2022 at 6:12 AM, documented the resident returned to the facility at 4:14 AM with documentation the resident was medically and psychiatrically cleared to return to the facility. The resident was immediately placed on 1:1 supervision per the Supervisor's request. There was no further documentation in the medical record that 1:1 supervision was continued or discontinued. A Physician's Progress Note dated 7/7/2022 at 10:50 AM, documented Resident #1 had returned to the facility after psychiatric clearance from the hospital following their suicide attempt. The resident stated they cut their left ankle with the intention that they did not want to live any longer. The medical doctor (MD) documented the resident would need to be monitored very closely and a psychiatry consult should be obtained. There was no documentation in the medical record that the resident was evaluated by a psychiatrist or psychologist upon return to the facility. Review of the CNA Assignment Sheets for all shifts dated from 7/6/2022- 8/11/2022, did not document that CNAs were assigned for 1:1 supervision of the resident. There were no flow sheets that documented 1:1 supervision was provided for the resident. The document titled Incident and Accident Statement Form: Summary of Investigation dated 8/11/2022 at 3:30 PM, documented the resident self-lacerated both ankles with a sharp object. The resident had a history of psychiatric admissions, suicidal ideation, and attempts. The resident was assessed by a Registered Nurse (RN), placed under 1:1 supervision, first aid was applied to both ankles, Emergency Medical Services was called per the direction of the Nurse Practitioner (NP) on a telehealth call, and the resident was sent to the hospital for treatment and a psychiatric evaluation. The Medical Director was notified. A Health Status Note dated 8/11/2022 at 5:05 PM, documented the Registered Nurse Manager (RNM) was participating in a telehealth conference with the NP and another resident when they were interrupted by a commotion in Resident #1's room. As they started toward the resident's room, they were told it was urgent. Upon entering the room, the RNM observed the resident lying on the floor vomiting and surrounded by blood. There were also blood pools under the bed and on the window side of the room. After a quick assessment, it was determined there were lacerations of the resident's feet. A Code Blue was called, and staff responded. An LPN provided direct pressure on the wounds while other staff attempted to start intravenous fluid (an IV). The NP was still on the telehealth connection. 911 was called, responded, and the resident was sent to the hospital. A Physician Progress Note dated 8/11/2022 at 3:43 PM, documented the NP was on a telemedicine call with nursing when Resident #1 was found in their bedroom on the floor lying in a pool of blood. It was observed that the resident had found a sharp object, possibly a razor blade and lacerated their left ankle. Code Blue was called, and emergency procedures were applied. The NP documented it was not the resident's first suicide attempt, the last suicide attempt was in July (7/5/2022). The resident was being sent to the hospital via ambulance for psychiatric evaluation. It was discussed at length with the Acting Director of Nursing (DON) that the resident should be sent out for psychiatric evaluation as per the facility. During an interview on 8/15/2022 at 10:23 AM, CNA #1 stated they knew the resident but when they were on their assignment, the only thing Resident #1 needed was to have their items set up for their personal hygiene. The resident was independent, would wander around the unit and went off the unit as well. During an interview on 8/15/2022 at 11:16 AM, RNM #1 stated they were not directly involved with Resident #1's first suicide attempt on 7/5/2022 but did state the resident received 1:1 supervision for a few days following their return to the facility. They stated did not know why the supervision was discontinued. RNM #1 stated in retrospect, they could have taken additional measures to attempt to prevent a recurrence following the resident's first suicide attempt. They could have implemented room checks to look for sharp objects and they could have put the resident on safety checks. RNM #1 stated when the second suicide attempt occurred on 8/11/2022, they were on a telehealth conference with the NP regarding another resident when they heard commotion coming from the resident's room. As they approached the room, a CNA stated it was urgent. RNM #1 stated when they entered the room, they saw the resident lying on the floor in a pool of blood and they were vomiting. They requested a code blue be called because they needed more assistance. The RNM stated they did a quick assessment, and the resident was bleeding from both ankles. An LPN held direct pressure on the resident's ankles. The NP was still on the telehealth line and gave direction. 911 was called and they attempted to start an IV but could not access a vein likely due to the resident's blood loss. Emergency Medical Services arrived quickly, and the resident's care was turned over to them. The resident was transported to the hospital. The RNM stated when the CNAs were cleaning up the resident's room, they found a sharp object that looked like a piece of metal with tape wrapped around it. RNM #1 stated following the first incident, the resident was placed on the psychiatrist's list to be seen but they were unsure it the resident was. The DON was unavailable for interview regarding the 7/5/2022 incident. They were on leave with an unknown date of return to the facility. During an interview on 8/15/2022 at 12:00 PM, the Acting Director of Nursing (DON) stated because Resident #1 had a history of recent self-harm, staff on the resident's unit should have been made aware of the resident's history when they were admitted so they could monitor the resident and interventions put into place such as to make sure there were no sharp objects in their room they could harm themselves with and nonmetal silverware and paper products on their meal trays. The Acting DON stated the initial care plan should have documented the resident had a history of suicidal ideation with the goal to prevent any further suicide attempts. The Acting DON stated starting and discontinuing 1:1 supervision was a nursing/medical provider judgement. There was no specific sheet to document 1:1 supervision. The Acting DON stated when Resident #1 returned from the hospital for evaluation following the 7/5/2022 incident, they should have been seen psychiatry immediately. During a subsequent interview on 8/17/2022 at 9:01 AM, RNM #1 stated the initial care plan should have addressed the resident's self-harm behavior and suicidal ideation if the nurse that wrote the care plan had picked up on it. The RNM stated the initial care plan would have put a task in the electronic medical record for the CNA Care Card depending on what they felt would have been an appropriate intervention at that point given the resident's history of self-harm. The RNM stated for example, they could have done room searches periodically, not knowing the full extent of the situation on admission and could have removed silverware on admission, but that could have been a dignity issue. A psychological/psychiatric consult could have been done within the first couple of weeks of the resident's admission. RNM #1 stated Resident #1 was not put on any special precautions or observation and nothing official was done for resident supervision following their 7/5/2022 suicide attempt. During an interview on 8/17/2022 at 10:13 AM, the Admissions Coordinator (AC) stated they had been on the unit (on 8/11/2022) to provide the RNM a phone for a telehealth visit with another resident. The AC stated CNA #5 came to the door of Resident #1's door and yelled to call a code. The AC stated they went to the room along with others to see what was happening. When they looked in the room, there was blood everywhere. The resident was on the floor and was vomiting. They were asked to call 911 and they told the dispatcher there was a great amount of blood but did not know where it was coming from, was asked if there was a weapon and if the resident was a harm to anyone else and stated no. They reiterated the resident was on the floor in a lot of blood. The AC stated Emergency Medical Services and the New York State Police responded to the facility. During an interview on 8/17/2022 at 11:28 AM, CNA #3 stated it was sometime after 3:00 PM (on 8/11/2022) when they went to Resident #1's unit because they were giving CNA #4 a ride home. CNA #3 stated a call light went off and a CNA (CNA #5) for the oncoming shift had just arrived and went to answer it. CNA #5 came to the door of the room and yelled for help, that seriously, they needed help. CNA #3 stated they and CNA #4 went to the resident's room and there was blood all over the floor. The CNA stated they had started to look around the room to see what the resident may have used to cut themselves and found a sharp object that was under the covers on the resident's bed. CNA #3 stated they turned it over to the infection control lady and it was put in a safety bag. During an interview on 8/17/2022 at 11:39 AM, CNA #4 stated the last time they saw Resident #1 was at 2:27 PM in the dining room. The CNA stated sometime around 3:00 PM, they were at the desk doing their books when CNA #5 came to the unit to start their shift. Resident #1's call light went off, so CNA #5 went to answer it and found the resident on the floor in blood and vomit. CNA #5 yelled for help and to come quickly. CNA #4 stated they, CNA #3, and the Unit Secretary responded to the room with the RNM. CNA #4 stated a Code Blue was called and other staff responded. CNA #3 was the one who found the blade. CNA #4 stated they were trying to find the source of the bleeding and found it to be at the bottom of resident's left ankle. During an interview on 8/17/2022 at 1:14 PM, the Medical Director stated after Resident #1's 7/5/2022 suicide attempt they insisted on and received medical and psychiatric clearance before they would accept Resident #1 for readmission. The Medical Director stated they were told by the hospital the resident was not a suicide risk and the facility did not need to put any additional interventions in place for the resident. When discussing the 8/11/2022 suicide attempt, the Medical Director stated it was their third attempt. The first was the incident of self-harm the resident was admitted to the hospital for prior to admission to the facility, then the 7/5/2022 and 8/11/2022 suicide attempts. The Medical Director stated they would have expected the resident to be seen by a psychologist following the 7/5/2022 incident. The Medical Director stated sometimes care plan interventions were risk mitigation (reducing the severity or seriousness of something). The Medical Director stated the facility could always learn and do better. They stated they did not like a bad outcome. The facility could make it part of the admission process for residents who have a history of suicidal ideation/attempts to have interventions in place in their care plan. During an interview on 8/18/2022 at 11:17 AM, the Acting Director of Social Work (DSW) stated it was confirmed by the Psychologist they had not met with Resident #1 following their 7/5/2022 suicide attempt and they received an email from the psychiatrist that they had no record of having seen the resident. The Acting DSW stated in order for a resident to receive psychological/psychiatric services, they must be notified a request was being made, the resident must sign a consent form, the referral form was filled out and then it was sent to both the psychologist and psychiatrist. The Acting DSW stated the referral paperwork had been completed for Resident #1 and there was a blank consent form for services with it. They stated they did not know why the consent form was blank or why the referral was never sent. The Social Workers were responsible for obtaining resident consent for services and sending the consent form and referral paperwork to the psychologist and psychiatrist. The Acting DSW stated Resident #1 should have been seen by the psychologist/psychiatrist following the first suicide attempt. I think this was what you were looking for (blue highlighted documentation). It documents the process and the Acting DSW stated they did not know why the referral was sent. Specifically, Resident #1 was admitted to the facility with a recent history of self-harm. On 7/5/2022, Resident #1 made their first suicide attempt using a piece of glass to cut their ankle and stated they did not want to die a slow death in a nursing home and that they would do better next time. The resident was sent to the hospital by ambulance, required stitches, was medically and psychiatrically cleared, and returned to the facility on [DATE]. On 8/11/2022, the resident made their second suicide attempt using a razor blade that had been removed from a disposable razor. The resident sliced both ankles. A Certified Nursing Assistant (CNA) responded to the resident's call light and found the resident lying on the floor in a pool of blood, bleeding profusely and vomiting. The resident was transferred to the hospital by ambulance and was admitted . This is evidenced by: During an observation on 8/15/2022 at 12:33 PM, the object the resident cut themselves with was a blade removed from a disposable razor that measured 3.5 centimeters (cm) x 0.50 cm. It was wrapped in dirty plastic tape of the type used to secure dressings, with a sharp edge protruding. 10 NYCRR 415.12(h)(1) The Hospital Discharge Summary dated 6/30/2022 at 9:12 AM, documented Resident #1 attempted to hurt themselves by cutting their arms with a plastic knife. The resident's family had a history of suicides and the resident stated they were afraid of doing the same. The initial Comprehensive Care Plan (CCP) dated 7/1/2022, documented Resident #1 exhibited behavior symptoms such as socially inappropriate, verbally aggressive/abusive, physically aggressive/abusive, hallucinations, delusions, and wandering behaviors. There was nothing in the care plan that documented the resident's recent history of self-harm. The CCP revised on 7/6/2022 for Behavior Symptoms/Provocative with Suicidal Ideation, documented that the resident was to receive paper products, plastic silverware, and no glass or metal utensils. There were no other interventions addressing suicidal ideation. The CCP for Major Depressive Disorder and Anxiety Disorder dated 7/19/2022, documented the resident had a history of several hospitalization s for mental illness. The care plan goal documented the resident would work with psychology and psychiatry services. The intervention dated 7/22/2022, documented the resident's stability and safety would be maintained. A Health Status Note dated 7/5/2022 at 3:24 AM, documented that at 2:15 AM, documented a Licensed Practical Nurse (LPN) observed blood on the resident's floor. On assessment by the RN, it was documented the resident was lying in their bed with a large amount of blood on the floor and a 5 cm laceration to their left ankle. The resident stated they had intentionally cut themselves with a piece of glass and wanted to die. They did not want to die a slow death in a nursing home and that they would do better next time. The resident was transported to the hospital via ambulance. A Physician's Progress Note dated 7/7/2022 at 10:50 AM, documented Resident #1 had returned to the facility after psychiatric clearance from the hospital following their suicide attempt. The resident stated they cut their left ankle with the intention that they did not want to live any longer. The MD documented the resident would need to be monitored very closely and a psychiatry consult should be obtained. During a subsequent interview on 8/17/2022 at 9:01 AM A psychological/psychiatric consult could have been done within the first couple of weeks of the resident's admission. RNM #1 stated Resident #1 was not put on any special precautions or observation and nothing official was done for resident supervision following their 7/5/2022 suicide attempt. During an interview on 8/17/2022 at 1:14 PM, the Medical Director stated after Resident #1's 7/5/2022 suicide attempt they insisted on and received medical and psychiatric clearance before the would accept Resident #1 for readmission. The Medical Director stated they were told by the hospital the resident was not a suicide risk and the facility did not need to put any additional interventions in place for the resident. When discussing the 8/11/2022 suicide attempt, the Medical Director stated it was their third attempt. The first was the incident of self-harm the resident was admitted to the hospital for prior to admission to the facility, then the 7/5/2022 and 8/11/2022 suicide attempts. The Medical Director stated they would have expected the resident to be seen by a Psychologist following the 7/5/2022 incident. The Medical stated sometimes care plan interventions were risk mitigation (reducing the severity or seriousness of something). The Medical Director stated the facility could always learn and do better. They stated they did not like a bad outcome. The facility could make it part of the admission process for residents who have a history of suicidal ideation/attempts to have interventions in place in their care plan. During an interview on 8/17/2022 at 9:01 AM, #1 stated Resident #1 was not put on any special precautions or observation and nothing official was done for resident supervision following their 7/5/2022 suicide attempt, but they did implement plastic utensils and paper products and was not to have any glass or metal utensils. During an interview on 8/15/2022 on 12:00 PM, the Acting DON stated because the resident had a history of a recent suicide attempt, staff on the resident's unit should have been made aware of the resident's history of suicidal ideation so they could monitor the resident, interventions should be put in in place to keep the resident safe, such as nonmetal and paper products on their trays, and make sure there were no sharp objects in their room they could harm themselves with. The Acting DON stated the initial care plan should have documented the resident had a history of suicidal ideation and to prevent any further suicide attempts. During an interview on 8/18/2022 at 11:17 AM, the Acting Director of Social Work (DSW) stated it was confirmed by the Psychologist they had not met with Resident #1 following their 7/5/2022 suicide attempt and they received an email from the Psychiatrist that they had no record of having seen the resident. The Acting DSW stated in order for a resident to receive psychological/psychiatric services, they must be notified a request was being made, the resident must sign a consent form, the referral form filled out and then it was sent to both the Psychologist and Psychiatrist. The Acting DSW stated the referral paperwork had been completed for Resident #1 and there was a blank consent form for services with it. They stated they did not know why the consent form was blank or why the referral was never sent. The Social Workers were responsible for obtaining resident consent for services and sending the consent form and referral paperwork to the Psychologist and Psychiatrist. The Acting DSW stated Resident #1 should have been seen by the Psychologist/Psychiatrist following the first suicide attempt. The SW stated attempts/suicide ideations were urgent for psychiatry/psychology to see the resident. When discussing the 8/11/2022 suicide attempt, the Medical Director stated it was their third attempt. The first was the incident of self-harm the resident was admitted to the hospital for prior to admission to the facility, then the 7/5/2022 and 8/11/2022 suicide attempts. The Medical Director stated they would have expected the resident to be seen by a Psychologist following the 7/5/2022 incident. The Medical stated sometimes care plan interventions were risk mitigation (reducing the severity or seriousness of something). The Medical Director stated the facility could always learn and do better. They stated they did not like a bad outcome. The facility could make it part of the admission process