Every finding on record at The Pines at Glens Falls CTR for Nursing & Rehab

Based on observation, record review and interviews conducted during the survey, the facility failed to ensure that drug records were in order; and that an account of all controlled drugs was maintained and periodically reconciled in six (6) of six (6) narcotic books reviewed on Units 2, 3, and 4. Specifically, the shift-to-shift staff signature form for controlled drugs, titled Shift Count did not consistently include the signatures of staff members at each shift change, validating the correct narcotic count. This is evidenced by: A facility policy titled, Controlled Substance Handling (including handling of dropped or refused doses), undated, documented that all controlled drugs would be subject to special receipt, handling, storage, disposal and record keeping. Further documented, in pertinent part, 4. All stocks of controlled substances received shall be delivered to the nursing unit and logged into the official count by two nurses: the nurse who received the delivery, and the nurse in charge of the unit. (a) All controlled substances shall be immediately secured in the double locked wall cabinet in the medication room by the receiving nurse. (b) If the nurse receiving is also the charge nurse, a nurse from another unit shall be asked to verify the count and log the receipt; 7. The mediation nurse on duty maintains possession of the keys to controlled drugs; 13. A physical inventory of all controlled drugs was made at the change of each shift by two licensed nurses and was documented on an audit record (a) If a nurse was late, the supervisor would go to the floor and count with the nurse who was leaving. The drugs were NEVER to leave the cabinet on the floor for purposes of conducting a count. Once the next shift nurse arrives, the supervisor would return to the floor and perform another count. During observations on 3/13/2026 at 10:00 AM, narcotic sheets on both carts of Unit 3, North and South, were noted to not be consistently signed by two nurses shift to shift. A review of the Unit 3, North side narcotic book documented missing signatures for the following dates: 2/11/2026 2 PM oncoming nurse, 2/11/2026 8 PM off-going nurse, 2/12/2026 2 PM oncoming nurse, 2/12/2026 10 PM off-going nurse, 2/14/2026 6 AM oncoming nurse, 2/14/2026 2 PM off-going nurse, 2/19/2026 2 PM oncoming nurse, 2/19/2026 10 PM off-going nurse, 2/28/2026 6 AM oncoming nurse, 2/28/2026 2 PM off-going nurse, 3/04/2026 2 PM oncoming nurse, and 3/04/3026 6 PM off-going nurse. A review of the Unit 3, South side narcotic book documented missing signatures for the following dates: 2/06/2026 6 AM off-going nurse, 2/09/2026 6 PM off-going nurse, 2/13/2026 6 AM oncoming nurse, 2/13/2026 2PM oncoming and off-going nurse, 2/13/2026 10 PM off-going nurse, 2/19/2026 2 PM oncoming nurse, 2/19/2026 10 PM off-going nurse, 2/23/2026 6 PM off-going nurse, 3/01/2026 6 AM oncoming nurse, 3/03/2026 2 PM oncoming nurse, and 3/10/2026 10 PM oncoming nurse. A review of the Unit 2, North side narcotic book documented missing signatures for the following dates: 2/18/2026 6 AM off-going nurse, 2/21/2026 6 AM oncoming nurse, 2/21/2026 10 PM off-going nurse, and 3/13/2026 6 AM on coming nurse. A review of the Unit 2, South side narcotic book documented missing signatures for the following dates: 2/04/2026 8 PM oncoming nurse, 2/04/2026 9:30 PM off-going nurse, 2/06/2026 6 AM oncoming nurse, 2/06/2026 2 PM off-going nurse, 2/09/2026 2 PM oncoming nurse, 2/11/2026 6 AM oncoming nurse, 2/11/2026 2 PM oncoming and off-going nurses, 2/11/2026 10 PM off-going nurse, 2/12/2026 6 AM oncoming nurse, 2/12/2026 10 PM off-going nurse, 2/17/2026 10 PM oncoming nurse, 2/13/2026 6 AM off-going nurse, 2/19/2026 6 AM oncoming nurse, 2/19/2026 2 PM off-going nurse, 3/02/2026 2:30 PM oncoming nurse, 3/02/2026 10 PM off-going nurse, 3/08/2026 10 PM off-going nurse, and 3/13/2026 6 AM oncoming nurse. A review of the Unit 4, North side narcotic book documented missing signatures for the following dates: 2/11/2026 11 PM oncoming nurse, 2/13/2026 2 AM oncoming nurse, 2/13/2026 11 AM off-going nurse, 2/17/2026 10 PM oncoming nurse, 2/18/2026 6 AM oncoming and off-going nurses, 2/18/2026 10 AM off-going nurse, 2/20/2026 2 PM oncoming nurse, 2/20/2026 10 PM off-going nurse, 2/23/2026 2 PM oncoming nurse, 2/23/2026 10 PM off-going nurse, 2/26/2026 10 PM oncoming nurse, 3/12/2026 6 AM oncoming nurse, and 3/12/2026 2 PM off-going nurse. A review of the Unit 4, South side narcotic book documented missing signatures for the following dates: 1/31/2026 6 AM oncoming nurse, 1/31/2026 6 PM off-going nurse, 2/06/2026 10 PM oncoming nurse, 2/07/2026 6 AM off-going nurse, 2/11/2026 10 PM oncoming nurse, 2/11/2026 6 AM oncoming and off-going nurse, 2/12/2026 2 PM off-going nurse, 2/13/2026 2 PM oncoming nurse, 2/13/2026 10 PM off-going nurse, 2/17/2026 2 AM oncoming nurse, 2/17/2026 6 AM off-going nurse, 2/17/2026 9 AM oncoming nurse, 2/17/2026 2 PM off-going nurse, 3/05/2026 6 AM oncoming nurse, and 3/05/2026 2 PM off-going nurse. During an interview on 3/13/2026 at 10:30 AM, Licensed Practical Nurse #3 stated that the narcotic count book was supposed to be signed by both the oncoming and the off-going nurse at the time of the count at change of shift. During an interview on 3/13/2026 at 10:56 AM, Licensed Practical Nurse #6, orienting with Licensed Practical Nurse #5, stated that they knew that the narcotic count should be done at change of shift by two nurses and the narcotic book should be signed at the time of the count. During an interview on 3/13/2026 at 10:46 AM, Licensed Practical Nurse #7 stated that they did not sign the narcotic book at the change of shift that morning because the book was very cumbersome. Licensed Practical Nurse #7 stated that they were aware that the oncoming and off-going nurse were supposed to sign together at the time of the narcotic count. During an interview on 3/13/2026 at 10:53 AM, Licensed Practical Nurse #2 stated that the narcotic count was to be done with two nurses, who should both sign the narcotic book together at the time of the count. During an interview on 3/17/2026 at 10:00 AM, Registered Nurse #4 stated that the procedure of narcotic counting was that the nurses were supposed to go through each narcotic card. One nurse had the cards; the other nurse had the book. They were to compare card number and make sure that they matched the book number. Once all