for residents who have a history of suicidal ideation/attempts to have interventions in place in their care plan. During an interview on 8/17/2022 at 1:14 PM, the Medical Director stated after Resident #1's 7/5/2022 suicide attempt they insisted on and received medical and psychiatric clearance before the would accept Resident #1 for readmission. The Medical Director stated they were told by the hospital the resident was not a suicide risk and the facility did not need to put any additional interventions in place for the resident. The facility did not know whether the resident had been seen by psych and had to send an email to ask if the resident was s The resident told the Medical Director they had made the attempt because just prior, they had seen their daughter and son in bed together having sex. be a red flag to get her some psych help? 7/5 physician notet cleared psych in discharge document from Dr [NAME] .not a suicide risk, need to be monitored veryclosely, we should obtain psych eval Based on observation, record review, and interviews during an abbreviated survey (Case #NY 510), the facility did not ensure that each resident received adequate supervision to prevent accidents for 1 (Resident #1) of 3 residents reviewed for accidents. Specifically, for Resident #1, who was admitted to the facility with a recent history of self-harm and hospitalization for mental health issues, the facility did not provide adequate supervision and did not put interventions in place to mitigate the risk of further self-harm and attempt of suicide after the resident was found lying in their bed with a large amount of blood on the floor and a cut to their left ankle on 7/5/2022. Resident #1 stated they had intentionally cut themselves, wanted to die, and stated they would do better next time. On 8/11/2022, the resident was found lying on the floor in a pool of blood, was vomiting and bleeding from both ankles and was sent to the hospital. This resulted in actual harm to Resident #1 that was not immediate jeopardy. This was evidenced by: The facility policy and procedure for Suicide Threats with the effective dates of 8/17, 10/18 and a revision date of 8/2022, documented that resident suicide threats shall be taken seriously and addressed appropriately. The policy interpretation and implementation documented that staff shall report any resident threats of immediately to the Nurse Supervisor/Charge Nurse/Social Services. Resident #1 was admitted to the facility with diagnoses of non-suicidal self-harm, [CONDITION(S)], and major depressive disorder. The Minimum Data Set (MDS-an assessment tool) dated 8/10/2022, documented the resident was cognitively intact, could be understood, and could understand others. The Hospital Discharge Summary dated 6/30/2022 at 9:12 AM, documented Resident #1 was admitted to the hospital on 6/6/2022 following an attempt to hurt themselves by cutting their arms with a plastic knife. The resident's family had a history of suicides and the resident stated they were afraid of doing the same. It documented Resident #1 needed the 1:1 sitter for 20 days until the 1:1 sitter was discontinued on 6/26/2022 when the resident was cleared psychologically. The Admission Note dated 6/30/2022 at 2:36 PM, documented the resident was admitted from the hospital for long term care. It documented the resident's mood/behavior concerns were sad/depression, anxiety, and potential for violence. The note did not document the resident had been admitted to the hospital because they harmed themselves by cutting themselves with a plastic knife. The initial Comprehensive Care Plan (CCP) dated 7/1/2022, did not include documentation of the resident's recent history of self-harm. A Physician's Progress Note dated 7/5/2022 at 2:25 AM, documented the Physician's Assistant was notified by nursing staff regarding a self-harm incident. Resident #1 stated that they wanted to hurt themselves and want to die. Staff found the resident with a lot of blood in their room. They had taken a piece of glass and cut their ankle. Pressure was applied to the wound, and it may require stitches. Emergency Medical Services (EMS) was called as the resident was openly expressing self-harm and would require 72-hour psychiatric hold at the hospital. The resident was being transferred to the closest emergency room for evaluation of their ankle wound as well as psychiatric evaluation. A Health Status Note dated 7/5/2022 at 3:24 AM, written by a Licensed Practical Nurse (LPN), documented that at 2:15 AM, blood was observed on the resident's floor. On assessment by the Registered Nurse (RN), it was documented the resident was lying in their bed with a large amount of blood on the floor and a 5 cm laceration to their left ankle. The resident stated they had intentionally cut themselves with a piece of glass and wanted to die. They did not want to die a slow death in a nursing home and that they would do better next time. The resident was transported to the hospital via ambulance. A Health Status Note dated 7/6/2022 at 6:12 AM, documented the resident returned to the facility at 4:14 AM with documentation the resident was medically and psychiatrically cleared to return to the facility. The resident was immediately placed on 1:1 supervision per the Supervisor's request. There was no further documentation in the medical record that 1:1 supervision was continued or discontinued. There was no further documentation in the medical record that 1:1 supervision was continued or discontinued. The CCP revised on 7/6/2022 for Behavior Symptoms/Provocative with Suicidal Ideation, documented that the resident was to receive paper products, plastic silverware, and no glass or metal utensils. The CCP did not include documentation of other interventions that addressed suicidal ideation. A Physician's Progress Note dated 7/7/2022 at 10:50 AM, documented Resident #1 had returned to the facility after psychiatric clearance from the hospital following their suicide attempt. The resident stated they cut their left ankle with the intention that they did not want to live any longer. The Medical Doctor (MD) documented the resident would need to be monitored very closely and a psychiatry consult should be obtained. A CCP with an initial date of 7/19/2022 and a revision date of 7/19/2022 for (Resident #1) has diagnosis of major depressive disorder and anxiety disorder with a history of several hospitalization s for Mental Illness documented a goal that the resident will work with psychology and psychiatry services with a date initiated of 7/19/2022 and a revision date of 7/22/2022. A facility document titled Medication Review Report (with a print date of 8/17/2022) under the section for order summary documented the following; -Psychiatry consult and treatment and follow-up per recommendation with an order date of 6/30/2022. -Psychology consult, treatment and follow-up per recommendation with an order date of 6/30/2022. A Health Status Note dated 8/11/2022 at 5:05 PM, documented the Registered Nurse Manager (RNM) was participating in a telehealth conference with the NP and another resident when they were interrupted by a commotion in Resident #1's room. As they started toward the resident's room, they were told it was urgent. Upon entering the room, the RNM observed the resident lying on the floor vomiting and surrounded by blood. There were also blood pools under the bed and on the window side of the room. After a quick assessment, it was determined there were lacerations of the resident's feet. A Code Blue was called, and staff responded. An LPN provided direct pressure on the wounds while other staff attempted to start intravenous fluid (an IV). The NP was still on the telehealth connection. 911 was called, responded, and th [TRUNCATED]

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure one of eight sampled residents (Resident (R) 5) was free from a chemical restraint. The facility initiated an antipsychotic medication, [MEDICATION(S)], to control R5's behavior of yelling. The [MEDICATION(S)], initially ordered as an injectable dose, was changed to an oral medication, and continued to be administered in increasing dosages for a period of more than three months. This deficient practice resulted in psychosocial harm to R5 who experienced the ongoing inability to feel emotion and to interact with family members. Findings include: Review of the Abuse Prevention Program/Clinical Protocol, revision date of 01/2021, revealed Policy Statement, our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the residents' symptoms. Review of the Antipsychotic Medication Use policy, revision date of 01/2021, revealed Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated . the attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others . the attending physician and facility staff will identify acute psychiatric episodes . diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . antipsychotic medications will generally only be considered if the following conditions are also met: the behavioral symptoms present a danger to the resident and others and the symptoms identified as being to [CONDITION(S)] or [CONDITION(S)] (such as auditory, visual, or other hallucinations; delusions, paranoia . or behavioral interventions have been attempted . antipsychotic medications will not be used unless behavioral symptoms are not due to a medical condition or problem . the physician shall respond appropriately by changing or stopping problematic doses of medications. Review of R5's Face Sheet located in the electronic medical record (EMR) revealed R5 was admitted to the facility on [DATE]. Review of the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R5's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/03/21 revealed no behavioral symptoms of [CONDITION(S)], such as hallucinations (perception of nonexistent object or event) and/or delusions (false beliefs), no physical behavior toward others such as hitting, kicking, pushing, scratching, grabbing, or abusing others. Review of this MDS revealed R5 had intact cognition, could make her needs known, and had no difficulty understanding others. During an interview on 07/13/21 at 8:45 AM, R5 stated she was receiving [MEDICATION(S)] (an antipsychotic medication used to treat severe mental illness) that caused a decline in her emotional status. R5 stated, I can't cry at all. My daughters came to see me yesterday and I had not seen them since April and I had no emotion. It makes me groggy and slow. I asked to see the nurse practitioner (NP) [NP's name]. I want to tell her about the [MEDICATION(S)] and ask her to reduce it. I know I'm an addict [to narcotic pain medication] but I'm not crazy. I feel sedated and over medicated. I'm very slow rolling over in bed. I get Tylenol for pain because I can't have narcotics and I understand why, but I don't understand why I need [MEDICATION(S)]. During an interview on 07/13/21 at 9:00 AM, Certified Nursing Assistant (CNA) 1 stated, She [R5] is usually calm and I have never seen her yelling, talking to herself, or having behaviors. She [R5] likes to watch TV and doesn't come out of her room very much. She [R5] has never had physical aggression like hitting, biting, kicking, or trying to hurt herself or others. During an interview on 07/13/21 at 9:10 AM, Charge Nurse 1 stated, She [R5] is well-controlled on [MEDICATION(S)]. She [R5] has no behaviors and I have never seen her get aggressive. She doesn't have hallucinations or delusions and she doesn't yell. Review of R5's Progress notes, located in the EMR under the Progress Notes tab and dated 03/29/21 at 06:13 PM, revealed . continues on po [oral] antibiotic for [CONDITION(S)] [urinary tract infection] for 3 additional days . was offered a shower this evening but refused due to being so tired after the long ride from the hospital and asked if she could just get some sleep tonight . orientation status is person place time . no mood/behavior concerns. Review of R5's Progress Notes, dated 04/01/21 at 07:11 AM, revealed Resident alert and responsive, all care and meds [medications] tolerated. Resident up all night yelling and talking to herself, being combative with staff. Review of R5's Progress Notes, dated 04/01/21 at 11:00 AM, revealed Resident alert and oriented, slept well. All meds and care tolerated. No behavior issue noted this tour. Review of R5's Progress Notes, dated 04/03/21 at 11:45 PM, revealed Resident was yelling most of the shift . the NP [Nurse Practitioner] was informed . new order to give [MEDICATION(S)] IM [injection into the muscle] 2.5 mg [milligram] X [times] 1 now and [MEDICATION(S)] [narcotic pain medication] 5 mg. It was given with positive effect. Review of R5's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The two injections of [MEDICATION(S)] were given less than four hours apart. Review of R5's Progress Notes, dated 04/03/21, revealed no documentation to indicate the reason for the second IM injection of [MEDICATION(S)] administered on 04/03/21 at 8:25 PM. Review of R5's MAR, dated 04/03/21 at 8:25 PM, revealed one tablet of 5-325mg [MEDICATION(S)]-acetaminophen was also administered along with the second injection of [MEDICATION(S)]. This MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R5's MAR, dated April and May 2021, revealed the following increases in the dosage of [MEDICATION(S)]: On 04/04/21 at 9:00 PM, [MEDICATION(S)] 1 mg tab by mouth [po] twice daily [BID] for [CONDITION(S)] for 7 days. This dosage equaled two milligrams of [MEDICATION(S)] a day. On 04/09/21 at 5:20 PM, [MEDICATION(S)] 1 mg tab po three times daily [TID] for [CONDITION(S)] for one day. This dosage equaled three milligrams of [MEDICATION(S)] a day. On 04/10/21 through 04/15/21 R5 did not receive any [MEDICATION(S)]. On 04/16/21 at 8:00 AM, [MEDICATION(S)] 1 mg three tabs po TID for [CONDITION(S)]. This dosage equaled nine milligrams of [MEDICATION(S)] a day. On 05/06/21 at 3:46 PM, [MEDICATION(S)] 1 mg three tabs po TID for [CONDITION(S)] disorder [mental disorder with symptoms of [CONDITION(S)] and mood disorder]. This dosage equaled nine milligrams a day. Review of the MAR, dated 06/01/21 through 06/30/21, revealed R5 received three tabs of one milligram of [MEDICATION(S)] three times a day for [CONDITION(S)] disorder. Review of the MAR, dated 07/01/21 through 07/16/21, revealed R5 received three tabs of one milligram of [MEDICATION(S)] three times a day for [CONDITION(S)] disorder. During an interview on 07/14/21 at 9:45 AM, the Director of Nursing (DNS) stated, There should have been documentation [of the reason] for the second injection of [MEDICATION(S)]. Yelling is what the nurse documented as the indicator for the injections. Yelling is not an acceptable indicator for the use of [MEDICATION(S)]. During a second interview on 07/15/21 at 9:00 AM, R5 stated, I've never been to a psychiatrist or admitted to a mental health hospital. The NP has never told me I have [CONDITION(S)] [serious mental disorder of hallucinations, delusions, and disorganized thinking]. I can't cry anymore, and I feel numb. I know I need to be here but I don't need to be sedated. During an interview on 07/15/21 at 9:45 AM, a family member (F5) stated she had visited R5 a few days ago and had noticed a marked difference in her. F5 stated She was not herself; she didn't smile and was unemotional, she didn't even ask about her grandchildren which was not like her at all. She kept dozing off during our visit and had a blank stare. F5 stated, She was taking [MEDICATION(S)] [an opioid pain medication] at home for chronic back pain and has been withdrawing from that since she went to the hospital. She has many medical problems but she has never been admitted to a psychiatric hospital, has never seen a psychiatrist and has never been on daily antipsychotics until she came here. She has had verbal outbursts but has never been violent or tried to hurt anyone. She looked like a zombie on Monday. I have never heard anyone say she has [CONDITION(S)]. She does have confusion at times from alcohol use. I think they gave her that diagnosis [of [CONDITION(S)]] to use the [MEDICATION(S)]. During an interview on 07/15/21 at 1:35 PM, the NP who prescribed the [MEDICATION(S)] for R5 stated, I ordered the [MEDICATION(S)] injections on 04/03/21. I was told she was yelling and throwing her phone. I agree that agitation is not an acceptable diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . I did not want her to get out of bed and fall while walking. The second injection was because she was trying to hit staff with her cell phone. Her family member told me she was coming off [MEDICATION(S)]. I have been very careful not to give her daily opioids and she is only receiving Tylenol for pain. I didn't know she had a urinary tract infection ([CONDITION(S)]) and a catheter on admission. I don't have any progress notes related to her behavior or documentation related to the [MEDICATION(S)] orders. I don't recall asking the nurse who called me on 04/03/21 if the staff had attempted any non-drug interventions. I could have started with the administration of the pain medication to see if that was effective rather than ordering the injections of [MEDICATION(S)]. I don't recall that she was having any violent behavior or that she was harmful to herself or others. I changed her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse who called the NP on 04/03/21 and administered the two [MEDICATION(S)] injections was out of the country at the time of the survey and attempts to contact were unsuccessful. During an interview on 07/15/21 at 4:00 PM, CNA 7 stated, I was here that night [04/03/21] but I don't remember her [R5] ever being violent. She may have been yelling but I don't know. She will ask for her Tylenol and sometimes she will cuss but she has never been aggressive. I just give her time to cool down. She has never been combative with me. During an interview on 07/16/21 at 1:25 PM, the Medical Director stated, I reviewed her chart [referring to R5]. The [MEDICATION(S)] was not justified for agitation and she [referring to the NP] should not have ordered it. It was used as a chemical restraint. I always promote non-drug interventions before using an antipsychotic. She [R5] was not showing violent behavior and was not a threat to herself or others.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure antipsychotic medications (medications used to treat serious mental illnesses) were administered only when there was an acceptable indication for use; when specific target behavioral symptoms of [CONDITION(S)] were identified and monitored; when specific side effects were monitored; and with a medical justification for duplicative medications for five of eight residents (Resident (R) 5, R6, R1, R7, and R2) out of total sample of 24 residents. This deficient practice resulted in psychosocial harm (inability to feel emotions) to R5. Findings include: Review of the Antipsychotic Medication Use policy, revised on 01/2021, revealed Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated . the attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others . the attending physician and facility staff will identify acute psychiatric episodes . diagnoses alone do not warrant the use of antipsychotic medication . antipsychotic medications will generally only be considered if the following conditions are also met: the behavioral symptoms present a danger to the resident and others and the symptoms identified as being to [CONDITION(S)] or [CONDITION(S)] (such as auditory, visual or other hallucinations; delusions, paranoia . or behavioral interventions have been attempted . antipsychotic medications will not be used unless behavioral symptoms are not due to a medical condition or problem . the physician shall respond appropriately by changing or stopping problematic doses of medications. Review of the Medication Therapy/Drug Regimen Review, revised on 01/2021, revealed, All resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks . all medication orders will be supported by appropriate care processes and practices . all decisions related to medications shall include appropriate elements of the care process, such as: adequately detailed assessment, review of causes of symptoms, principles of prescribing for the elderly, each resident's wishes, goals, condition and prognosis. Review of the Behavioral Assessment, Intervention and Monitoring, revised on 01/2021, revealed, Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment . residents who do not display symptoms of, or have been diagnosed with, a mental, psychiatric psychosocial adjustment . will not develop a pattern of decreased social interaction . that cannot be explained or attributed to a specific clinical condition that makes that pattern unavoidable. Appropriate assessment and treatment of behavioral symptoms requires differentiating between behavioral symptoms that can be managed by treating underlying factors, and those that cannot. As part of the initial assessment, the nursing staff and attending physician will identify individuals with a history of impaired cognition, altered behavior, or mental illness (e.g. [CONDITION(S)] or [CONDITION(S)]). The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in behavior, including . pain, infection . interventions will be adjusted based on the impact on behavior and other symptoms, including any adverse consequences related to treatment. The nursing staff and the physician will monitor for side effects and complications related to psychoactive medications; for example, lethargy, abnormal involuntary movements, anorexia, or recurrent falling. 