the narcotics were counted and the amounts matched, the nurses were to sign the book together. During an interview on 3/17/2026 at 10:21 AM, Licensed Practical Nurse #8 stated that they took all the narcotic cards from the cart and put them in the narcotic room at the end of their shift to facilitate an easier counting experience for the nurse they shift changed with. The procedure they followed was that the oncoming nurse takes the keys, one nurse pulls the narcotic cards and counts the amount of pills, the other nurse ensured that the narcotic book matched the cards. The two nurses read the numbers together for every resident on the unit. They both signed the book at the end of the count. During an interview on 3/18/2026 at 11:15 AM, Director of Nursing #1 stated that they were made aware of the nurses not signing the narcotic count book shift to shift consistently while survey was ongoing. Director of Nursing #1 stated that they intended to do a house wide education regarding the proper procedure. The procedure should be that two nurses checked the narcotic cards, counted the medication together, and signed the narcotic book together every shift change at the time of the count. 10 New York Codes, Rules, and Regulations 415.18(b)(3)

Based on record review, observation, and interviews conducted during the survey, the facility failed to ensure the provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, residents reported during interviews that the facility was short-staffed at times, this resulted in call bells not being answered promptly with long wait times for care to be provided. This is evidenced by: The Facility Assessment Exhibit #1- Staffing, dated 07/2025, documented: 2nd Floor Rehabilitation unit desired staffing Day shift: Certified Nursing Assistants five (5) and two (2) Licensed Practical Nurses seven (7) days a week. Evening shift: Certified Nursing Assistants four (4) and two (2) Licensed Practical Nurses (7) days a week. Night shift: Certified Nursing Assistants three (3) and one (1) Licensed Practical Nurse (7) days a week. 3rd and 4th floor desired staffing Day shift: Certified Nursing Assistants four (4) and two (2) Licensed Practical Nurses on weekdays. Certified Nursing Assistants five (5) and two (2) Licensed Practical Nurses on weekends. Evening shift: Certified Nursing Assistants four (4) and two (2) Licensed Practical Nurses seven (7) days a week. Night shift: Certified Nursing Assistants two (2) and one (1) Licensed Practical Nurse (7) days a week. The facility staffing sheets provided documented that: On 03/03/2026, the 2nd floor Rehabilitation unit had two (2) Certified Nurses Assistants for the night shift. The 4th floor had one (1) Licensed Practical Nurse on the evening shift and one (1) Certified Nurse Assistant for the night shift. On 03/04/2026, the 4th floor had one (1) Licensed Practical Nurse on the evening shift. On 03/05/2026, the 2nd floor Rehabilitation unit had two (2) Certified Nurses Assistants for the night shift. The 3rd floor had one (1) Licensed Practical Nurse on the day shift. The 4th floor had three (3) Certified Nurses Assistants for the day and evening shifts. On 03/06/2026, the 2nd floor Rehabilitation unit had two (2) Certified Nurses Assistants for the night shift. The 3rd floor had one (1) Licensed Practical Nurse with three (3) Certified Nurses Assistants for the day shift and one (1) Certified Nurse Assistant for the night shift. The 4th floor had three (3) Certified Nurses Assistants for the day and evening shifts. On 03/07/2026, the 2nd floor Rehabilitation unit had three (3) Certified Nursing Assistants for the evening shift and two (2) Certified Nurses Assistants for the night shift. The 3rd floor had four (4) Certified Nurses Assistants for the day shift and three (3) Certified Nurses Assistants for the evening shift. On 03/08/2026, the 2nd floor Rehabilitation unit had two (2) Certified Nurses Assistants for the night shift. The 3rd floor had three (3) Certified Nurses Assistants on the day shift, one (1) Licensed Practical Nurse and two (2) Certified Nurses Assistants for the evening shift, and one (1) Certified Nurse Assistant for the night shift. On 03/09/2026, the 2nd floor Rehabilitation unit had four (4) Certified Nurses Assistants for the day shift and two (2) Certified Nurses Assistants for the night shift. The 3rd floor had one (1) Certified Nurse Assistant for the night shift. The 4th floor had one (1) Licensed Practical Nurse on the evening shift and one (1) Certified Nurse Assistant for the night shift. On 03/10/2026, the 2nd floor Rehabilitation unit had four (4) Certified Nurses Assistants for the day shift. The 3rd floor had one (1) Licensed Practical Nurse with three (3) Certified Nurses Assistants for the day shift and one (1) Certified Nurse Assistant for the night shift. The 4th floor had one (1) Licensed Practical Nurse for the evening shift and one (1) Certified Nurse Assistant for the night shift. On 03/11/2026, the 2nd floor Rehabilitation unit had two (2) Certified Nurses Assistants for the night shift. On 03/12/2026, the 3rd floor had one (1) Licensed Practical Nurse with three (3) Certified Nurses Assistants for the evening shift and the night nursing supervisor covered as a floor nurse with one (1) Certified Nurse Assistant for the night shift. On 03/13/2026, the 2nd floor Rehabilitation unit had three (3) Certified Nurses Assistants for the evening shift and two (2) Certified Nurses Assistants for the night shift. The 4th floor had three (3) Certified Nurse Assistant for the evening shift. On 03/14/2026, the 2nd floor Rehabilitation unit had four (4) Certified Nurses Assistants for the day shift and two (2) Certified Nurses Assistants for the night shift. The 3rd floor had four (4) Certified Nurses Assistants for the day shift. On 03/15/2026, the 2nd floor Rehabilitation unit had four (4) Certified Nurses Assistants for the day shift and two (2) Certified Nurses Assistants for the night shift. The 3rd floor had four (4) Certified Nurses Assistants for the day shift and one (1) Licensed Practical Nurse with three (3) Certified Nurses Assistants for the evening shift. The 4th floor had four (4) Certified Nurses Assistants for the day shift and one (1) Certified Nurse Assistant for the night shift. On 03/16/2026, the 2nd floor Rehabilitation unit had two (2) Certified Nurses Assistants for the night shift and two (2) Certified Nurses Assistants for the night shift. The 3rd floor had one (1) Licensed Practical Nurse with three (3) Certified Nurses Assistants for the evening shift and one (1) Certified Nurse Assistant for the night shift. The 4th floor had one (1) Certified Nurse Assistant for the night shift. On 03/17/2026, the 2nd floor Rehabilitation unit had two (2) Certified Nurses Assistants for the night shift. 10 New York Codes, Rules, and Regulations 415.12(h)(1)(2)

Based on observation, record review and interviews during the recertification survey, the facility did not ensure that food was stored, prepared, distributed, or served following professional standards for food service safety in 3 of 3 resident unit nutrition rooms and the central kitchen. Specifically, proper food temperature tracking was not tracked, several expired items were identified, and proper dating of open items was not followed. This is evidenced by: During inspection in the central kitchen on 3/10/2026 at 1:00PM the following items were found to be out of compliance with New York State food safety regulations: Review of food temperature logs showed the production temperature logs nor the service logs located on the steam tables had been completed on four shifts since 01/01/2026. The following items were found to be out of their original packages and undated: In the walk-in refrigerator Three stacks of American cheese in plastic cling wrap One portion of sliced ham in plastic cling wrap In the walk-in freezer Two packages of frozen waffles In the dietary refrigerators on each unit: Pitchers of various unlabeled types of juice Opened bottles of thickened juice of three flavors per unit Items identified in walk in refrigerator past printed expiration date: Two quart size containers of sour cream One gallon of barbecue sauce One 1.36 liter bottle of tomato juice On the second floor dietary room, dietary staff were observed using the stem thermometer to check temperatures of the food in the steam tray without using proper sanitizing practices During interview, on 3/12/2026 at 3:00PM, Kitchen Manager #1stated they will inspect all the items and ensure they are dated once they are removed from the original packaging and discarded otherwise. They will also work on retraining staff to ensure proper temperature logs are recorded at all stages of food preparation and service. 10 New York Codes, Rules, and Regulations 415.14(h)

Based on observations, record review, and interviews during a survey, the facility failed to ensure it maintained 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 five (5) (Resident #s 29, 50, 58, 67, and 123) of 30 residents reviewed. Specifically, Resident #s 29 and 67's Foley bag (indwelling urinary catheter collection bag) was hanging under their wheelchair and touched the floor. Resident #s 50, 58, and 123's nebulizer device (coverts liquid medication into a fine mist for direct inhalation) mouthpiece (attached to medication reservoir) and/or mask and tubing were uncovered. This is evidenced by: Policy and Procedure titled, Infection Prevention & Control Program, revised 4/2025, documented the purpose of the policy to maintain an infection prevention and control program based on current nationally recognized evidence-based guidelines to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Nursing staff were responsible for an active surveillance program and were to assess staff adherence to infection prevention guidelines as needed. Intent of the program documented the program would conduct surveillance rounds to monitor and investigate potential causes of infection to prevent infections occurring in the facility. Policy and Procedure titled Urinary Catheterization, revised 4/2024, documented the presence of an indwelling urinary catheter was a risk factor for acquiring a multidrug-resistant organism. Enhanced barrier precautions (the use of gown and gloves) were indicated when high contact care was bundled for residents with an indwelling catheter. A sterile, continuously closed drainage system would be maintained for indwelling catheters. Drainage bags would always be covered for privacy and placed below the level of the resident's bladder to facilitate drainage and prevent stasis (stoppage of movement) of urine. Policy and Procedure titled, Nebulizer Treatments, revised 2/2023, documented when the nebulizer treatment was complete, the reservoir was to be disconnected from the nebulizer machine, cleaned per manufacturer's instruction and placed in a plastic bag. Resident #29: Resident #29 was admitted to the facility with the diagnoses of nondisplaced intertrochanteric fracture of right femur (hip fracture), displaced fracture of upper end of left humerus (arm fracture), and retention of urine. The Minimum Data Set (an assessment tool) dated 3/09/2026, documented the resident was able to be understood, understood others, and was severely cognitively impaired. A physician order dated 3/04/2026 documented Resident #29 was to have an indwelling catheter to drain urine due to urinary retention. During observation of Resident #29, the resident's Foley bag was hanging under their wheelchair, did not have a privacy cover, and touched the floor on: 3/16/2026 at 9:55 AM 3/10/2026 at 12:22 PM 3/12/2026 at 9:49 AM Resident #67: During observation of Resident #67, the resident's Foley bag was hanging under their wheelchair and touched the floor on: 3/10/2026 at 12:06 PM 3/16/2026 at 9:55 AM Resident #58 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs), history of recurrent pneumonia (infection that inflames the air sacs in one or both lungs), and mild vascular dementia (changes in thinking or memory that occur when there is not enough blood flow). The Minimum Data Set, dated [DATE], documented the resident was cognitively intact. The resident was usually able to make themselves understood and understood others. Review of physician orders documented an order dated 2/26/2026 for ipratropium-albuterol solution 0.5-2.5, 3 milligrams/3 milliliters inhaled orally two times a day for shortness of breath or wheezing lung sounds pre and post nebulizer treatment. The resident also had an order for treatments to be done every four hours as needed. During observation of Resident #58, the resident's nebulizer equipment was uncovered at the bedside on: 3/10/2026 at 2:05 PM 3/12/2026 at 1:50 PM 3/16/2026 at 12:10 PM 3/17/2026 at 11:30 AM During an interview on 3/17/2026 at 10:21 AM, Licensed Practical Nurse #8 stated nebulizer devices should be unplugged, and the mask should be in a bag