1. Review of R5's undated Face Sheet, located in the electronic medical record (EMR) under the Profile tab, revealed R5 was admitted to the facility on [DATE]. Review of the Diagnosis History tab in the EMR, R5's primary reason for admission included hydronephrosis (kidney obstruction) with secondary diagnoses that included chronic pain syndrome, major depressive disorder, anxiety, opioid dependency, and [CONDITION(S)]. Review of R5's Patient Review Instrument (PRI), located in the hard chart, dated 03/26/21, and completed prior to admission to the facility, revealed R5 did not have a serious mental illness and was not a danger to self or others. Review of R5's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/03/21 revealed no behavioral symptoms of [CONDITION(S)], such as hallucinations (perception of nonexistent object or event) and/or delusions (false beliefs), physical behavior toward others such as hitting, kicking, pushing, scratching, grabbing, or abusing others. Further review of this MDS revealed R5 had intact cognition, could make her needs known, and had no difficulty understanding others. This MDS revealed R5 did not have an active diagnosis of [CONDITION(S)] (serious mental disorder of hallucinations, delusions, and disorganized thinking) and was not receiving an antipsychotic medication. Review of R5's quarterly MDS with an ARD of 05/26/21 revealed no hallucinations, delusions or behavioral symptoms directed toward others. Further review of this MDS revealed [CONDITION(S)] was added as an active diagnosis. During an interview on 07/13/21 at 8:45 AM, R5 stated she was receiving [MEDICATION(S)] (an antipsychotic medication used to treat severe mental illness) that caused a decline in her emotional status. R5 stated, I can't cry at all. My daughters came to see me yesterday and I had not seen them since April, and I had no emotion. It makes me groggy and slow. I asked to see the Nurse Practitioner (NP) [NP's name]. I want to tell her about the [MEDICATION(S)] and ask her to reduce it. I know I'm an addict but I'm not crazy. I feel sedated and over medicated. I'm very slow rolling over in bed. I get Tylenol for pain because I can't have narcotics and I understand why, but I don't understand why I need [MEDICATION(S)]. During an interview on 07/13/21 at 9:00 AM, Certified Nursing Assistant (CNA) 1 stated, She [R5] likes to watch TV and she doesn't come out of her room very much. She [R5] has never had physical aggression like hitting, biting, kicking, or trying to hurt herself or others. During an interview on 07/13/21 at 9:10 AM, Charge Nurse 1 stated, She [R5] is well-controlled on [MEDICATION(S)]. She [R5] has no behaviors and I have never seen her get aggressive. She doesn't have hallucinations or delusions and she doesn't yell. Review of R5's Progress notes, located in the EMR under the Progress Notes tab and dated 03/29/21 at 06:13 PM, revealed . continues on po [oral] antibiotic for [CONDITION(S)] [urinary tract infection] for 3 additional days . was offered a shower this evening but refused due to being so tired after the long ride from the hospital and asked if she could just get some sleep tonight . orientation status is person place time . no mood/behavior concerns. Review of R5's Progress Notes, dated 04/01/21 at 07:11 AM, revealed Resident alert and responsive, all care and meds [medications] tolerated. Resident up all night yelling and talking to herself, being combative with staff. Review of R5's Progress Notes, dated 04/01/21 at 11:00 AM, revealed Resident alert and oriented, slept well. All meds and care tolerated. No behavior issue noted this tour. Review of R5's Progress Notes, dated 04/03/21 at 11:45 PM, revealed Resident was yelling most of the shift . the NP [Nurse Practitioner] was informed . new order to give [MEDICATION(S)] IM [injection into the muscle] 2.5 mg [milligram] X [times] 1 now and [MEDICATION(S)] [narcotic pain medication] 5 mg. It was given with positive effect. Review of R5's Medication Administration Record (MAR), dated 04/01/21 through 04/30/21, revealed two injections of [MEDICATION(S)] were given on 04/03/21 at 4:55 PM and again at 8:25 PM. Further review of the April 2021 MAR revealed 04/03/21 at 4:55 PM [MEDICATION(S)] [MEDICATION(S)] solution 5 milligrams [mg]/Milliliter [ml] [administered] 2.5 mg Intramuscular [IM] injection for [CONDITION(S)] [difficulty determining what is real and what is not real such as hallucinations and delusions] and 8:25 PM [MEDICATION(S)] [MEDICATION(S)] solution 5 mg/ml 2.5 mg [administered] IM injection for [CONDITION(S)]. The two injections of [MEDICATION(S)] were given less than four hours apart. Review of R5's Progress Notes, dated 04/03/21, revealed no documentation to indicate the reason for the second IM injection of [MEDICATION(S)] administered on 04/03/21 at 8:25 PM. Review of R5's MAR, dated 04/03/21 at 8:25 PM, revealed one tablet of 5-325mg [MEDICATION(S)]-acetaminophen was also administered along with the second injection of [MEDICATION(S)]. This MAR included, [MEDICATION(S)]-acetaminophen 5-325 mg 1 tab po [orally] one time only for one day now. Review of R5's MAR, dated April and May 2021, revealed the following increases in the dosage of [MEDICATION(S)]: On 04/04/21 at 9:00 PM, [MEDICATION(S)] 1 mg tab by mouth (po) twice daily (BID) for [CONDITION(S)] for 7 days. This dosage equaled two milligrams of [MEDICATION(S)] a day. On 04/09/21 at 5:20 PM, [MEDICATION(S)] 1 mg tab po three times daily (TID) for [CONDITION(S)] for one day. This dosage equaled three milligrams of [MEDICATION(S)] a day. On 04/16/21 at 8:00 AM, [MEDICATION(S)] 1 mg three tabs po TID for [CONDITION(S)]. This dosage equaled nine milligrams of [MEDICATION(S)] a day. On 05/06/21 at 3:46 PM, [MEDICATION(S)] 1 mg three tabs po TID for [CONDITION(S)] disorder [mental disorder with symptoms of [CONDITION(S)] and mood disorder]. This dosage equaled nine milligrams a day. Review of the MAR, dated 06/01/21 through 06/30/21, revealed R5 received three tabs of one milligram of [MEDICATION(S)] three times a day for [CONDITION(S)] disorder. Review of the MAR, dated 07/01/21 through 07/16/22, revealed R5 received three tabs of one milligram of [MEDICATION(S)] three times a day for [CONDITION(S)] disorder. During an interview on 07/14/21 at 9:45 AM, the Director of Nursing (DNS) stated, Yelling is what the nurse documented as the indicator for the injections. Yelling is not an acceptable indicator for the use of [MEDICATION(S)]. During a second interview on 07/15/21 at 9:00 AM, R5 stated, I've never been to a psychiatrist or admitted to a mental health hospital. The NP has never told me I have [CONDITION(S)]. I can't cry anymore, and I feel numb. I know I need to be here, but I don't need to be sedated. During an interview on 07/15/21 at 9:45 AM a family member (F5) stated she had visited R5 a few days ago and had noticed a marked difference in her. F5 stated, She [R5] was not herself, she didn't smile and was unemotional, she didn't even ask about her grandchildren which was not like her at all. She kept dozing off during our visit and had a blank stare. F5 stated, She [R5] was taking [MEDICATION(S)] [a narcotic pain medication] at home for chronic back pain and has been withdrawing from that since she went to the hospital. She has many medical problems, but she has never been admitted to a psychiatric hospital, has never seen a psychiatrist and has never been on daily antipsychotics until she came here. She has had verbal outbursts but has never been violent or tried to hurt anyone. She looked like a zombie on Monday. I have never heard anyone say she has [CONDITION(S)]. She does have confusion at times from alcohol use. I think they gave her that diagnosis [of [CONDITION(S)]] to use the [MEDICATION(S)]. During an interview on 07/15/21 at 1:35 PM, the NP who prescribed the [MEDICATION(S)] for R5 stated, I ordered the [MEDICATION(S)] injections on 04/03/21. I was told she was yelling and throwing her phone. I agree that agitation is not an acceptable diagnosis for [MEDICATION(S)]. I did not want her to get out of bed and fall while walking. The second injection was because she was trying to hit staff with her cell phone. Her family member told me she was coming off [MEDICATION(S)]. I have been very careful not to give her daily opioids and she is only receiving Tylenol for pain. I didn't know she had a urinary tract infection ([CONDITION(S)]) on admission. I don't have any progress notes related to her behavior or documentation related to the [MEDICATION(S)] orders. I don't recall asking the nurse who called me on 04/03/21 if the staff had attempted any non-drug interventions. I could have started with the administration of the pain medication to see if that was effective rather than ordering the injections of [MEDICATION(S)]. I don't recall that she was having any violent behavior or that she was harmful to herself or others. I changed her diagnosis from [CONDITION(S)] to [CONDITION(S)] disorder because I thought it would help her get a psychiatric evaluation faster. The nurse who called the NP on 04/03/21 and administered the two [MEDICATION(S)] injections was out of the country at the time of the survey and attempts to contact were unsuccessful. During an interview on 07/15/21 at 4:00 PM, CNA7 stated, I was here that night [04/03/21] but I don't remember her [R5] ever being violent. She may have been yelling but I don't know. She will ask for her Tylenol and sometimes she will cuss but she has never been aggressive. I just give her time to cool down. She has never been combative with me. During an interview on 07/16/21 at 1:25 PM, the Medical Director stated, I reviewed her chart [R5]. The [MEDICATION(S)] was not justified for agitation and she [the NP] should not have ordered it. It was used as a chemical restraint. I always promote non-drug interventions before using an antipsychotic. She [R5] was not showing violent behavior and was not a threat to herself or others. I have not evaluated her for [CONDITION(S)]. Review of nursing progress notes dated 04/03/21 through 07/14/21 revealed no behavior monitoring, no documentation of side effects, and no new behaviors. 2. Review of R6's undated Face Sheet, located in the EMR under the Profile tab, revealed R6 was admitted to the facility on [DATE]. Review of the Diagnosis History tab in the EMR revealed R6's diagnoses included unspecified dementia with behavioral disturbance and psychotic disorder with delusions. Review of R6's MAR, dated 11/3/20, revealed R6 was admitted on an antipsychotic medication [MEDICATION(S)] 2.5 mg 1 tablet po (orally) at bedtime for psychotic disorder and [MEDICATION(S)] 5mg 1 tablet po two times a day for psychotic disorder. Review of R6's admission MDS with an ARD of 11/05/20 revealed [CONDITION(S)] was not an active diagnosis. Further review of this MDS revealed R6 had verbal symptoms directed toward others and had rejection of care that had an impact on self and others but no hallucinations or delusions. Review of R6's quarterly MDS with an ARD of 03/13/21 revealed [CONDITION(S)] had been added as an active diagnosis without any new behaviors, hallucinations, and/or delusions. This MDS was signed by the MDS Coordinator. During an interview on 07/14/21 at 2:20 PM, the MDS Coordinator stated, I added the [CONDITION(S)] diagnosis to the MDS dated [DATE] because psychotic disorder is not an acceptable diagnosis for the antipsychotic. The MDS Coordinator was unable to provide documentation from R6's medical record to support the diagnosis of [CONDITION(S)]. 3. Review of the MDS (Minimum Data Set) tab in the electronic medical record (EMR) revealed that R1, a [AGE] year-old resident, was initially admitted to the facility on [DATE]. Review of the Med Diagnosis tab in the EMR revealed R1's diagnoses included a cerebral infarction due to an embolism (stroke due to blood clot) vascular dementia with behavioral disturbance, [CONDITION(S)], [CONDITION(S)], restlessness and agitation, and major depressive disorder. Review of the Orders tab in the EMR revealed that R1 had an order for [MEDICATION(S)] (an antipsychotic) at the time of the 12/10/20 admission. Review of the 12/10/20 order revealed that the indication for the antipsychotic was depression. R1 remained on [MEDICATION(S)] until 12/18/20, at which time this medication was discontinued. Review of the Progress Notes, located under the Progress Notes tab in the EMR, revealed R1 had no orders for an antipsychotic after 03/09/21 and through her discharge home on 03/22/21 after completing rehabilitation. Further review of the MDS tab revealed R1 was readmitted to the facility on [DATE]. Review of the 04/15/21 Admission Note, revealed R1 was readmitted to the facility for skilled therapy after being hospitalized . Review of the Orders tab revealed that at the time of the 04/15/21 admission, R1 had orders for two different antipsychotics: [MEDICATION(S)] 5 milligrams (mg) via gastrostomy (g) -tube (feeding tube) in the evening for psychotic disorder, and [MEDICATION(S)] 1 mg via g-tube two times a day for [CONDITION(S)]. On 04/22/21, the [MEDICATION(S)] was increased to two 5-mg tablets in the evening for psychotic disorders, and the [MEDICATION(S)] was increased to two 1-mg tablets three times per day for vascular dementia. On 04/29/21, the indication for the [MEDICATION(S)] was changed to [CONDITION(S)] disorder; however, the indication for the [MEDICATION(S)] remained vascular dementia until 05/15/21, when the indication for this medication was also changed to [CONDITION(S)] disorder. On 05/11/21, the [MEDICATION(S)] was reduced back to one 5-mg tablet each evening. As of 07/16/21, R1 continued on both [MEDICATION(S)] and [MEDICATION(S)] on a daily basis. Review of physician/Nurse Practitioner (NP) notes under the Progress Notes tab in the EMR, as well as Physician Monthly Progress Note/Medication Review entries under the Evaluations tab in the EMR revealed no documentation explaining the rationale for duplicate antipsychotic therapy. There was no justification documented for the use of the duplicate therapy or documentation which explained how the expected benefits outweighed the known risks of using two different antipsychotics. Review of a hard copy Medication Regimen Review, dated 04/30/21, revealed that the consultant pharmacist (RPh) identified that the [MEDICATION(S)] use is for a diagnosis other than an approved psychiatric condition, vascular dementia. Resident is using other medication for [CONDITION(S)] disorder. Please evaluate and update this order, if appropriate, to [CONDITION(S)] disorder. On 05/04/21, the NP marked that she agreed and changed the diagnosis for [MEDICATION(S)] to [CONDITION(S)] disorder. Although the indication for the two antipsychotics was changed to [CONDITION(S)] disorder (an appropriate rationale for an antipsychotic), review of R1's EMR and hard copy record revealed no evidence that the NP who gave this diagnosis completed a thorough evaluation, which included a 04/05/21 psychiatric assessment which showed no [CONDITION(S)]-related diseases, and/or ruled out of other medical diagnoses, such as R1's vascular dementia, as possible root causes of the behaviors which were the reason for the use of the antipsychotics. Cross-reference: F684the failure to follow professional standards of practice related to the diagnosis of [CONDITION(S)] disorder. Interview on 07/16/21 at 1:15 PM with the Medical Director revealed he was also the resident's attending physician. The Medical Director stated that, I'm not a big fan of [MEDICATION(S)]. If we can avoid it, there are better, safer drugs. The Medical Director stated that there were three approved medications for dementia, and antipsychotics were not included in that class, adding No one with dementia should ever get an antipsychotic - absolutely not. Further review of R1's comprehensive care plan, initiated 04/15/21, revealed a Focus Area statement that the resident used [CONDITION(S)] medications r/t [related to] agitation and depression. Approaches to meet the goal of minimal side effects or adverse reactions related to use of [CONDITION(S)] medications included Monitor/record occurrence of target behavior symptoms . and document per facility protocol. Review of this care plan also revealed a Focus Area related to behavior symptoms. Interventions for this problem area included Document all behaviors. Attempt to identify pattern to target interventions. Review of the Orders tab which included the resident's Medication Administration Records (MAR) and Treatment Administration Record (TAR) for 2021, as well as all the other 15 tabs in the EMR, as well as the hard-copy record, revealed no evidence of ongoing, consistent monitoring related to behaviors associated with the use of antipsychotic medications. Further review of R1's comprehensive care plan, initiated 04/15/21, also revealed that it called for staff to evaluate side effects of medications, and Monitor/record/report to MD [doctor] prn [as needed] side effects and adverse reactions of psychoactive medications. Review of the Progress Notes tab located in the EMR, revealed multiple undated entries which stated that the facility's medication system has identified a black box warning for the following order: [MEDICATION(S)] Tablet .Black Box Warning: Warning: Increased mortality in elderly patients with dementia -related [CONDITION(S)]. Elderly patients with dementia-related [CONDITION(S)] treated with antipsychotic drugs are at an increased risk of death . [MEDICATION(S)] is not approved for the treatment of patients with dementia-related [CONDITION(S)]. NP updated states to continue. Although the facility's medication system identified the use of this medication as increasing the risk of death and provided alerts with the information, review of all 16 tabs of the EMR revealed no evidence of monitoring for the possibility for adverse reactions, including death from use of this medication. Review of a Pharmacy Monograph dated 04/14/21, revealed that in addition to the black box warning about the potential for death, serious side effects also include, but are not limited to mental, mood, or behavior changes that are new or worse, feeling very tired or weak, very bad headache or dizziness, passing out, trouble controlling body movements, twitching, change in balance, trouble swallowing or speaking, shakiness, trouble moving around or stiffness, fast or abnormal heart beat, chest pain that is new or worse, trouble passing urine, unexplained bruising or bleeding, change in eyesight, hallucinations, seizures. Other side effects included feeling sleepy, anxiety, dry mouth, more saliva, constipation diarrhea, upset stomach, headache, restlessness, and trouble sleeping. However, there was no evidence that facility staff were aware of all the potential side effects of [MEDICATION(S)] and were consistently monitoring for their presence to assure R1 was free from potential adverse reactions Observation on 07/12/21 at 12:04 PM and 07/13/21 at 8:36 AM, revealed R1 was asleep in bed. An additional observation on 07/13/21 at 2:30 PM, revealed R1 was still in bed. Upon entry to the room, R1 was calm. However, as the surveyor introduced herself, R1 began crying, and could not be interviewed, as she continued to cry and state she was cold. Observation on 07/16/21 at 12:14 PM, revealed R1 was sitting on the side of her bed. As soon as the surveyor introduced herself, R1 became tearful, and cried as she kept repeating, I want to go home. An attempt to interview R1 about her diagnoses and medications were not successful, based on her cognitive status. Interview with Licensed Practical Nurse (LPN) 2 on 07/13/21 at 2:25 PM revealed she was R1's nurse that day. When asked to name possible side effects for which she should monitor, she replied, agitation and trying to get out of bed. LPN2 stated there was no routine behavior or side effect monitoring and if she saw something different, I would tell the Unit Manager and document it. 4. Review of R7's Orders tab revealed that R7 was admitted to the facility on [DATE] on two different antipsychotics: [MEDICATION(S)] ([MEDICATION(S)]) 200 mg at bedtime for dementia with behavioral disturbance and PRN [MEDICATION(S)]. Further review of the Orders tab revealed that, as of 03/27/21 through 07/16/21, R7 continued to receive 50 mg of [MEDICATION(S)] at night for [CONDITION(S)] disorder. Review of R7's comprehensive care plan, initiated 02/12/21, revealed a Focus Area statement that the resident exhibits behavior symptoms. Interventions for this problem area included administering [CONDITION(S)] medications as ordered and Document all behaviors. Attempt to identify pattern to target interventions. Further review of R7's comprehensive care plan, initiated 02/12/21, revealed that it called for staff to Monitor/document side effects and effectiveness, and Monitor/record/report to MD prn side effects and adverse reactions of psychoactive medications. Review of the Orders tab which included R7's MAR and TAR for 2021, as well as all the other 15 tabs in the EMR revealed no evidence of ongoing, consistent monitoring related to behaviors association with the resident's need for the medication. In addition, there was no evidence of ongoing, consistent monitoring for side effects related to R7's use of [MEDICATION(S)]. 