labeled with the resident's name. During an interview on 3/17/2026 at 10:00 AM, Registered Nurse Manager #4 stated the nebulizer device should be unplugged when not in use, and the mask/tubing in a bag. If the treatment was just given, the nurse might place it in a holder until it was dry then would place it in the bag. During an interview on 3/17/2026 at 11:20 AM, Licensed Practical Nurse #2 stated when a resident had a nebulizer treatment order, the nebulizer device would have weekly tubing changes. The nebulizer mask was cleaned after use and placed inside a plastic bag labeled with the resident's name. Foley bags should be covered, never on the floor, and if found on the floor the bag was considered contaminated. During an interview on 3/17/2026 at 11:25 AM, Registered Respiratory Therapist #1 stated nebulizer equipment was stored in a bag labeled with the resident's name at the bedside. Nebulizer tubing was changed weekly. Registered Respiratory Therapist #1 conducted in-services for respiratory policies, procedures, and services for the facility routinely and for new services or when facility staff may need a refresher. During an interview on 3/18/2026 at 11:15 AM, acting Director of Nursing #1 stated nebulizer devices should be unplugged when not in use. The masks should be in plastic bags when they are not in use and dry. If they were just used, the masks might not be in the bag to ensure they dried appropriately. Once they were dried, the staff should put the masks back in the bag. Foley bags were supposed to have cover bags and should be secured off the floor. 10 New York Codes, Rules and Regulations 415.19(a)(1-3)

Based on observation, record review, and interviews conducted during the survey, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice. Specifically, (a.) for eight (8) residents (Resident #s 2, 6, 23, 45, 50, 93, 118, and 137), medications were left at resident bedsides without orders and/or evaluations indicating residents were capable of self-administration; (b.) insulin pens were not individually stored, separating resident pens from comingling; and (c.) Tylenol and Senna (an over-the-counter herbal stimulant laxative used for short-term relief of constipation) pills were loose in medicine cups in one (1) medication cart on the Unit four (4). This is evidenced by: A facility policy titled Medication Storage, undated, documented that medications must be stored in accordance with manufacturer's specifications and secured in locked storage areas in compliance with State and Federal requirements and accepted professional standards of practice. Access to medications was limited to only authorized personnel. Storage areas may include, but were not limited to, drawers, cabinet, medication rooms, refrigerators and carts. A facility policy titled Medication Pass Policy, undated, documented in pertinent part, do not pre-pour medications: administer them as they were prepared; always observe resident until they have swallowed all medications that have been administered. Do not leave medication in medication cup at the bedside or on tableside. A facility policy titled Self-Administration, last revised 10/2024, documented to maintain the residents' rights to maintain a high level of independence, residents who requested to self-administer medications were permitted to do so if the center's self-evaluation had determined that the practice would be safe for the resident and there was a health care provider's order to self-administer medication(s)/treatments. The documented procedures were, in pertinent part, (1) If the resident requested to self-administer medications, a Self-Administration Evaluation was completed by the licensed nurse to evaluate the resident's safety and understanding of their medication/treatments; (2) If the evaluation determines it was safe for the resident to self-administer, the licensed nurse would obtain an order from the Healthcare Provider for self-administration for the specific medication(s)/treatments; and (3) Upon obtaining the order for the medication/treatment the licensed nurse would instruct the resident in the process of storing the medications safely which should include a locked box. Resident #2 Resident #2 was admitted to the facility with diagnoses of atrial fibrillation (an irregular rapid heart rate), hypertension (high blood pressure), aphasia following cerebral infarction (difficulty speaking and/or swallowing after having a stroke). The Minimum Data Set (an assessment tool), dated 2/26/2026, documented the resident was usually understood, usually understood others, and was minimally cognitively impaired. During an observation on 3/10/2026 at 11:01 AM, Resident #2 was noted to have saline nasal spray on their bedside table. During an observation on 3/16/2026 at 10:30 AM, Resident #2 was noted to have saline nasal spray on their bedside table. There was no documented evidence that Resident #2 had an evaluation that allowed for medications at the bedside. There was no documented evidence that Resident #2 had a physician order for saline nasal spray. Resident #6 Resident #6 was admitted to the facility with the diagnoses of displaced fracture of anterior wall of left acetabulum (a broken left hip), fracture of left pubis (a break in one of the small bones of the pelvis), and age-related osteoporosis (a condition characterized by weak, fragile bones). The Minimum Data Set, dated [DATE], documented the resident was able to understand others, be understood, and was mostly cognitively intact. During an observation on 3/11/2026 at 8:09 AM, Resident #6 had a medication cup on their bedside table that was identified to be Calcium Carbonate chewable tablet. Resident #6 stated that this was the only pill that staff left at their bedside because the resident preferred to take it slowly due to its chalky taste. A physician order dated 2/24/2026 at 7:00 AM documented Resident #6 was to be given Calcium Carbonate Antacid Oral Tablet Chewable 500 milligrams, give one (1) tablet by mouth one time a day for osteoporosis. There was no documented evidence that Resident #6 had a physician order to self-administer medications. There was no documented evidence that Resident #6 had an evaluation to self-administer medications. Resident #23 Resident #23 was admitted to the facility with the diagnoses of unspecified dementia (a progressive neurological disease causing memory problems), cortical age-related cataract, bilateral (a condition where clouding develops in the outer layer of the lens of both eyes), and iron deficiency anemia (a blood disorder where the body lacks sufficient iron). The Minimum Data Set, dated [DATE], documented the resident was able to understand others, be understood, and was mostly significantly cognitively impaired. During an observation on 3/10/2026 at 11:20 AM, Resident #23 had a bottle of Refresh tears (lubricant eye drops) on their bedside table. During an observation on 3/12/2026 at 1:45 PM, Resident #23 had a bottle of antifungal powder on their bedside table. There was no documented evidence that Resident #23 had physician orders for Refresh Tears or antifungal powder. There was no documented evidence that Resident #23 had a physician order to self-administer medications. There was no documented evidence that Resident #23 had an evaluation to self-administer medications. Resident #45 Resident #45 was admitted to the facility with the diagnoses of retention of urine (the inability to fully empty the bladder, resulting in urine accumulation), hypertension (high blood pressure), and anemia (a condition marked by a deficiency of red blood cells). The Minimum Data Set, dated [DATE], documented the resident was able to understand others, be understood, and was mildly cognitively impaired. During an observation on 3/10/2026 at 11:25 AM, Resident #45 had a bottle of saline nasal spray on their bedside table. A Medication Self-Administration Safety Screen dated 5/05/2025, documented the resident was able to self-administer Ocean Spray nasal spray and keep the medication in their room. The physician's order for Saline Nasal Solution dated 7/02/2025 documented to administer one (1) spray in each nostril every four hours as needed for dry nose. There was no documented evidence that there was a physician order that Resident #45 could self-administer saline nasal spray, nor keep it in their room. Resident #50 Resident #50 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty or discomfort in breathing), chronic diastolic congestive heart failure (a long-term condition where the left ventricle becomes still and cannot relax properly to fill with enough blood), and atrial fibrillation (an irregular rapid heart rate). The Minimum Data Set, dated [DATE], documented the resident was cognitively intact, could be understood, and understood others. During an observation on 3/10/2026 at 11:30 AM, Resident #50 had a bottle saline nasal spray on their bedside table. During an observation on 3/12/2026 at 1:50 PM, Resident #50 had a bottle of generic Flonase and saline nasal spray on their bedside table. During an observation on 3/16/2026 at 10:22 AM, Resident #50 was noted to have nasal sprays, Tums (over-the-counter antacid containing calcium carbonate used to rapidly relieve heartburn, sour stomach, acid indigestion, and upset stomach), and antifungal powder on their bedside table. A Medication Self-Administration Safety Screen dated 9/16/2025, documented the resident was able to self-administer nasal spray and nasal solution and keep the medication in their room. The physician's order for Calcium Carbonate Antacid oral tablet, dated 7/07/2025, documented to give two (2) tablets by mouth as needed for indigestion/heartburn. The physician's order for Saline Nasal Solution dated 9/16/2025 documented to administer two (2) spray in both nostrils two times a day for dry nares, oxygen use unsupervised self-administration able to self-administer. There was no documented evidence that Resident #45 had an order for antifungal cream, nor that they could self-administer the medication, nor keep it in their room. There was no documented evidence that there was a physician order that Resident #45 could self-administer Calcium Carbonate Antacid, nor keep it in their room. Resident #93 Resident #93 was admitted to the facility with the diagnoses of hypertension (high blood pressure), displaced fracture of lateral end of right clavicle (a broken collarbone near the should joint where the bone segments have shifted out of alignment), and hyperlipidemia (high cholesterol). The Minimum Data Set, dated [DATE], documented the resident could make themselves understood, understood others and was cognitively intact. During an observation on 3/16/2026 at 9:41 AM, Resident #93 was noted to have Tums antacids on their bedside table. There was no documented evidence that Resident #93 had physician orders for Tums or antacids in general. There was no documented evidence that Resident #93 had a physician order to self-administer medications. There was no documented evidence that Resident #93 had an evaluation to self-administer medications. Resident #118 Resident #118 was admitted to the facility with the diagnoses of obstructive sleep apnea (a serious sleep disorder where breathing repeatedly stops and starts because throat muscles relax too much, causing the airway to collapse), congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), and chronic pain (unresolvable pain). The Minimum Data Set, dated [DATE], documented the resident could make themselves understood, understood others and was cognitively intact. During an observation on 3/10/2026 at 11:40 AM, Resident #118 had a bottle saline nasal spray on their bedside table. During an observation on 3/12/2026 at 2:00 PM, Resident #118 had a bottle saline nasal spray on their bedside table. A physician's order dated 8/21/2025 documented Resident #118 was to receive saline nasal solution, two (2) sprays in each nostril every 12 hours as needed for dry nasal passages. There was no documented evidence in the order that the resident was able to keep the medication at the bedside. A Medication Self-Administration Safety Screen dated 8/18/2025, documented the resident was able to self-administer nasal spray and Icy Hot topical analgesic spray and keep the medication in their room. The was no documented physician order for Icy Hot topical analgesic spray for Resident #118. Resident #137 Resident #137 was admitted to the facility with diagnoses of atrial fibrillation (a rapid uncontrolled heart rate), chronic pain (unrelieved pain), and gastro-esophageal reflux disease without esophagitis (a form of heartburn without visible damage to the esophagus). The Minimum Data Set, dated [DATE], documented the resident could make themselves understood, understood others and was cognitively intact. During an observation on 3/12/2026 at 9:38 AM, Resident #137 was noted to have Refresh tears eye drops on their beside