5. Review of R2's Orders tab revealed that R2 was admitted to the facility on [DATE] on [MEDICATION(S)], an antipsychotic, for psychotic symptoms. Further review of the Orders tab revealed that, from 03/28/21 to 07/16/21, R2 continued to receive 2.5mg of [MEDICATION(S)] each day for [CONDITION(S)] disorder, [CONDITION(S)], and major/manic depressive disorder. Review of R2's comprehensive care plan, initiated 07/09/20, revealed a Focus Area statement that the resident uses [CONDITION(S)] medications. Interventions for this problem area include, Monitor/record occurrence of target behavior symptoms . and document per facility protocol. Further review of R2's comprehensive care plan, initiated 07/09/20, revealed that it called for staff to give medications as ordered and Monitor/document side effects and effectiveness. Review of the Orders tab which included R2's MAR and TAR for 2021, as well as all the other 15 tabs in the EMR revealed no evidence of ongoing, consistent monitoring related to behaviors associated with the resident's need for the medication. In addition, there was no evidence of ongoing, consistent monitoring for side effects related to the resident's use of [MEDICATION(S)]. Interview on 07/13/21 at 2:35 PM with LPN 2 revealed there was no routine monitoring for either behaviors or side effects. LPN2 stated that if she saw something different she would tell the unit manager and document it; however, LPN2 confirmed, routine monitoring did not occur. Interview on 07/13/21 at 5:05 PM with Charge Nurse 1 revealed that both behavior monitoring and monitoring of side effects related to antipsychotic use were up to now been by exception. Charge Nurse 1 confirmed that currently there was no system of identifying the resident-specific target behaviors related to the resident's antipsychotic use or routine monitoring for behaviors. Charge Nurse 1 also stated there was no system of identifying the specific side effects associated with each [CONDITION(S)] medication a resident used, and no ongoing monitoring for these side effects. Interview with the Assistant Director of Nursing Services (ADNS) on 07/12/21 at 1:06 PM confirmed that behavior monitoring was only done by exception. The ADNS stated that there was no routine monitoring, and the nurse would only write a progress note about a behavior if it occurred. When interviewed about monitoring for behaviors and/or side effects on 07/15/21 at 5:20 PM, the Director of Nursing Services (DNS) stated that both definitely need to be done. However, she confirmed, It is not happening now. The DNS stated that the facility needed to also include the specific target behaviors that resulted in the use of an antipsychotic.

Based on observation, record review and interviews during an abbreviated survey (Case #NY 685), the facility did not ensure a resident with a pressure ulcer received the necessary treatment and services consistent with professional standards of practice to promote healing for 1 (Resident #1) of 3 residents reviewed. Specifically, an unstageable pressure ulcer on the resident's left buttock was identified by three Certified Nurse Aides (CNA) and a Licensed Practical Nurse (LPN) between 8/29/19 and 9/5/19 which was not communicated to a Registered Nurse (RN) for assessment. From 8/30/19 to 9/5/19, nurses allowed CNAs to apply a physician-prescribed medicated skin cream to the resident's bottom, the nurses did not visualize the resident's bottom and did not report the pressure ulcer to an RN or physician for assessment. Subsequently, on 9/6/19 the resident had a large wound on his left buttock covered with eschar with a strong foul odor and was transferred to the hospital for treatment. This resulted in actual harm that is not immediate jeopardy. The findings were: The Policy and Procedure (P&P) for Pressure Ulcers Assessment, Prevention and Management with an effective date of 11/2016, documented a resident who had a pressure ulcer was to receive necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new pressure ulcers from developing. It further documented Licensed Practical Nurse (LPN) and/or Certified Nurse Aide (CNA) responsibility was to inspect the skin of all individuals at risk for skin breakdown at least once each shift and report any changes or areas of concern to the nurse. Resident #1: Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 8/11/19, documented the resident was cognitively intact, could make himself understood, and could understand others. The resident required the extensive assistance of two for bed mobility, transfers, incontinence care, and was not able to walk. The MDS also documented the resident was at risk for developing pressure ulcers but had no pressure ulcers at the time of the assessment. The Comprehensive Care Plan, updated on 5/24/19, documented the resident was at risk for pressure ulcer development related to a prior history of a Stage 3 pressure ulcer, immobility, and incontinence. The goal was that Resident #1 would have no avoidable skin breakdown. The documented intervention was for nursing staff to monitor the resident's skin and document and/or report changes to the MD as needed. The Registered Nurse (RN) Weekly Wound Assessment form dated 8/23/19 documented an area of Moisture Associated Skin Damage to the scrotum, for which the resident had been treated since 7/12/19, had healed. The 9/2019 Treatment Administration Record (TAR) documented the resident was to have [MEDICATION NAME]/A&D/Zinc cream (a combination medication used to treat inflamed skin infections) applied to both buttocks every shift as a preventative skin treatment. The TAR was not signed that the treatment was administered on 9/1/19 (3 PM- 11 PM shift), 9/3/19 (7 AM- 3 PM shift), and 9/3/19 and 9/5/19 (11 PM- 7:00 AM shift). The 9/2019 Medication Administration Record [REDACTED]. There was no further documentation in the resident's medical record regarding the 9/5/19 skin check. The 9/2019 CNA Documentation Survey Report for skin checks every shift, documented the following: 7 AM- 3 PM shift- 9/1- 9/5/19, no skin issues. 3 PM- 11 PM shift - 9/1 and 9/2/19, 9/4/9/5/19, no skin issues. 9/3/19 - no skin checks documented. 11 PM- 7 AM shift- 9/1 and 9/2/19 no skin issues. 9/3/19 documented not applicable, and 9/4 and 9/5/19 no skin issues. The RN Weekly Wound Assessment form dated 9/6/19, documented the resident had an unstageable pressure ulcer that measured 9.5 centimeters (cm) in length x 6.8 cm in width. A Progress Note dated 9/6/19 at 9:57 PM, written by the Nurse Practitioner (NP), documented the resident had a large wound to the sacral region covered with eschar and with a strong foul odor. She ordered a transfer to the hospital for treatment of [REDACTED]. An undated facility Investigative Summary included a written statement dated 9/9/19 by RN #3 which documented she had not been notified of any open areas on Resident #1 since his MASD healed on 8/23/19. The Investigation Summary documented there was a delay in treatment of [REDACTED]. The LPNs and CNAs were responsible for that and were supposed to report any changes or areas of concern to a nurse. During an interview on 9/17/19 at 11:34 AM, RN #3 (the wound care nurse) stated she assessed the resident on weekly wound rounds for an open area on his scrotum, that had healed on 7/12/19. After that, she continued to assess the area for four more weeks. She discontinued wound rounds for him on 8/23/19 because the area had remained healed, and there were no wounds on the resident's buttock at that time. During an interview on 9/20/19 at 9:29 AM, LPN #2 stated that on 8/29/19 a CNA asked if she needed help with a dressing for the resident's buttock. LPN #2 looked in the TAR and there was no treatment for [REDACTED]. On inspection of the resident, there was an unstageable ulcer on the resident's left buttock. The ulcer was scabbed over, and it was larger than a silver dollar. Because of the appearance of the wound, she thought it had been there for a period of time. There were no signs/symptoms of infection and no dressing. She instructed the CNA to apply the prescription cream to his buttocks, but to avoid the area of the pressure ulcer. She did not report the wound to an RN or to the LPN Unit Manager (LPNUM), and did not pass the information on in 24-hour report. During an interview on 9/18/19 at 12:50 PM, CNA #3 stated on that 9/4/19 she was assigned to the resident and provided his evening care. When she cleaned his buttocks, she saw a blackish/greenish area. She did not notify the nurse because it looked old, like it had been there for a while. During an interview on 9/20/19 at 10:09 AM, RN #2 stated she worked on 9/3/19 and 9/4/19 and was unaware the resident had a wound on his buttocks. She stated the CNAs were usually reliable in reporting skin changes to the nurses, but she was never informed this resident had a wound. RN#2 stated the nurses were not always available to apply the [MEDICATION NAME]/A&D/Zinc cream so she gave the CNAs a small amount of the cream to apply to the resident. She then signed in the TAR that the treatment had been completed. If she had administered the treatment herself, she would have assessed the area, called the MD and started the appropriate paperwork. She stated she missed two (9/3/19 and 9/4/19) opportunities to assess the resident's wounds by having the CNAs apply the cream. During an interview on 9/18/19 at 12:20 PM, CNA #1 stated she gave the resident a bed bath on 9/5/19 and saw a wound on the resident's bottom. She reported the wound to a nurse but could not remember the nurse's name. During an interview on 9/18/19 at 11:57 AM, LPN #3 stated a CNA applied the [MEDICATION NAME]/A&D/Zinc Cream on 9/5/19 but she (LPN #3) signed that the cream had been administered. CNA #1 reported to her she had applied the cream but did not report there were any concerns with the resident's skin. She stated it was her understanding that at this facility, the CNAs could administer a cream that contained an antifungal medication, so she had the CNA do it because she was busy that day. She stated she was not aware the resident had skin breakdown on his buttocks, and that if she applied the cream herself, she would have had an opportunity to observe the resident's buttocks. During an interview on 9/17/19 at 12:42 PM CNA #2 stated she discovered the resident's wound on 9/6/19 at 2:20 PM when she put him to bed for an afternoon rest break and provided incontinence care. She smelled a foul odor and thought it was feces, but it was not, the smell was coming from the wound. She notified LPN #1, who saw the wound and notified the supervisor. During an interview on 9/19/19 at 1:33 PM, LPN #1 stated CNA #2 asked her to look at the resident's buttocks on 9/6/19. On inspection, there was a necrotic (dead) tissue area on the resident's left buttock. She reported this to the LPNUM and the NP. She also stated that she had been allowing the CNAs to apply the medicated cream to the resident, and as a result she had not seen the resident's bottom and was not aware the resident had a wound on his buttock. During an interview on 9/20/19 at 9:19 AM, the DON stated there was a correlation between the administration of the prescription cream by the CNAs and the development of the pressure ulcer because the nurses were not observing the resident's skin. The CNAs were not supposed to apply the cream because it was a prescribed medicated cream and should have been applied by the nurses. Because the cream was ordered for three times a day, there were 27 missed opportunities from 8/29/19- 9/6/19 for a nurse to report the wound to a supervisor and medical provider, and that caused a delay in the proper treatment of [REDACTED]. During an interview on 9/20/19 at 12:13 PM, the MD stated Resident #1 had multiple risk factors for skin breakdown as he was incontinent and had impaired mobility. He was not told about Resident #1's left buttock wound until 9/11/19. The MD stated the LPN who saw the wound on 8/29/19 should have reported it to an RN so interventions could have been implemented to prevent the wound from getting worse. During a subsequent interview on 9/30/19 at 3:26 PM, the DON stated education was key for prevention of another incident. She stated the Nurse Managers were monitoring skin checks to ensure they were being completed correctly. An audit tool was developed for their use. Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement at the time of this survey: - A full house audit was completed on 9/6/19 for skin checks on every resident who was at risk for skin breakdown. No new skin issues were identified. - All nurses and CNAs were re-educated on 9/8/19 for monitoring skin integrity. - An audit tool was developed for skin checks that included the resident name, the order for a skin check, that the skin check was on the MAR, the skin inspection was done on shower day and documented, and that the shower was documented in the CNA tasks. - On 9/6/19, the staff involved in the incident received disciplinary action, re-education for monitoring skin integrity, and were suspended pending the outcome of the investigation. The LPNUM involved in the incident was terminated. 10 NYCRR 415.12 (c)(1)

Based on record review and interviews during an abbreviated survey (Case# NY 122), the facility did not ensure each resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, for 1 (Resident #12) of 26 residents reviewed for quality of care. Specifically, on [DATE] at 1:04 AM the physician was notified that Resident #12 had black emesis, and the physician ordered staff to closely monitor the resident. There was no documentation the resident was monitored between 1:04 AM and 8:47 AM on [DATE]. Subsequently, at 8:47 AM on [DATE] the resident presented with coffee ground emesis with blood clots, and was transferred to the hospital where he was diagnosed with [REDACTED]. The resident expired at the hospital at 2:30 PM. This resulted in actual harm that is not immediate jeopardy. This was evidenced by: Resident #12: This resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated [DATE], documented the resident was cognitively intact. The Policy and Procedure (P&P) titled Physician Notification dated ,[DATE], documented in the event a licensed nurse recognized a change in the resident's condition, the unit RN or supervisor was to complete an assessment of the resident. Based upon the assessment, the physician was to be notified. The nursing director was to be notified of any change in condition necessitating prompt physician intervention. It was the responsibility of the unit nurse to document the signs and symptoms that were first recognized, indicating a possible change in status, in the progress notes. The RN who completed the assessment and notified the physician was responsible for reflecting all information in the progress note. The RN was to also enter information in the progress notes that would be reflected on the 24-Hour report. The Comprehensive Care Plan (CCP) for At Risk for Bleeding secondary to NSAIDS (non-steroidal anti-[MEDICAL CONDITION] medications)/Anticoagulant (a blood thinner) Use, last updated on [DATE], documented a goal that the resident would be free from the side effects of anticoagulant medications, and would be free from signs and symptoms (s/s) of abnormal bleeding. Nursing staff were to administer medications as prescribed, monitor effectiveness of medications given, observe for adverse reactions, and monitor for s/s of abnormal bleeding (skin bruising, bleeding gums, black stools, coffee ground emesis). A History and Physical Report dated [DATE], documented the resident was to continue on [MEDICATION NAME] (a blood thinner) for [MEDICAL CONDITION] embolism (blood clot in an artery, in the lung). The Medication Administration Report (MAR) dated ,[DATE], documented the resident was to receive [MEDICATION NAME] 150 mg at 9:00 AM and 9:00 PM daily. The Weights and Vitals Summary dated [DATE], documented the resident's blood pressure was ,[DATE] (normal range of blood pressure is between ,[DATE] and ,[DATE]) at 8:44 PM. The MAR indicated [REDACTED]. The Medication Administration Note by LPN #9, dated [DATE] at 12:38 AM, documented the resident was spitting out clots of bright red blood and the resident's blood pressure was ,[DATE]. LPN #9 documented the Supervisor was notified. A Nursing Progress Note, written by Registered Nurse Supervisor (RNS) #3 dated [DATE] at 1:04 AM, documented there was black emesis on the floor, and the resident looked pale and weak. The physician (MD) was called immediately, new orders were given, and it was documented the resident needed to be seen by the Nurse Practitioner (NP) in the morning for further evaluation. Staff were to monitor the resident closely, and nursing was to report any changes in the resident's condition to the physician. There was no documentation of the parameters for close monitoring. There was no further documentation about the resident's condition until [DATE] at 8:47 AM. A Change in Condition note written by the LPN nurse manager (LPNM #5) dated [DATE] at 8:47 AM, documented the following change in condition: coffee ground emesis (vomit that is dark brown and resembles coffee grounds from an upper gastrointestinal (GI) bleed) with blood clots, that started on [DATE] in the morning. The resident was on blood thinners and one dose of the medication had been held. The resident had generalized weakness and was sleepy. The resident had GI blood, nausea and/or vomiting, a decreased appetite/fluid intake, had a new onset of hematemesis (vomiting blood) with clots, and coffee ground emesis with clots. The resident complained of moderate acute abdominal pain, diffuse/localized pain, and was unrelieved by antacids or laxatives, and his stomach area was aching. All changes in condition were reviewed with MD #1 on [DATE] at 8:45 AM. MD #1's recommendations were to send the resident to the hospital. A Nursing Progress Note by RNS #1 dated [DATE] at 10:11 AM, documented the resident had gross amounts of coffee