table. Resident #137 stated at that time that their family had brought it in for them and they did not have a physician order for it. There was no documented evidence that Resident #137 had physician orders for Refresh Tears eye drops. There was no documented evidence that Resident #137 had a physician order to self-administer medications. There was no documented evidence that Resident #137 had an evaluation to self-administer medications. During observations on 3/13/2026 at 10:07 AM, Lantus insulin pens for multiple residents were noted to be loose in the top drawer of the South side medication cart of Unit three (3). The pens and caps were noted to be labeled; however, they were not in individual bags allowing multiple resident insulin pens to touch each other and created the opportunity for them to cross contaminate each other. During an interview on 3/13/2026 at 10:10 AM, Licensed Practical Nurse #11 stated that they did not know that insulin pens needed to be separated so they were not touching. During observations on 3/13/2026 at 10:53 AM, Lantus insulin pens for multiple residents were noted to be loose in the top drawer of the North side medication cart of Unit three (3). The pens and caps were noted to be labeled; however, they were not in individual bags allowing multiple resident insulin pens to touch each other and created the opportunity for them to cross contaminate each other. During an interview on 3/12/2026 at 11:00 AM, Licensed Practical Nurse #2 stated that they knew the pens needed to be labeled but did not know they needed to be stored separately. During observations on 3/13/2026 at 10:46 AM, two (2) medication cups were noted to be observed in the top drawer of the South side medication cart on Unit four (4). One medication cup had Tylenol written in black ink on the side and was full of white tablets. The other medication cup had Senna written in black ink on the side and was half full of orange tablets. During an interview on 3/13/2026 at 10:50 AM, Licensed Practical Nurse #7 stated that the pills were Tylenol and Senna but that they had not placed the medication cups with pills in the top drawer of the cart. When asked if they had been assigned to the cart since 6 AM that morning, Licensed Practical Nurse #7 stated that they had. Licensed Practical Nurse #7 removed the cups from the top drawer and disposed of the medications. During an interview on 3/13/2026 at 10:56 AM, Licensed Practical Nurse #6 stated that residents had to have an order to keep medications at their bedside. If Licensed Practical Nurse #6 found medications in a resident's room, they would remove them and let the unit manager know. During an interview on 3/17/2026 at 10:00 AM, Registered Nurse # 4 stated that to have medications at the bedside, a resident needed to have an evaluation done for competency. The resident's mental capacity would be looked at and the provider would need to be involved. If the resident was deemed capable and the physician wrote an order to have them, residents could keep medications in their room. Registered Nurse #4 stated that there were two (2) or three (3) residents that were able to keep medications in their room. During an interview on 3/17/2026 at 10:21 AM, Licensed Practical Nurse #8 stated that if they found medications at the bedside, they would confiscate them and given them to the supervisor. Licensed Practical Nurse #8 stated that residents need a physician order to have medications at the bedside. Eye drops and nasal sprays were the only things that were usually left at the bedside. Licensed Practical Nurse #8 stated that they were unsure if there was an evaluation involved or if any current residents on the unit had the ability to have medications at the bedside. During an interview on 3/17/2026 at 11:20 AM, Licensed Practical Nurse #2 stated that saline nasal sprays needed to have a physician order and should be kept in the medication cart. Any antifungal powders should have an order, should have the resident's name on them, and should be kept in the medication cart. During an interview on 3/18/2026 11:15 AM, Director of Nursing #1 stated that if a resident had medications at the bedside, they should have had an evaluation to determine if they were capable of self-administration, a physician order to self-administer the specific medication the resident was evaluated for, the medication should be kept in a locked drawer, not loose on the bedside tables, and there should be a care plan associated with the medication that the resident was self-administering. 10 New York Codes, Rules, and Regulations 415.18(d)

Based on record review and interviews conducted during a survey, the facility failed to ensure that comprehensive care plans were developed and implemented according to professional standards for two (2) (Resident #s 38 and 110) of 30 residents revised. Specifically, (a.) Resident #38 had a diagnosis of muscular dystrophy (a group of diseases that cause muscles to become weaker and lose mass over time), ambulated via a power wheelchair, and frequently left the facility unsupervised to attend outside activities. A care plan for leave of absence was not developed and implemented, and (b.) Resident #110 received medications for constipation and a care plan for constipation was not developed and implemented. This is evidenced by: Policy and Procedure titled, Baseline/Comprehensive Person-Centered Care Plan, revised 3/2023, documented a comprehensive person-centered care plan would be developed after the completion of the comprehensive assessment (Minimum Data Set), would be periodically reviewed by a team of qualified persons after each assessment or reassessment, and would be implemented by qualified members of facility staff. Goals, interventions, and responsible team member for implementation would be identified for each identified problem. Policy and Procedure titled, Safe Unsupervised LOA (Leave of Absence) Policy, revised 3/2023, documented it was the facility's policy to allow residents the opportunity to go on an unsupervised Leave of Absence with an order from a Healthcare Provider, and within the framework structured to ensure their safety and wellbeing, as well as the safety and wellbeing of others. The resident would be educated on the Leave of Absence Policy. A Leave of Absence evaluation would be completed on residents whose Healthcare provider had written an unsupervised Leave of Absence order at the time of admission or readmission. An