ground emesis, and complained of having severe abdominal pain. The Nurse Practitioner (NP #1) evaluated the resident and ordered that the resident be sent to the hospital for evaluation. There was no documented note from the nurse practitioner. The Nursing Home to Hospital Transfer Form completed by LPNM #5 on [DATE] at 8:47 AM, documented the resident had coffee ground emesis with clots. The emergency medical services (EMS) Patient Care Record dated [DATE], documented facility called EMS on [DATE] at 9:31 AM and EMS was at the resident's bedside at 9:40 AM. The resident stated, I am so scared. The resident was in his bed, lying on his right side, conscious and sluggish. Coffee ground emesis was present on the floor in front of the resident and was also puddled beneath the resident, and dried on his beard, face, and lips. The resident stated he felt like crap and everything was dark. He stated he did not feel good the day before and during the morning he began vomiting, and eventually began having large blood clots. The resident also complained about having chest pain, weakness, vision changes, and abdominal pain. The resident's blood pressure readings were ,[DATE], ,[DATE], and ,[DATE], along with elevated heart and respiratory rates. It was documented the resident was distressed. The EMS impression of the resident's condition was hypovolemic shock (an emergency condition in which severe blood or fluid loss makes the heart unable to pump enough blood to the body) caused by a GI bleed. A facility staff member reported they had been trying to call 911 for 3 hours but could not without the Supervisor's permission. The Hospital Emergency Department (ED) Provider Note dated [DATE] at 10:37 AM, documented the resident presented with hematemesis and [MEDICAL CONDITION] (low blood pressure). Per EMS, the nursing staff at the nursing home found the resident vomiting several hours prior to calling EMS. EMS reported they did not get any further history other than the episode of hematemesis, 3 hours prior to their service being called. Upon examination in the ED, the resident was in severe distress. He had dried blood in his mouth, on his right arm and his sheets, and the blood appeared very dark. He was hypotensive upon arrival and had evidence of a GI bleed. An emergent release of blood for transfusion and medications were ordered, as there was concern about the hematemesis and thought the [MEDICAL CONDITION] might be related to blood loss [MEDICAL CONDITION] (loss of red blood cells exceeds production of new, causing tiredness, shortness of breath, and pale skin). The patient received blood [MEDICAL CONDITION], IV fluid, and several medications. The patient was admitted to the medical intensive care unit for severe electrolyte abnormalities including [MEDICAL CONDITION] (high level of potassium in the blood), acute [MEDICAL CONDITION], and GI bleed. The Cardio/Respiratory Death Pronouncement documented, the patient was declared dead at 2:30 PM on [DATE]. During an interview on [DATE] at 4:51 PM, LPN #9 stated that, on [DATE], she saw the resident was bleeding and held the 9:00 PM dose [MEDICATION NAME]. She said the resident was spitting out blood. She obtained the resident's vital signs and then called RNS #3 to let him know she was holding the [MEDICATION NAME] because of the bleeding. RNS #3 told her he would call the MD and would call her back. At around 12:30 AM on [DATE], the resident was spitting out dime-sized blood clots, a little at a time. She took the resident's vitals and then called RNS #3. RNS #3 told her the MD was called and gave orders for [MEDICATION NAME] (a medication used to treat stomach and esophagus problems and relieves symptoms such as heartburn, difficulty swallowing, and persistent cough) tablet, the resident was to be evaluated by the NP in the morning, and for the resident to be monitored. She questioned RNS #3 about the [MEDICATION NAME] order, because she said it looked like the resident was having a GI bleed. She said RNS #3 told her to keep an eye on the resident. She was not given any specific details about how often, and what to monitor the resident for. She said RNS #3 came to the unit a couple times to see how the resident was doing. At around 5:30 AM, she went into the resident's room and saw on the floor in front of his bed, he had vomited a lot more. The emesis was bright red in color and had 1 or 2 clots that were about 6 inches in length. She said the resident was sleepy and, out of it. She took the resident's vital signs, then called RNS #3. Between 6:00 AM and 6:30 AM, she saw NP #1, and asked her if she could see the resident. LPN #9 said she did not document the resident's condition at that time. During an interview on [DATE] at 6:03 PM, RNS #3 stated, LPN #9 called him to see the resident between 12:00 AM and 1:00 AM on [DATE]. He said there was black emesis on the floor in front of his bed. He called MD #1 between 12:00 AM and 1:00 AM on [DATE] and told MD#1 what was happening with the resident, and MD #1 gave orders for [MEDICATION NAME] by mouth. RNS #3 stated he was not sure if he told MD #1 the resident was receiving blood thinners but was certain MD #1 asked about it. He could not remember if he gave LPN #9 any specific direction about close monitoring of the resident and stated vital signs should have been documented in progress notes. There should have been a note from LPN #9, especially when the resident was being monitored. He believed he checked on the resident during the night but could not recall if LPN #9 notified him about the increased vomiting of blood and blood clots at 5:30 AM on [DATE]. During an interview on [DATE] at 10:22 AM, RNS #1 stated that on [DATE] between 9:00 AM and 9:30 AM, she was called to see the resident. When she walked into the room, the resident was complaining of severe abdominal pain. There was emesis on the floor and in the basin on the bed, that looked like coffee and was brownish/reddish in color. The resident said he was in excruciating pain. She notified NP #1, and an order was given to send the resident to the hospital. RNS #1 stated that if there was an order for [REDACTED]. During an interview on [DATE] at 4:08 PM, LPNM #5 stated she saw the resident on the morning of [DATE], immediately after his condition was reported to her, and observed the resident vomiting bright red blood. She immediately had the resident sent to the hospital. LPNM #5 stated, if LPN #9 was told to closely monitor the resident on [DATE], she should have gotten vital signs every hour because he was actively bleeding, and that the LPN should have written a nursing note. She said LPN #9 should have been monitoring the resident's condition and communicating with RNS #3 throughout the night. During an interview on [DATE] at 12:23 PM, Director of Nursing stated, when she learned about the bleeding sometime on the morning of [DATE], she thought that it might have just started, and they were sending him out, and was not aware that it had begun during the night of [DATE] to [DATE]. She stated when something happened at the facility during the night shift, the nurses typically called her, but they did not call that night. If LPN #9 was directed to do close monitoring of the resident, she would have expected the vitals to be done every 15 minutes. She would not expect the nurse to document the vitals every 15 minutes, but a note should have been written to say they were monitoring and aware of the condition. She stated, Blood is alarming in long term care. Residents are not supposed to be bleeding. During an interview on [DATE] at 10:36 AM, MD #1 stated it was the facility's policy to notify him prior to sending a resident to the hospital. The MD reviewed the resident record and stated that there was an 8-hour window between 1:00 AM and 9:00 AM on [DATE], and stated there was no documentation of the resident's condition. He said nursing should have written a note at 3:00 AM, that the resident was re-assessed, and when there was an increase in the resident's vomiting blood and blood clots at 5:30 AM, he should have been called. 10 NYCRR 483.25

Based on medical record review and interviews during a partial extended abbreviated survey (Case #NY 073) it was determined that the Administration failed to ensure that the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, the Administration failed to ensure that residents were assessed after an allegations of abuse was reported, failed to implement timely interventions to protect the resident from immediate further abuse and failed to identify, investigate and report abuse timely. A resident, who is alert & oriented, reported that he had witnessed two certified nurses aides (CNAs) taunting another resident by yanking, hitting, and kicking the baby dolls that the resident carried. The resident believes the baby dolls are his grandchildren. Per video surveillance the resident became visibly upset. There was no assessment of the resident, the accused remained on duty and the facility did not immediately investigate or report the witnessed incident to the state health department or to the local police department. This has the potential to affect all residents in the facility. This resulted in no actual harm but had the potential for serious harm that is Immediate Jeopardy. Refer to F225- Abuse- scope and severity-L During an interview on 9/3/13 at 1:55 pm, the Administrator stated that she was on vacation at the time of the incident and returned to the facility on [DATE] and was informed of the investigation findings. The Administrator stated that she reviewed the investigation, viewed the video and was very disturbed by the actions of CNA #4 and stated that CNA #5 was a spectator and blocked the resident's path and that both CNAs had been terminated prior to her return. The Administrator stated that she directed the report to the Department of Health (DOH) and to the local police agency. The Administrator stated that she was concerned that the reports to the DOH and the police had not already been made as these reports did not need to wait until her return. The Administrator stated "CNA #6 was not involved." The Administrator and the surveyor reviewed the video and the Administrator stated "oh, so she sees them and walks away", I didn't realize there was another witness to the incident, we should have interviewed her and obtained a statement. I don't know why it wasn't done. The Administrator reviewed CNA #5's time sheet, noted that she worked on 8/19/13 from 2:55 pm until 11:15 pm and the Administrator stated that she should have been suspended immediately and not worked that shift. The Administrator was asked if CNA #4 would have been in the facility in uniform working in any capacity after the incident of 8/17/13. The Administrator stated that CNA #4 worked in the facility as a private duty aide for another resident, however, when she (the administrator) returned from vacation and found that CNA #4 was still working privately within the facility, she directed that CNA #4 not be allowed in the facility. The Administrator stated that after the allegation of abuse was reported the RN should have assessed the resident for physical and psychological harm. During an interview on 9/25/13 at 4:00 pm, the Administrator stated that upon her return from vacation, she instructed the Director of Nurses (DON) at the time to insure that CNA #4 was not allowed in the building. The Administrator reviewed the Release of Responsibility for Out on Pass with Responsible Party signed by CNA #4 on 9/1/13 and stated, "I told the DON not to allow CNA #4 in the building, there was a misunderstanding, and after you left on 9/10/13, I sent a memorandum to the receptionist so that it was clear that CNA #4 should not be in the building or given access to any of our residents." During an interview on 9/25/13 at 9:00 am, the Vice President (VP) of Operations stated that he was aware that the Administrator was on vacation at the time of Resident #2's incident. The VP of Operations stated that he was aware of the allegation of abuse assumed that the facility staff had thoroughly investigated the incident and notified the Department of Health and law enforcement. The VP of Operations stated that he didn't involve himself in the investigation and learned upon the administrator's return that the appropriate notifications had not been made nor were abuse reporting and investigation procedures were not completely followed. The VP of Operations stated "I wish I had looked at the tape, that's my mistake." 10NYCRR 415.26

Based on observation, medical record review and staff interview during a partial extended abbreviated survey (Case #NY 165 and #NY 073) the facility failed to ensure that all alleged violations involving mistreatment, neglect or abuse were reported immediately to the administrator of the facility, and that all alleged violations were thoroughly investigated for two (#s-1 and 2) of three residents reviewed. Specifically, an alert & oriented resident , reported that he witnessed two CNAs taunting Resident #2 by yanking, hitting, kicking the dolls that the resident carried. The resident believed the baby dolls are his grandchildren. Per video surveillance the resident became visibly upset. There was no assessment of the resident, the accused remained on duty and the facility did not immediately investigate or report the witnessed incident to the state health department or to the local police department. This has the potential to affect all residents in the facility. This resulted in no actual harm but had the potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care. The facility was able to remove the immediacy prior to exit by implementing the following: -Revision of the Policy and Procedure for Abuse, Neglect and Mistreatment -100% of all scheduled staff have been re-educated on Abuse, Neglect and Mistreatment Reporting. -100% of all scheduled Administrative and Nursing Supervisory staff have been re-educated on Abuse Reporting, Investigations, including removal of the accused pending investigative findings or permanently restricting accused from the facility and the Elder Justice Act. Additional licensed agency staff will receive education prior to accepting assignment. -All Registered Nurses, Nurse Managers and Social Workers have been re-educated on the importance of identifying and care planning for objects that are significant to the residents psychosocial well being. -All Registered Nurses were inserviced on the importance of doing a head to toe physical and psychological assessment following an allegation of physical, mental or verbal abuse. This is evidenced by the following: Resident #2 The resident was admitted to the facility on [DATE] diagnosed with [REDACTED]. The Minimum (MDS) data set [DATE] assessed the resident with severe cognitive impairment. Note dated 8/19/13 signed by Registered Nurse (RN) #1 documented that RN #1 received a report from Resident #2's son that an evening Certified Nurse's Assistant (CNA) had upset Resident #2 by yanking, hitting and kicking the baby dolls that Resident #1 carries. It is documented that an alert and oriented resident, Resident #10, had observed the incident but wanted to remain anonymous. RN #1 documented that while speaking with Resident #2's son, Resident # 10 approached them and reported that he had witnessed CNA #4 hit the baby doll in the head a couple of times, and was pulling at the baby's clothes and Resident #2 got upset and started kicking at CNA #4 and CNA #4 ran into a closet laughing and Resident #2 started kicking at the door and was very angry. Investigation Summary documented that an investigation was initiated on 8/20/13 for an incident that occurred on 8/17/13. The summary documented "that video surveillance was reviewed for timeline, individuals involved and sequence of events. It further documented that the video revealed CNA #4 and CNA #5 taunting the resident and clearly showed CNA #4 slapping the doll, throwing the doll and kicking the doll as well as the resident running after CNA #4 to retrieve the doll. The video further showed that CNA #5 stood by not intervening and also slapping the doll. The conclusion documented that there was a failure to maintain an environment that protects the resident from abuse, neglect or mistreatment; that both CNAs did not protect the resident by not maintaining the resident's right to be free from abuse, neglect and mistreatment and that both CNAs involved in the taunting understood that Resident #2 believes these dolls to be a family member. Follow-up action included that CNA #4 and CNA#5 were terminated on 8/20/13." The summary documented that the Department of Health was notified of the incident on 8/26/13 and law enforcement was notified on 8/27/13. The summary is signed by the Director of Nursing on 8/26/13. Release of Responsibility for Out on Pass with Responsible Party documented that CNA #4 signed out a resident of the facility on 9/1/13 at 11:00 am and returned the resident to the facility at 11:00 pm. During an interview on 9/3/13 at 10:30 am, Resident # 10 stated that he witnessed CNA #4 hitting and throwing Resident #2's baby dolls. Resident #10 stated that he informed the resident's son the following day and the next day he reported the incident to RN #1. Resident # 10 stated that he was concerned because a few days after he reported the incident, he saw CNA #4 in uniform in the facility elevator and thought she was working with another resident. Resident #3 stated, "I don't think that's right, I thought that someone like that shouldn't be working here anymore." During an interview on 9/3/13 at 12:45 pm, RN #1 stated that Resident #2's son reported an incident that he was told about from another resident. RN #1 stated that she was very concerned about the allegation because Resident #2 treats and thinks that the baby dolls are his grandchildren. RN #1 stated that while talking to Resident #2's son, Resident # 10 approached them and reported what he had seen. RN #1 stated that she reported the concern to the Assistant Director of Nursing who was going to review the video tapes to determine what had happened. The RN #1 stated that she did not go and assess the resident, but stated that it is the facility's policy to assess a resident after an allegation of abuse, neglect or mistreatment. RN #1 stated "I think I didn't assess him because the report indicated that it had occurred prior to the current shift." RN#1 stated that if the incident had occurred on her shift, she would have gone right away to assess the resident. RN #1 stated that she heard later that another CNA had witnessed it and then it came out that the other CNA was involved in the incident. During an interview on 9/3/13 at 1:45 pm, the ADON stated that he was responsible for the investigation into the incident. The ADON stated on 8/19/13 he received a report from RN #1 that Resident #2's son had reported an incident in which a CNA was taunting the resident. The ADON stated on 8/19/13, he reviewed the video surveillance and viewed the incident in which CNA #4 was taunting the resident, and CNA #4 was terminated effective 8/20/13 however, she had not worked since 8/17/13. The ADON stated that during the review of the video, he identified that CNA #5 was standing in the hallway watching the incident, failed to intervene and then blocked Resident #2's path. The ADON stated that CNA #5 was terminated effective 8/20/13. The ADON reviewed CNA #5's time sheet documenting that CNA #5 worked in the facility on 8/19/13 from 2:55 pm until 11:15 pm. The ADON stated that on 8/19/13, he didn't think that CNA #5 was working. The ADON was asked to review the video surveillance with the surveyor and was asked to identify a third person in the video who enters the scene, watches the interaction between CNA #4 and Resident #2 and then exits. ADON identified the third person as CNA #5, however, upon further review observing three different CNAs, the ADON stated that he did not know who the third person observed in the video was. Upon review of the staffing schedule, the ADON stated "that must be CNA #6". The ADON stated he does not know all of the CNAs, did not know who CNA #6 was, had not identified CNA #6 as a part of the investigation and had not interviewed CNA #6 regarding the incident. The ADON stated that he did not realize that there were three different aides, and had he identified CNA #6 as different from the two others, the CNA would have been interviewed regarding the incident, and based on the video review, would have been suspended for failure to intervene and report the incident. During an interview on 9/3/13 at 1:55 pm, the Administrator stated that she was on vacation at the time of the incident and returned to the facility on [DATE] and was informed of the investigation findings. The Administrator stated that she reviewed the investigation, viewed the video and was very disturbed by the actions of CNA #4 and stated that CNA #5 was a spectator and blocked the resident's path and that both CNAs had been terminated prior to her return. The Administrator stated that she directed the report to the Department of Health (DOH) and to the local police agency. The Administrator stated that she was concerned that the reports to the DOH and the police had not already been made as these reports did not need to wait until her return. The Administrator was asked about the appropriateness of CNA #6's conduct related to abuse prevention. The Administrator stated "CNA #6 was not involved." The Administrator and the surveyor reviewed the video and the Administrator stated "oh, so she sees them and walks away", I didn't realize there was another witness to the incident, we should have interviewed her and obtained a statement. I don't know why it wasn't done. The Administrator reviewed CNA #5's time sheet, noted that she worked on 8/19/13 from 2:55 pm until 11:15 pm and the Administrator stated that she should have been suspended immediately and not worked that shift. The Administrator was asked if CNA #4 would have been in the facility in uniform working in any capacity after the incident of 8/17/13. The Administrator stated that CNA #4 worked in the facility as a private duty aide for another resident. When she (the administrator) returned from vacation and found that CNA #4 was still working privately within the facility, she directed that CNA #4 not be allowed in the facility. The Administrator stated that after the allegation of abuse was reported the RN should have assessed the resident for physical and psychological harm. During an interview on 9/25/13 at 3:30 pm, the Director of Nursing (DON) stated that she was aware of the incident with Resident #2 and was working on inservicing all nursing staff on Abuse Reporting, Investigations and the Elder Justice Act but had not had the time to get to all nursing staff yet. The DON stated that she had prepared a tool book to be utilized by nursing staff after an incident to insure that resident's were assessed and care planned thoroughly, however, all inservices had not taken place yet. During an interview on 9/25/13 at 4:00 pm, the Administrator stated that upon her return from vacation, she instructed the DON at the time to insure that CNA #4 was not allowed in the building. The Administrator reviewed the Release of Responsibility for Out on Pass with Responsible Party signed by CNA #4 and stated, "I told the DON not to allow CNA #4 in the building, there was a misunderstanding, and after you left on 9/10/13, I sent a memorandum to the receptionist so that it was clear that CNA #4 should not be in the building or given access to any of our residents." During an interview on 9/25/13 at 9:05 pm, the Registered Nurse Supervisor (RNS) on duty stated that she works for an agency and was responsible for the facility from 3:00 pm - 11:00 pm this date. The RNS stated that she had not worked in the facility through her agency in about a month and did not receive any education or inservice before beginning her shift. The RNS stated that she did see a new tool book in the supervisors office and was going to ask the Assistant Director of Nursing about it, but didn't have time. In an interview on 9/25/13 at 9:00 am, the Vice President (VP) of Operations stated that he was aware that the Administrator was on vacation at the time of Resident #2's incident. The VP of Operations stated that he was aware of the allegation of abuse, assumed that the facility staff had thoroughly investigated the incident and notified the Department of Health and law enforcement. The VP of Operations stated that he didn't involve himself in the investigation and learned upon the administrator's return that the appropriate notifications had not been made nor were abuse reporting and investigation procedures completely followed. The VP of Operations stated "I wish I had looked at the tape, that's my mistake." Resident #1 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE], assessed the resident as having a short-term memory problem and was rarely/never understood and rarely/never understands. The Nursing Home Incident form received by the Department of Health (DOH) on 8/27/13 at 5:23 pm documented that a reportable incident occurred at the facility on 8/24/13 at 10:30 pm. It further documented that there was reasonable cause to believe that abuse, neglect, or mistreatment occurred. A review of the electronic medical record progress notes from the evening of 8/24/13 through 8/26/13 revealed no documentation of the incident or a Registered Nurse (RN) assessment of the resident. The nurse progress note, undated, not timed and handwritten by the Registered Nurse Supervisor (RNS), documented that the resident was assessed related to an allegation that a Certified Nurse Aide (CNA) "tossed" a bedpan at the resident twice. The resident was alert and pleasant and there were no abrasions, lacerations, or bruising noted. The resident showed no verbal or non-verbal cues to indicate the presence of mental health changes due to the incident. Vital signs were documented and were within normal limits. It was further documented that the Director of Nursing (DON) was notified at 11:30 pm. A late entry social work progress note dated 8/26/13 at 12:57 pm, documented the Social Worker (SW) and DON checked in on resident and resident continues to adjust to environment. The resident exhibited no signs or symptoms of distress and does not wish to talk at this time. The social work progress note dated 8/27/13 at 12:51 pm, documented checked in on resident and resident visiting with her son. Discussed incident with aide and resident states she is not fearful and feels safe in facility. Resident exhibits no signs or symptoms of distress. A late entry nurse progress note dated 8/27/13 at 6:33 pm, documented as reported by supervisor on 8/24/13, CNA #1 was assisting resident with the use of a bedpan when CNA #2 entered the room to help. CNA #2 approached the resident's right side and pushed her forward onto her left hip. Resident attempted to reposition herself with CNA #2 pushing her over more. Resident grabbed the bedpan and motioned that she was going to throw it. The resident threw the bedpan at CNA #2 with CNA #2 retrieving it and tossing it back at the resident twice. The physician's note dated 8/27/13, documented on August 25 th, the resident had an altercation with a CNA. Following that, an examination was done. The physician further documented she felt the resident had no side effects from the altercation. The employee warning record dated 8/27/13, documented a potential reportable event occurred on 8/24/13. It documented the DON did not inform the Administrator and did not follow facility policy regarding the Elder Justice Act. The plan of care note dated 8/28/13 at 10:08 am, documented as reported by supervisor on 8/24/13, altercation occurred with CNA and resident regarding a bedpan being tossed at resident twice. Seen by psychologist and MD. No signs or symptoms of physical or psychological injury noted. In a written statement provided by the facility dated 8/24/13, CNA #1 documented that she was in Resident #1's room assisting her with the bedpan. The resident was attempting to place the bedpan underneath herself, however had the bedpan the wrong way. At this time, CNA #2 entered the room. CNA #1 asked CNA #2 for her assistance with the resident. CNA #2 proceeded to walk over to the resident's ride side and pushed her onto her left hip, causing the resident to yell out in pain. The resident attempted to roll back however CNA #2 pushed her over more. The resident then grabbed the bedpan and threatened to throw it at CNA #2. CNA #2 stated "go ahead, I dare you" and resident proceeded to throw the bedpan at her. CNA #2 then picked up the bedpan and tossed it back at the resident, hitting her with it. The resident picked up the bedpan for a second time and threw it at CNA #2. CNA #2 picked up the bedpan again and tossed it back to the resident, hitting her a second time. CNA #2 then stated "sianara" to the resident and walked out of the room. The Investigation Summary dated 8/27/13 at 1:00 pm, documented that video surveillance was reviewed for timeline, individuals involved and sequence of events. Video revealed views of CNAs entering and exiting resident's room. The security camera timeline noted the following: 10:29:52 pm-CNA #1 enters room 10:31:40 pm-CNA #2 enters room 10:33:02 pm-Unknown person enters room 10:33:29 pm-Unknown person exits room 10:33:44 pm-CNA #2 exits room 10:35:11 pm-CNA #1 exits room During an interview on 9/10/13 at 12:15 pm, the RNS stated that at the end of the shift on 8/24/13, CNA #1 approached him and reported the incident that had occurred between the resident and CNA #2. He stated sometime after 11:00 pm he went up to assess the resident. When asked why his assessment was on a separate document and not documented in the electronic medical record, the RNS stated he wrote it on a separate document as that was easier to file and he knew that document would go with the investigation. When asked if he was aware that during the incident a third unknown person entered and exited the room, he stated no. He further stated he called the DON immediately and made her aware of the incident. During an interview on 9/10/13 at 3:35 pm, the Assistant Director of Nursing (ADON) stated that he was asked by the DON to obtain the security video from the evening of the incident. He stated he reviewed the video, however did not identify who the unknown person was entering and exiting the room during the incident. After consulting another staff member, while the DOH surveyor was onsite, the ADON determined the third unknown person was another CNA working on the unit that evening. When asked why he did not identify this person and obtain a statement from them while completing the investigation, he stated that the DON completed this investigation and he was more concerned with another investigation he was working on. He further stated now looking at it they should have identified this person and obtained a statement from them as they could have also been a witness to the alleged abuse of the resident. During an interview on 9/17/13 at 12:10 pm, the DON stated she was made aware of the incident that occurred 8/24/13 on 8/26/13. She stated she does not recall being called by the RNS the night the incident occurred and did not know if the RNS was aware of the incident that evening. She stated the resident was assessed by a Registered Nurse on 8/26/13. She stated that she had not asked for the security video and she had not reviewed it. She further stated that she was not aware a third CNA had entered the room during the incident as she would have interviewed and obtained a statement from her. During an interview on 9/10/13 at 2:30 pm, the Administrator stated that she did not realize that another CNA had entered and exited the room during the incident. She further stated they should have interviewed and obtained statements from all staff members that could have had knowledge regarding the alleged abuse of this resident. 10 NYCRR 415.4(b)(1) (2) (3)

Based on medical record review and staff interviews during a complaint investigation (NY 097), the facility did not provide the necessary care and services to attain or maintain the highest practicable physical and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, for 1 (Resident # 3) of 2 residents reviewed, the facility did not notify the MD of persistent diarrhea and did not adequately assess or follow physician orders [REDACTED]. Subsequently, at the family's insistence, the resident was sent out to the emergency department (ED) on the evening of [DATE] and admitted to the hospital's intensive care unit (ICU) with [DIAGNOSES REDACTED]. The resident expired after being admitted to the hospital on [DATE]. This resulted in actual harm for Resident #3. This is evidenced by the following: Resident # 3 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident to have moderately impaired cognition. In a discharge summary from a local rehabilitation center the nurse practitioner dictated on [DATE], that Resident # 3 is being discharge after being treated for [REDACTED]. On [DATE] the resident's blood urea nitrogen (BUN indicative of dehydration) was 41 (normal ,[DATE]), creatinine was 1.3 (normal XXX,[DATE].3, indicative of kidney function) sodium (Na) was 136 (normal ,[DATE] indicative of hydration status). Resident #3 ' s notice of Transfer/Discharge letter dated [DATE], documented that the resident was being transferred to the hospital for a "decline in condition." The EMT (emergency medical transport) report from the transport of Resident #3 to the emergency department on [DATE], documented that the nursing home staff stated that the resident has experienced a steady decline in her mental status over the last month. The EMTs arrived at 7:21pm. The first note by EMT's is at 7:23pm and the entry is "found patient in nursing home bed, pale in color, weak and cold." First set of vital signs is documented at 7:25pm hours as BP (blood pressure) ,[DATE], HR (heart rate) 94, SaO2 90% (oxygen saturation, normal ,[DATE]%) . At 7:30pm hours BP was ,[DATE] and HR 96. These vital sign measurements indicate that the resident is unstable. The bowel movement records revealed that from [DATE] at 2:40pm to [DATE] at 7:25pm, Resident # 3 had eleven episodes of loose stools ranging from small to large amounts. A review of nurse's notes for the same period revealed two additional episodes of the resident having loose stools on [DATE] at 9:58pm and on [DATE] at 1:36pm for a total of 13 documented episodes of loose stools in 6 days. The physician's orders [REDACTED]. A second order for [MEDICATION NAME] 2mg by mouth every four hours as needed for loose BM's and an order for [REDACTED]. The medication administration record for Resident #3 revealed that the resident received [MEDICATION NAME] three times (twice on [DATE] and once on [DATE]), contrary to the physician's orders [REDACTED]. The computer record for percentages of food (solids) consumed at meals from [DATE] to [DATE] revealed that Resident # 3 consumed 26 to 50% of her meal 5 times, 51 to 75% of her meal 3 times, 76 to 100% of her meal 5 times and totally refused her meal 3 times. The computer record for fluids consumed at meals from [DATE] to [DATE] revealed that Resident # 3 consumed 25 % at two meals, 50 % at 7 meals, 75% at one meal and 100% at 4 meals. Resident # 3 refused all fluids at three meals. The facility policy for intake record nutrition/hydration, under the fluids section in # 9, the author documented, "The nurse manager will do an ongoing daily review to determine which residents need to have fluids encouraged. Residents with intake of less than 1000cc's will have fluids encouraged. Under the section titled "solids" the author documented, "Residents who leave 25% or more of food uneaten at most meals for one week or more will be assessed by the nurse manager or designee. Referrals to disciplines will be made if appropriate." Nurse's notes documented that on [DATE] the resident received Milk of Magnesia and on [DATE] the resident was given a [MEDICATION NAME] suppository after 4 days without a bowel movement. On [DATE] the nurse manager (NM) documented that Resident #3 has vomited, had "loose BM's" and the physician (MD) was contacted and ordered [MEDICATION NAME] and a clear liquid diet for 24 hours and the daughter was notified. There was no documented follow-up registered nurse (RN) assessment from [DATE] to [DATE], when the resident was sent out to the ED per family request. Additionally, there was no note addressing the frequency of the resident's loose bowel movements or the clear liquid diet that was ordered. A review of the emergency department (ED) record for Resident #3 dated [DATE], revealed a differential [DIAGNOSES REDACTED]. The resident was documented to be hypotensive (as low as ,[DATE]) for the first 6 hours in the ED with a sodium level of 130, a BUN of 143 and creatinine of 5.2. These results indicate critical values. On the hospital discharge summary the physician dictated that the resident was admitted and discharged on [DATE] with [DIAGNOSES REDACTED]. The patient's examination was remarkable for abdominal tenderness and [MEDICAL CONDITION] and the patient was treated in the intensive care unit with pressors (medication to maintain blood pressure) support. Later in the note, the physician (MD) dictated that the resident passed away at 10:03pm on [DATE]. During an interview on [DATE] at approximately 11:00am, the RN unit manager (RNUM) stated that in Resident # 3's time at the facility she had loose stools on occasion but that he did not have concerns about [MEDICAL CONDITION] because the loose stools were not that frequent and were not characteristic of [MEDICAL CONDITION] (foul smelling and the presence of mucous). On [DATE] at approximately 12:15pm, the RNUM stated that typically he would not notify the MD until after a resident had three episodes of loose stools and then he would ask for an order for [REDACTED]. The RNUM stated that he would not send stool for culture unless the MD ordered it or if the stool was foul-smelling or contained the mucous-type substance that is typical of [MEDICAL CONDITION] ([MEDICAL CONDITION]). The RNUM stated that Resident # 3 might not have been on I&O with actual numbers of cc's taken in, but that her I&O would have been monitored by the certified nursing assistants (CNA's) when they documented at the kiosk the percentages of food and fluids consumed by residents after each meal. On [DATE] at 7:45am the RNUM stated that he had not contacted the MD again when the resident continued to experience loose stools after she was started on [MEDICATION NAME] and he could not recall if he had done an assessment of the resident during the time but if he had, he would have documented it. He recalled Resident # 3's roommate also had loose stools at the time and that he might have thought it was a "GI bug." The RNUM added that in hindsight, the resident should have had an assessment and he or one of the other nurses should have contacted the MD to discuss the resident's persistent diarrhea. The RNUM stated that on [DATE] as he was waiting for the elevator to leave for the day the resident's daughter approached him and expressed her concerns that her mother was malnourished. The RNUM could not recall if he went back to see the resident or did an assessment on that day. During an interview on [DATE] at approximately 9:30am, the facility Medical Director (Med Dir) stated that he would expect to be contacted again or the doctor making rounds be notified, if a resident who was experiencing loose stools did not improve with the use of medication. The Med Dir stated that persistent loose stools needed to be addressed but he or other doctors would not know about it if nursing staff did not tell them. 10NYCRR415.12