unsupervised Leave of Absence care plan would be added to the resident's clinical record. The supervisors would maintain a list of the residents who had unsupervised Leave of absence orders. Resident #38: Resident #38 was admitted to the facility with diagnoses of muscular dystrophy (a group of diseases that cause muscles to become weaker and lose mass over time), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), and hypertension (high blood pressure). The Minimum Data Set (an assessment tool) dated 1/07/2026, documented the resident was cognitively intact. The resident was able to make themselves understood and understand others. Nursing Progress Note dated 1/09/2026 at 9:35 PM by Licensed Practical Nurse #10, documented resident returned from the hockey game at 5:30 PM. No new skin issues. Nursing Progress Note dated 1/13/2026 at 4:37 PM by Licensed Practical Nurse #10, documented the resident returned from the bank at 1:40 PM. No new skin issues. Denied pain and discomfort. Plan of Care Note dated 2/3/2026 at 3:26 PM by Registered Nurse Manager #3, documented the care plan was reviewed and revised. There were no other details in the note. Nursing Progress Note dated 2/21/2026 at 11:11 PM by Licensed Practical Nurse #9, documented the resident left the facility to see a hockey game and was out of the facility from 5:13 PM until 9:50 PM. The resident returned in good spirits. No new skin issues noted. There was no documented evidence of a Leave of Absence evaluation, provider order, or care plan for the Leave of Absence. During an interview on 3/11/2026 at 10:48 AM, Resident #38 stated they frequently left the facility via their power wheelchair for outside activities. Resident #38 stated when they entered a crosswalk, they always made sure they made eye-contact with the driver of the vehicle before proceeding. They sometimes came back to the facility when there was no receptionist, and they would ring the doorbell to be let in. One time they returned at 11:00 PM and the registered nurse supervisor let them in. During an interview on 3/17/2026 at 10:26 AM, Social Worker #1 stated Resident #38 had a very active social life outside of the facility. They were not sure if there was a care plan or physician order for Resident #38's Leave of Absence. Nursing and social work would have responsibility for developing and implementing the Leave of Absence care plan. During an interview on 3/17/2026 at 2:03 PM, Registered Nurse Manager #3 stated Resident #38 would leave the facility to attend hockey games and other events. The resident was required to sign out/in. Registered Nurse Manager #3 was responsible for nursing care plans. They stated they had never created a care plan for Leave of Absence and were not aware of a physician order for Resident #38's leave of absence. During an interview on 3/18/2026 at 10:08 AM, Administrator #1 stated they had a Leave of Absence policy and thought it was for overnight leaves. Resident #38 left the facility unsupervised to attend outside activities, was resourceful, and had their cell phone with them when they left the facility. Administrator #1 stated they would take care of the Leave of Absence care plan. During an interview on 3/18/2026 at 11:29 AM, Acting Director of Nursing #1 stated the facility had a Leave of Absence policy and it was for unsupervised leaves. They stated the policy applied to Resident #38 since they frequently left the facility unsupervised. They were not aware there was no assessment, physician order, or care plan for Leave of Absence for Resident #38. Resident #110: Resident #110 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (a progressive, uncurable lung disease that restricts airflow, causing chronic coughing, wheezing, and severe breathlessness), chronic kidney disease (a serious, long-term condition where kidneys were damaged and could not effectively filter waste from the blood), and peripheral vascular disease (a slow, progressive circulation disorder involving blood vessel narrowing, blockage, or spasms often affecting legs and feet). The Minimum Data Set, dated [DATE], documented the resident was understood by others, could understand others, and was cognitively intact. Review of the February 2026 and March 2026 Medication Administration Records documented Resident #110 received the following medications routinely and as needed for constipation (infrequent bowel movements or hard, dry stools that are difficult to pass): Miralax Oral Powder 17 grams per scoop give one (1) scoop by mouth in the morning every two (2) days for constipation. Psyllium oral powder 30% give one (1) packet by mouth one (1) time a day for constipation, mix with eight (8) ounces of water. Senna plus oral tablet 8.6-50 milligrams give two (2) tablets by mouth two (2) times a day for constipation. Milk of Magnesia suspension 400 milligrams per five (5) milliliters give 30 milliliters by mouth as needed for constipation daily if no bowel movement after six (6) shifts. Dulcolax oral tablet delayed release five (5) milligrams give one (1) tablet by mouth every 24 hours as needed for constipation. Dulcolax suppository 10 milligrams insert one (1) suppository rectally as needed for constipation if milk of magnesia is ineffective. There was no comprehensive care plan developed to address Resident #110's constipation. During an interview on 3/11/2026 at 12:43 PM, Resident #110 stated they were constipated a lot and used medications to relieve it. During an interview on 3/17/2026 at 1:10 PM, Registered Nurse #3 stated nursing was responsible for the development of nursing care plans. They stated the resident should have a constipation care plan and did not know why there was not one. During an interview on 3/17/2026 at 1:12 PM, Director of Nursing #1 stated that there should be a comprehensive care plan that addressed each resident concern or diagnosis, including constipation. 10 New York Code of Rules and Regulations 415.11(c)(1)