Based on medical record review and staff interviews the Quality Assurance (QA) program failed to have a program that readily identified issues that had the potential to cause serious harm to residents during a partially extended abbreviated survey (NY 5115, NY 365 and NY 775). Specifically, the QA program failed to have a procedure in place to identify and investigate medications that were not administered and/or not administered on time, due to the unavailability of medications from the facility's pharmacy. This resulted in no actual harm with the potential for serious harm that is Immediate Jeopardy for the health and safety of all residents. The Immediate Jeopary was lifted prior to exit. Refer to F 333 scope and severity- K- Significant Medication Errors During an interview on 01/30/2013 at approximately 3:30pm, the Director of Nurses (DON) stated that the facility did not identify medications that were omitted on the evening of resident's admissions or the day after admissions, as a problem because the facility had a policy that stated medications would be started within twenty-four hours after admission and that they did not have to be started the evening of admission. In regard to the [MEDICATION NAME] and Insulin not administered for an entire shift or for an entire day the DON stated the facility policy was to start medications within 24 hours and that the medical director had agreed to the policy. The DON stated she was not sure how frequently medications were being missed after residents were admitted . During an interview on 01/30/2013 at approximatley 2:30pm, the Facility Administrator stated that she was aware of late medication administration on occasion but was not aware of the larger issue. She stated there was no QA done with regard to medications being administered late or not being administered at all to newly admitted or readmitted residents because it had not been identified as a problem. The Administrator added that late medications for new admissions had been discussed at a meeting a few months earlier with the Medical Director and there was a policy written at that time about starting medications for residents within twenty-four hours of admission. The Administrator had identified the distance of the pharmacy (Long Island, NY) from the facility and the late arrivals of new residents from the hospitals as contributing factors to the problem of late medications. During an interview on 1/30/13 at approximately 4:30pm, the facility Medical Director (Med Dir) stated that he had attended a meeting several months earlier and the idea had been discussed to initiate a policy that would state that medications would start when they arrived at the facility; sometime within the first twenty-four hours after admission (admission orders [REDACTED]. The Med Dir stated he had never intended for medications like [MEDICATION NAME] or insulin or cardiac medications or other significant medications to be delayed or not administered at all on the day of admission. The Med Dir stated that was not at all acceptable and he had never agreed to that. 10NYCRR 415.27(a-c)

Based on medical record review, and staff interviews, the Administration failed to ensure that the facility operated in a manner that enabled it to effectively use its resources to maintain the highest practicable well-being and safety of each resident. Findings rising to the level of Immediate Jeopardy were identified on 01/30/2013. Concerns rising to the level of immediate risk to resident health and safety included the facility ' s failure to ensure that 11 of 25 residents reviewed during a partially extended abbreviated survey (#NY 115, #NY 365 and NY 775) received their physician ordered medications in a timely manner following their admission/readmission to the facility, due to the unavailability of the medication. The facility failed to identify the frequency of medication errors of omissions and failed to ensure that action was taken to prevent recurrence. This resulted in no actual harm with the potential for serious harm that is Immediate Jeopardy for the health and safety of all residents. The Immediate Jeopary was lifted prior to exit. Interviews revealed that the staff did not consistently following the facility policy by notifying the physician, pharmacy and supervisor when medications were not available for administration. Investigations further revealed that the omission of medications were not investigated to determine the root cause and to prevent further incidence. Additionally, staff failed to administer physician ordered medications at the time they were ordered to be given. This resulted in immediate jeopardy to resident health and safety. This was evidenced by: Refer to F 333 scope and severity- K- Medication Errors During an interview on 01/30/2013 at approximatley 3:30pm, the Director of Nurses (DON) stated that the facility did not identify medications that were omitted on the evening of resident ' s admissions or the day after admissions as a problem because the facility had a policy that stated medications would be started within twenty-four hours after admission and that they did not have to be started the evening of admission. In regard to the [MEDICATION NAME] and Insulin not administered for an entire shift or for an entire day, the DON stated the facility policy was to start medications within 24 hours and that the medical director had agreed to the policy. The DON stated she was not sure how frequently medications were being missed after residents were admitted . During an interview on 01/30/2013 at approximately 2:30pm, the Faclity Administrator stated that she was aware of late medication administration on occasion but not aware of the larger issue. She stated there was no QA done with regard to medications being administered late or not being administered at all to newly admitted or readmitted residents. The Administrator added that late medications for new admissions had been discussed at a meeting a few months earlier with the medical director and there was a policy written at that time about starting medications for residents within twenty-four hours of admission. The Administrator had identified the distance of the pharmacy (Long Island, NY) from the facility and the late arrivals of new residents from the hospitals as contributing factors to the problem of late medications. During an interview on 1/30/13 at approximately 4:30pm, the facility Medical Director (Med Dir) stated that he had attended a meeting several months earlier and the idea had been discussed to initiate a policy that would state that medications would start when they arrived at the facility; sometime within the first twenty-four hours after admission (admission orders [REDACTED]. The Med Dir stated he had never intended for medications like [MEDICATION NAME] or insulin or cardiac medications or other significant medications to be delayed or not administered at all on the day of admission. The Med Dir stated that was not at all acceptable and he had never agreed to that. 10NYCRR 415.26

Based on medical record reviews and staff interviews during a partially extended abbreviated survey (NY 5115, NY 365 and NY 775) it was determined that the facility did not ensure that residents were free of significant medication errors. Specifically, the facility failed to ensure that 11 (# 1,2,3,4,5,6,7,8,9,10,11 and 13) of 25 residents who were newly admitted or readmitted , received their physician (MD)ordered medications in a timely manner. This resulted is no actual harm with potential for serious harm that is Immediate Jeopardy and is Substandard Quality of Care. Additionally, the facility failed to follow the standard of practice in administering medications when Resident #11 received two and a half times the recommended dose of a medication for his entire stay at the facility. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This is evidenced by the following: The facility was able to remove the immediacy prior to exit by implementing the following: 1. All Medication orders were reviewed and reconciled with availability 2. Medication error reports were completed and residents were assessed for any adverse effects of medication that were not administered due to unavailability 3. All licensed staff were educated regarding: pharmacy services, emergency box medication, unavailable medications, obtaining emergency medications from local pharmacy and notification of the physician when medications are not available 4. Audits were conducted and continue regarding: medication availability, emergency box medication use and physician notification when medications are not available In a Policy & Procedure titled " admission orders [REDACTED] 1. Medications recommended on the resident ' s hospital discharge summary will be reviewed with the attending physician upon admission. 2. In the absence of the on-site physician visit, telephone orders will be obtained by reviewing the hospital discharge summary with the attending physician. 3. Unless otherwise specified by the physician in the initial order, medications will begin within 24 hours of admission. 4. Medications which the physician directs to be dispensed prior to the following morning will be obtained from either the emergency kit or local pharmacy according to the physician's order [REDACTED]. In a Policy & Procedure titled, " Medication Errors " dated 5/25/11, some items identified in the Policy section were: 1. To ensure that resident follow-up is monitored, analyzed and recommendations made and appropriate actions taken after an error has been discovered. 2. A medication error /omission report and discovery and error report are completed immediately after an error is discovered to ensure proper resident follow-up. 3. To establish a procedure for reporting, investigating, and monitoring medications errors and follow-up, whether they occur through the source of supply or in the administration of medications. 4. To monitor resident outcomes related to medication errors and provide follow-up to correct the problem and/or avoid a reoccurrence. 5. To identify administration related issues and address the policy, practice and in-service training needs identified. 6. Medication error means a discrepancy between what the physician ordered and what the resident did or did not receive. 7. A Medication Error/Omission Report are completed on all medication administration errors. 8. Medication Error/Omission Reports are reviewed by the Quality Assurance Committee. 9. All errors related to medications are reported to the supervisor, Assistant Director of Nursing or designee and attending physician. Resident # 1 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (1/9/13) assessed the resident to have long and short term memory impairment and severely impaired decision making ability. physician's order [REDACTED]. Resident # 1 ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]' s [MEDICATION NAME] 300 mg was ordered to be given at 12 midnight, 6:00am, 12 noon and 6:00pm. The record also indicated that the resident did not receive the drug at 6:00pm or midnight on 12/14/12 and at 6:00am and 12 noon dose on 12/15/12. The MAR indicated [REDACTED]' s rash and was not applied until the 7:00am to 3:00pm shift on 12/16/12. A nurse ' s note dated 12/14/13 at 4:30pm documented that the resident had been admitted to the facility with a feeding tube and at the feeding tube site on the left abdomen there is " thick tan drainage " and the wound was cleaned with normal saline. Later at 11:54pm, a second nurse wrote that the resident is on [MEDICATION NAME] for [MEDICAL CONDITION] at the peg tube site. In a note dated 12/15/12 at 6:54am the nurse wrote that the resident ' s medications have still not arrived form the pharmacy and MD# 1 was made aware. MD # 1 ' s instructions were to call the Long Island Pharmacy (LIP)and have them call the local pharmacy for the medications. On the next note dated 12/15/12 at 2:06pm, the nurse documented that the supervisor had been updated and still no medications available for Resident # 1. The LIP has been contacted and they state a " stat " run will be made at noon. MD#1 has been made aware and he instructed that medications should be given when they arrive. The next note dated 12/15/12 at 5:04pm documented that medications have arrived. During an interview on 1/30/13 a licensed practical nurse (LPN#1) stated that on 12/14/12 and 12/15/12 she was aware that Resident # 1 had not received some of his medications because they had not arrived from the pharmacy. She notified the supervisor and the resident ' s physician (MD#1) who instructed her to contact the pharmacy (LIP) and have them call the local pharmacy and have the drugs delivered that morning. She stated the facility pharmacy (LIP) told her there would be a stat delivery at noontime on 12/15/12 and so they would not call the local pharmacy. The resident ' s medications still did not arrive until around 5:00pm on 12/15/12. LPN#1 stated that both she and the nursing supervisor on duty called the pharmacy to ask when the medications would be delivered but the resident still missed a number of doses of antibiotics. During an interview on 2/1/13 at approximately 4:00pm, a pharmacist at the local pharmacy (approximately one-half mile from the facility), stated that [MEDICATION NAME] is a drug that they always have on hand to dispense. Resident #3 The resident was admitted to the facility on [DATE] at 6:20pm with [DIAGNOSES REDACTED]. The most recent MDS assessed the resident to be cognitively intact. In the hospital transfer summary dated 1/17/13, the nurse practitioner dictated the following list of medications for after discharge: [MEDICATION NAME] 25mg twice a day, [MEDICATION NAME] 40 mg twice a day, [MEDICATION NAME] (Tambocor) 50 mg twice a day, [MEDICATION NAME] 20mg daily at bedtime, Klonopin 0.5mg twice a day, [MEDICATION NAME] 325mg daily, [MEDICATION NAME] 10mg daily, [MEDICATION NAME] cream 1% twice daily to left arm and chest, [MEDICATION NAME] powder 2% three times a day to under breast, abdominal folds and groin area, [MEDICATION NAME] 21mg [MEDICATION NAME] daily and [MEDICATION NAME] 5 mg tablets,(2) every four hours as needed for pain. On the physician ' s admission order sheet, dated 1/17/13 at 21:35 hours, there are orders for [MEDICATION NAME] 25 mg twice a day for [MEDICAL CONDITION], [MEDICATION NAME] 40mg twice a day , Tambocor 50 mg twice a day for [MEDICAL CONDITION], Klonopin 0.5mg twice a day anxiety, [MEDICATION NAME] 325mg daily, [MEDICATION NAME] cream 1% to left arm and chest twice daily for itching and rash, [MEDICATION NAME] 10 mg orally daily for anxiety, Nicotine patch 21 mg every twenty-four hours [MEDICATION NAME] for smoking , [MEDICATION NAME] 5mg every four hours as needed for pain, [MEDICATION NAME] 100,000 units 5cc swish and swallow four times a day for one week, for thrush, Miconazol 2% powder apply to abdominal folds, under breasts and reddened areas twice a day. On Resident #3 ' s MAR indicated [REDACTED]00am and off at 8:00am. A review of the MAR indicated [REDACTED] 8:00pm on 1/18/13, the [MEDICATION NAME] was omitted at 8:00am on 1/18/13 and the [MEDICATION NAME] swish and swallow was omitted at midnight on 1/17/13 and 6:00am, 12:00 noon and 6:00pm on 1/18/13. A review of nurse ' s notes from 1/17/13 to 1/19/13 reveals there was no documentation addressing the residents omitted medications. During an interview on 1/30/13 at approximately 3:00pm an LPN (LPN # 2) stated that she recalled that Resident # 3 ' s medications did not come from the pharmacy for a day or two after the resident was admitted . She could not recall what medications were unavailable from the pharmacy, but if the medication was circled on the MAR, it was because they had not come from the pharmacy yet. The LPN stated that not receiving medications from the pharmacy was an ongoing and frequent problem. The LPN stated that many times the doctors were not called about the residents missing medications due to the medications being unavailable from the pharmacy, because it happened so frequently; almost daily. The LPN stated everyone knew that there was a problem with not receiving medications from pharmacy but nothing was being done to fix it. During an interview on 2/1/13 at 3:45pm, a registered nurse (RN#1) stated that on the evening of Resident #3 ' s admission (Thursday 1/17/13) she had at least two phone conversations with the pharmacy discussing the arrival of Resident # 3 ' s medications. The pharmacy did not deliver the medications that evening and RN#1 was concerned because the resident was taking cardiac medications and at that time, the pharmacy only made one delivery on Fridays and that was later in the day. RN#1 stated that the pharmacist assured her that they would make a special run the next morning (Friday) with Resident # 3 ' s medication. When RN#1 returned to work Friday evening at 3:00pm, she was told that the medications had still not arrived. RN# 1 stated she was not sure what happened to the medications but she thought that Resident # 3 did not get some of her medications until Saturday morning. Resident # 5 The resident was admitted to the facility on [DATE] at 3:15pm with [DIAGNOSES REDACTED]. The resident was assessed to have long and short term memory impairment. A review of the hospital discharge summary for Resident # 5 revealed a list of medications to be taken after discharge from the hospital that includes: [MEDICATION NAME] 50mcg/hr to be changed every 72 hours, [MEDICATION NAME] 15mg twice a day, [MEDICATION NAME] 60mg every 6 hours, [MEDICATION NAME] 200mg each day, [MEDICATION NAME] 1.5 mg each day at 6:00pm, [MEDICATION NAME] 325mg each day, [MEDICATION NAME] 20mg every 48 hours, [MEDICATION NAME] 50mg every six hours, [MEDICATION NAME]on sliding scale before meals and at bedtime each day, [MEDICATION NAME] 20mg each day at bedtime, [MEDICATION NAME] 20mg twice daily and [MEDICATION NAME] 45mg at bedtime. The discharge summary also documented that the resident had been receiving [MEDICATION NAME] 1.5mg at bedtime each day and would be staying on that dose after discharge. On the day of discharge (1/21/13) the resident ' s INR was 1.9 and because it was anticipated that the resident ' s next INR would be in therapeutic range, the hospitalist recommended the INR should be checked again on 1/23/13. On Resident # 5 ' s admission orders [REDACTED]. On Resident #5 ' s MAR indicated [REDACTED]. A review of the MAR indicated [REDACTED] on 1/21/13, the [MEDICATION NAME] placement was not checked on the 3:00pm to 11:0pm shift on 1/21/13, the 8:00pm dose of [MEDICATION NAME] I.R. was not administered on 1/21/13, the 6:00pm and 12:00 midnight dose of [MEDICATION NAME] was not administered on 1/21/13 and there was no FSBS obtained or insulin administered on 1/21/13 at 5:30pm and 8:30pm. A review of nurses' notes from 1/21/13 to 1/23/13, revealed there was no documentation addressing the resident's omitted medications. A review of Resident # 5's INR results revealed the following: On 1/21/13, upon discharge from the hospital, the INR was 1.9. The hospital physician recommended that an INR be drawn on 1/23/13. The next INR was drawn on 1/24/13 and was 1.5. The follwoing INR was drawn on 1/28/13, with a result of 1.8. During an interview on 1/29/13 at approximately 11:00am, the nurse manager (NM)stated that there were ongoing problems with pharmacy and the timeliness of the delivery of medications to the facility. The NM stated that in addition there were times when the drugs arrived late in the evening shift or didn ' t arrive until after the evening shift left at 11:00pm and the nursing staff, in particular agency staff, would not contact the MD to determine if the medications needed to be administered when the drugs arrived. The nurses didn ' t give the medications and would wait until the next day to start the medications. The NM stated that it was common knowledge that pharmacy delivery was a problem and that she was hopeful that something could be done about it. During an interview on 1/30/13 at approximately 4:00pm, a facility MD (MD#1) stated that he would receive calls from nursing staff telling him that residents' medications had not been delivered by the pharmacy. MD# 1 stated that he had heard about a policy (admission orders [REDACTED]. MD#1 stated that medications have to be delivered by the pharmacy on time. MD # 1 stated that he had been called more than once and told that residents' medications had not been administered for two days, because they were not available from the vendor pharmacy. MD# 1 repeated that this was not acceptable. During an interview on 1/30/13 at approximately 4:30pm, the facility Medical Director (Med Dir) stated that he had attended a meeting several months earlier and the idea had been discussed to initiate a policy that would state that medications would start when they arrived at the facility; sometime within the first twenty-four hours after admission (admission orders [REDACTED]. The Med Dir stated he had never intended medications like [MEDICATION NAME] or insulin or cardiac medications or other significant medications could be delayed or not administered at all on the day of admission. The Med Dir stated that was not at all acceptable and he had never agreed to that. During an interview on 1/31/13 at 3:00pm, a registered nurse (RN#2) stated that there have been pharmacy problems for a while and they needed to be fixed. During an interview on 2/1/13 at 3:00pm, an LPN (LPN#3) stated that she was thankful that someone was finally addressing the problems of late medication arrivals from the pharmacy and other problems dealing with the pharmacy having medications available when they were due to be administered. The LPN was hopeful that something could be done to correct the issues with the availability of medications. During an Interview with the registered nurse evening charge nurse (RNC) on 2/1/13 at 3:45pm, she recalled that the medications did not come from the pharmacy in time for Resident # 5's evening doses of medications. She could recall when the medications actually arrived but thought the resident had missed some of his medications and thought [MEDICATION NAME] might have been one of them. RNC stated that medications not arriving from the pharmacy was not unusual and she thought that staff just got used to not having them available to administer. Resident # 11 The resident was admitted to the facility for rehabilitation on 10/22/12, with [DIAGNOSES REDACTED]. His most recent MDS assessed him to have intact long and short term memory and able to make decisions. On the hospital discharge summary, faxed to the facility on 10.22.12 at 4:22pm, the physician dictated that the resident is being discharged on [MEDICATION NAME] (rasagiline) 2.5mg each day. On the top of the typed summary there is a note of caution stating, " Draft until signed. " There is no electronic or handwritten signature on the document. On the hospital patient discharge medication list (a list of the medications that the patient should take after discharge) prepared and stamped by the hospital pharmacist at the time of discharge, " Rasagaline ([MEDICATION NAME]) 0.5mg orally daily " is listed and the indication is [MEDICAL CONDITION] medication. On a consultation report dated 10/17/12, faxed to the facility on [DATE] at 4:22pm, Parkinson ' s is entered as the reason for the consultation. In the consult the physician dictated a list of medications and names Rasagiline 0.5mg daily. In the summary section of the report the physician dictated that the resident is followed by a neurologist at another hospital and the patient ' s Parkinson medications should not be adjusted until he is seen by that neurologist. The discharge instructions that accompanied the resident from the hospital to the nursing home list the medications the resident should take after discharge from the hospital. " Rasagiline ([MEDICATION NAME]) 0.5mg orally daily, " is listed. On Resident # 1 ' s facility admission orders [REDACTED]. On Resident #1 ' s MAR indicated [REDACTED]. The MAR ' s for October, November and December show that the drug was administered each day at 8:00am. In Resident #1 ' s discharge instructions from the nursing home dated 12/15/12 on line #1 of the list of Discharge Medications is written , [MEDICATION NAME] 1mg tablets, take 2 ? tables each day. On the manufacturer ' s warning to patients taking [MEDICATION NAME] they advise that, " Patients should not exceed a dose of 1mg per day of [MEDICATION NAME] in order to prevent a possibly dangerous increase in blood pressure. " In the Nursing 2011 Drug Handbook, 31st edition, the author writes in the indication & dosages section for [MEDICATION NAME], " As monotherapy, 1 mg P.O. once daily. As adjunctive therapy, initial dose is 0.5mg P.O. once daily. May increase to 1mg P.O. once daily. " During an interview on 2/1/13 at 4:00pm, a registered nurse (RN#1) stated that she had taken the orders from the physician over the phone and although she did not recall this particular set of orders, it was her routine for phone orders, to read the orders to the physician from the discharge summary and if he agreed with them she then wrote them on a physician's order [REDACTED]. RN#1 stated she would have read [MEDICATION NAME] 2.5mg to the physician, because that ' s what was listed on the discharge summary. She was not aware that other documents provided by the hospital listed [MEDICATION NAME] 0.5mg instead of 2.5mg. During an interview on 1/31/13 at approximately 3:30pm, Resident #1 ' s treating neurologist (MD#2) stated that 2.5mg of [MEDICATION NAME] each day would be an excessive dose for the resident. MD#2 referred to studies done that showed that any dose over 1mg of [MEDICATION NAME] each day had no benefit to patients, as the increase in side effects over 1mg, outweighed any benefit from increased effectiveness of the drug. MD#2 added that he had last seen Resident # 1 in August and at that time had increased his dose of [MEDICATION NAME] from 0.5mg to 1mg each day. During an interview on 2/1/13 at approximately 3:45pm an LPN (LPN # 3) stated that she had given the resident [MEDICATION NAME] on several occasions. She stated that she did not realize that 2.5mg was not the recommended dose. LPN#3 stated that she was not familiar with [MEDICATION NAME] and when she administers a drug that she is not familiar with, she would normally look it up in the drug book on the med cart and if there was any concern she would notify the MD. She could not recall if she looked up [MEDICATION NAME] when she first gave it and stated if she had called the MD she probably would have documented it. During an interview on 2/1/13 at approximately 4:00pm the facility Med Dir stated that although he had not ordered [MEDICATION NAME] 2.5mg each day for the resident, he had signed the telephone admission orders [REDACTED]. He stated that he had since spoken to a neurologist and had been advised that 2.5mg of [MEDICATION NAME] was more than is recommended. The Med Dir stated, I missed this one, 0.5 or 1mg each day would have been the correct dose. The Med Dir stated that after he was made aware of the difference in dosing for the resident he had reviewed the resident ' s medical record and he did not appear to have suffered any side effects from the 2.5mg dose. 10 NYCRR 415.12(m)(2)

Based on staff interview, review of the facility security camera log, medical record review and facility documents, including facility policies, the facility failed to ensure that the resident received adequate assessment for the need of increased supervision and assistance during unsupervised access to the outside grounds of the facility for one ( #1) of seven residents reviewed during an abbreviated survey (complaint investigation case # NY 993 ). Specifically, the facility failed to thoroughly assess and develop a care plan for a resident, with a significant medical change with subsequent intermittent confusion, for the need of increased supervision. The resident was previously assessed as not being at risk for elopement and was permitted unsupervised access to the outside grounds. The resident subsequently exited the facility and left the premises confused to his whereabouts. The resident was found by a passerby seven tenths of a mile from the nursing home and was not appropriately dressed for the weather ( the outside temperature was 32 degrees). The resident was returned by ambulance to the facility approximately 40 minutes later. The facility failed to act upon and care plan for the risk posed by the resident's confusion, which was well documented for several weeks prior to this event. There were no revisions to the plan of care to provide increased supervision for this resident. The facility took immediate action to abate and correct the concerns. This resulted in Immediate Jeopardy at past non-compliance. This is evidenced by the following : Resident # 1 The resident was admitted to the facility on [DATE] and readmitted from the hospital on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], assessed the resident to have had severe cognitive impairment. The MDS, dated [DATE], assessed the resident to have had moderate cognitive loss, able to understand and be understood. The MDS information documented on the 1/28/12 MDS did not include a staff assessment for mental status interview. The same MDS assessed the resident as having intact long and short term memory. The facility policy titled Elopement Risk Evaluation Form, last revised 11/08, documented to utilize the Elopement Risk Evaluation to evaluate a residents' risk for elopement prior to admission, at quarterly intervals thereafter, and if there is a significant change in cognition. Procedure # 3 on the form documented to circle "yes" or "no" answers to the questions asked starting at the top of the form. Procedure # 4 documented , whenever a "yes" answer is circled proceed to the next set of questions. Whenever a 'no" answer is circled you should STOP the assessment since there is no indication of risk for elopement. The Elopement Risk Evaluation Form, last revised 11/08, documented the first question in box # 1, "Resident is ambulatory or self mobile in wheelchair?", if "yes" proceed to Box # 2. The questions documented in Box # 2 documented, 1. New admission who has made statements questioning the need to be here, 2. Resident is confused or has dementia, 3. Resident is oriented but non-compliant with facility protocols regarding leaving the unit. For a "yes" answer proceed to Box # 3 and so forth. The Comprehensive Care Plan ( CCP), dated 5/25/10 and last revised on 3/2/12, documented the resident to be independent in electric wheelchair on the unit and staff assist of one in electric wheel chair for off the unit. The CCP did not include information regarding the resident being allowed to go outside of the building. The Certified Nursing Assistant (CNA) Accountability Record & Resident Plan of Care ( used to direct care), dated 3/2012, documented the resident to be independent in the wheelchair on and off the unit. The Nursing Admission /Readmission Record, dated 2/2/12 at 3:00 PM, documented that the resident was assessed as having intermittent confusion. The readmission Elopement Risk Evaluation Form, dated 2/2/12, time unknown , documented the resident assessed as not to be at risk for elopement. The Nurse's Progress Note (N/N), dated 2/2/12, documented that the resident's Health Care Proxy (HCP) called the facility at 9:30 PM and stated she was concerned as to the resident's increased confusion . The note further documented the resident was noted with confusion to place and the resident was reoriented to the facility and date. The documentation in the nursing notes dated 2/2/12 through 2/16/12 did not include documentation in regards of the residents cognitive status. The Fall Risk Assessment form, date 2/3/12, documented that the resident was assessed as having intermittent confusion. The Resident and Family Services Progress Notes, dated 2/13/12 documented the resident was noted to be alert with confusion. The note included that the resident was not able to recall the year, month or day. The N/N, dated 2/16/12, documented that a re-admission care conference was held with the resident and the HCP present. The summary note documented that the resident was noted to have intermittent confusion. The note included documentation that the current plan of care would continue and that no changes had been made. The Resident and Family Services Progress Notes, dated 2/20/12, documented that the resident had no changes in condition ( the note did not include documentation of specific dates or time frame) and that the resident continued to be alert with confusion. The N/N, dated 3/1/12 at 3:30 PM, documented that the resident was returned to the facility from a recent hospitalization . The Nursing Readmission Record, dated 3/1/12 at 3:30 PM, documented the resident was assessed as having intermittent confusion. The N/N, dated 3/1/12 at 6:00 PM, documented by the same nurse, documented the resident was alert and oriented to person, place and time. The Elopement Risk Evaluation Form, dated 3/2/12, documented that the resident was assessed not to be at risk for elopement. The facility Accident Report, dated 3/4/12, documented that at 5:25 PM, that a concerned citizen came into the facility to report the resident was in the upper parking lot of the facility. The charge nurse notified the supervisor who instructed the nurse to send a Certified Nursing Assistant (CNA) to assist the resident back into the building. The Charge nurse was not able to see the resident in the parking lot and therefore she sent two CNA's to go by way of vehicle to locate the resident. The resident was located in front of the Valatie Medical Arts Building , which is seven tenths of a mile from the facility . During an interview on 3/6/12 at 9:22 am, a second passerby, who found the resident in town, stated that on 3/4/12 at approximately 5:30 PM, he and his wife were passing through town. They noticed an elderly gentleman in a wheelchair, dressed in a T-shirt, sweat pants and no shoes. He stated that the gentlemen looked lost and confused so he turned around and went back to see if the gentleman needed help. He stated that the gentleman was able to identify himself and where he lived, but explained that he (the resident) was lost and did not know how to get back to the facility. The passerby stated that he notified 911. The county 911 service then notified the facility. He stated the facility sent 2 staff members to assist the resident back to the facility by way of his wheelchair. The passerby intervened and again called 911 to transport the resident back to the facility by way of ambulance. During an interview on 3/6/12 at 11:30 am, the resident stated that he has been having periods of confusion with a loss of the sense of direction over the past month or so. He stated that he has gone outside of the facility on occasions without a coat, but only for short periods of time. He further stated that he has never left the facility grounds unattended. The resident stated that on Sunday (3/4/12), he had left the facility to attend a church service in town, but when he left the service to go back he took a wrong turn and became lost. He stated that something's looked familiar but could not find his way back to the facility. He stated a gentleman and his wife stopped and offered their help to him. He stated that they wrapped him in a blanket and called the emergency squad who brought him back to the facility. During an interview on 3/6/12 at 12:22 PM, the Administrator stated that the resident had been assessed as being independent in the wheelchair both on and off the unit. She stated that the assessment done on 3/2/12 showed that he continued to be independent and not at risk for elopement. She then stated that there was some intermittent confusion noted which was what lead to the re-assessment on 3/4/12. The Administrator then stated "unfortunately, he decided to go to the village and got confused, which made him get lost." She then stated, "this was not an elopement" . On 3/6/12 at 2:40 PM a review of the facilities security camera log was completed by the investigator. The resident was seen on the video leaving an activity program on the first floor of the facility at 4:58 PM on 3/4/12 ( the program was confirmed to have been a church service). At 4:58 PM, the resident was observed leaving the front door of the facility and proceeding down the sidewalk towards the village. At 5:06 PM, the video shows an elderly gentleman entering the facility and speaking with the receptionist. The elderly gentleman was pointing outside towards the parking lot area of the facility. At 5:11 PM, the video showed 2 male staff members exiting the building by foot. At 5:55 PM, the camera log showed the resident returning to the facility by way of ambulance stretcher. A review of the witness statement written on 3/4/12, by the receptionist on duty the evening of 3/4/12, documented that at approximately 5:05 PM, the resident left the building as usual without a coat. Approximately 10 minutes later a citizen came into the building and stated that that the resident was leaving the parking lot. The receptionist notified the nurse in charge who informed her ( the receptionist) that the resident should not be that far away. The statement further documented that at 5:25 PM, a call was received from an off duty employee who stated that she had seen the resident on main street (in the village). The employee was made aware that staff were in route to find him. During an interview on 3/7/12 at 1:15 PM , the Registered Nurse Manager (RNM) stated that when the resident returned from the hospital on [DATE] he still had occasional periods of intermittent confusion. The RNM stated that his confusion was brief and he was easily re-directed. The RNM further stated that the resident's confusion was unpredictable. The RNM then stated if the elopement assessment has a "no" answer then the resident would not be at risk for elopement. She stated "we can get box happy" and let the form decide for us. During an interview on 3/7/12, at 1:30 PM, the Licensed Practical Nurse (LPN) stated that the resident had occasional periods of confusion and could be re-oriented easily with verbal cues, but it was not abnormal for him to get confused and need to be re-oriented to "come back to reality". During interviews on 3/7/12 between 1:00 PM and 1:45 pm, with several CNA's, they stated that the resident was new to the nursing unit and that they were not that familiar with him or his daily habits. During an interview on 3/7/12 at 12:40 PM, the Social Worker (SW), who documented on the resident's confusion on 2/13/12 and 2/20/12, stated that she had not been that familiar with the resident prior to his transfer to the fifth floor in 2/12. She stated that she documented the resident "with confusion" based on how he answered the questions during the interview for Brief Interview for Mental Status (BIMS) section of the MDS. The SW stated that the residents recall was poor during those interviews. She stated this confusion was discussed during the care conference meeting held on 2/16/12. During an interview on 3/7/12 at approximately 3:30 PM, the Director of Nursing stated that she was not aware of the resident having had intermittent confusion. She stated that if there was documentation of intermittent confusion it still would not have fit the criteria for an elopement risk but should have been considered. As a result of the 3/4/12 incident, the resident's confusion was immediately assessed and the resident was re-evaluated for being at risk for elopement. A wanderguard alarm bracelet was place on the residents personal electric wheelchair. The risk for wandering /elopement was added to the CCP. The facility's policy for Elopement Risk Evaluation and Elopement Risk Evaluation Form were revised on 3/7/12 to include assessment for intermittent or constant confusion. The policy was revised to include if the resident shows any indication of being at risk for elopement that is not captured on the assessment tool the resident should be categorized "at risk" and to initiate protocols ( application of wanderguard and updating the CCP). After all steps have been completed document the reasons for the decision on the reverse side of the form. Additionally, the facility has implimented a new policy,dated 3/12, titled Out on Pass Procedure. This policy documented any resident wishing to exit the facility for any reason to an area other than one of the enclosed patio must sign out at the nursing unit. Residents assessed by Physical/Occupational therapy for appropriateness to leave the facility independently must have a physicians order allowing them to do so. Residents must obtain a pass from the nursing unit to provide to the receptionist prior to exiting the facility. The pass must document the resident's destination and anticipated time of return. The receptionist will log the residents departure time and anticipated time of return. The receptionist will notify the supervisor directly if a resident does not return at the anticipated time. Residents who do not follow the out-on-pass procedure must be reassessed for risk for elopement. 10NYCRR415.12(h)(1)