Based on observation and interviews conducted during the survey, the facility failed to ensure that residents were provided with treatment and care according to professional standards for one (1) (Resident #91) of 30 residents reviewed. Specifically, Resident #91 had a Port a Cath (implanted venous access device) with a sterile dressing that was undated and not adhered to skin creating a risk for Central Line Blood Stream Infection. This is evidenced by: The facility policy titled Implanted Venous Port Accessing dated 01/2022 documented a sterile dressing would be changed at least every seven (7) days and with any complications. The dressing was to be labeled with the date, time, and nurse initials. The facility policy titled Central Venous Access Device CVAD Dressing change dated 01/2022 documented dressing changes where to be done as per Intravenous (administered into a vein) order and when dressing becomes compromised, such as when wet, loose, or soiled. Vascular access device (medical device that provides reliable access to the blood stream) should be monitored at least every two (2) hours during a continuous infusion and at least once per shift when not in use. Resident #91 Resident #91 was admitted to the facility with diagnoses of cholecystitis (inflammation of the gallbladder), Type 2 diabetes mellitus with chronic kidney disease (chronic high blood sugar levels causing chronic kidney disfunction) and chronic kidney disease stage 3B (moderate to severe loss of kidney function). The Minimum Data Set (an assessment tool) dated 01/24/2026, documented they could be understood, understand others, and was cognitively intact. Record Review: Review of Medication Administration Record dated 02/01/2026-02/28/2026 documented: Sterile membrane dressing was to routinely be changed on day shift weekly on Wednesdays revealed there was no documented evidence of a Port-a-Cath dressing change on 02/25/2026 Sterile dressing change as needed. documented on 02/16/2026 a sterile dressing changed, was documented. There were no other as needed sterile dressing changes documented. Supervisor to check Intravenous site every evening shift Monday, Wednesday, and Friday revealed no documented evidence completed on 02/02/2026, 02/04/2026, 02/06/2026, 02/13/2026, 02/16/2026, 02/25/2026, or 02/27/2026. There was no documented medication administration order to check vascular access device every two (2) hours while the resident had continuous infusion or every shift while vascular access was not in use. Review of Medication Administration Record dated 03/01/2026-03/15/2026 documented: There were no as needed sterile dressing changes documented. Supervisor to check Intravenous site every evening shift on Monday, Wednesday, and Friday revealed no documented evidence of intravenous site check, completed on 03/04/2026 or 03/13/2026. There was no documented medication administration order to check vascular access device every two (2) hours while the resident had continuous infusion or every shift while vascular access was not in use. Review of care plan tilted, Intravenous Therapy Port-a- Cath initiated on 10/12/2025 revised on 3/10/2026 documented interventions were to monitor site for placement and signs/symptoms of infection every shift. Change dressing every seven (7) days and as needed. Observations: During an observation on 03/10/2026 at 11:06 AM, Resident #91 was in their room lying in their bed, alert and orientated watching television. Sterile dressing was noted to be peeling off and not adhered to skin at their Port-a-Cath site on their right upper chest from the bottom extending up to the Port-a-Cath site. There was clear tape present on the bottom potion of the dressing that was not adhered to skin. The dressing was not dated or labeled with a signature or initials. During an observation on 03/16/2026 at 12:00 PM, Resident #91 was in their room lying in their bed, alert and orientated watching television. Sterile dressing was noted to be peeling off and not adhered to skin at their Port-a-Cath site on their right upper chest from the bottom extending up to the Port-a-Cath site. The dressing was not dated or labeled with a signature or initial. During an observation on 03/17/2026 at 11:00 AM, Resident #91 was in their room lying in their bed, alert and orientated watching television. Hydration infusion was running via infusion pump. Sterile dressing was noted to be peeling off and not adhered to skin at their Port-a-Cath site, on their right upper chest from the bottom extending up to the Port-a-Cath site. The dressing was not dated or labeled with a signature or initials. Interviews: During an interview on 03/10/2026 at 11:06 AM, Resident #91 stated their dressing frequently peels off. The nurses would sometimes put a piece of tape over the bottom if they noticed it. During an interview on 03/16/2026 at 11:23 AM, Nurse Educator #1 stated Registered Nurse #4 changed the resident's dressing weekly on Wednesday's. They were aware of the difficulties keeping the residents dressing intact and adhering to skin. The resident refuses showers and baths which causes an issue with the sterile dressing adhering. They administered the residents' hydration fluids as ordered, and if they were not in the building another Registered Nurse would. They would expect the resident's Port-a-Cath dressing to be intact and labeled with minimally a date. If the residents' Port-a-Cath dressing was to be observed to be peeling, they would expect the dressing to be reenforced or changed. During an interview on 03/16/2026 11:56 AM, Registered Nurse #4 stated they changed the resident's Port-a-Cath and sterile dressing on the day shift weekly on Wednesdays. They stated the resident refuses to bathe which causes their sterile dressing to continuously peel off. If they observed the dressing peeling off, they would replace the dressing, as well as label dressing with date, time, and their initials. If another staff member observes the residents' dressing not to be intact, they typically would tell them, and they would change the dressing. Surveyor brought to their attention dressing was peeling off and was not labeled with date, time or initials. They stated label must have come off. They reviewed the resident's medication administration record, they stated there was no order to monitor dressing every shift. During an interview on 03/18/2026 at 11:15 AM, Director of Nursing #1 stated Central Line/Port-a-Cath dressing should always be clean, dry, intact, and labeled with a date. If the dressing was not intact it would be a potential for infection. 10 New York Codes, Rules, and Regulations 415.12(h)(1)(2)

Based on record reviews and interviews conducted during the survey, the facility failed to ensure a comfortable homelike environment with reasonable care for protection of residents clothing from loss or theft for one (1) (Resident #42) of two (2) residents reviewed. Specifically, Resident #42 was admitted to the facility with personal clothing that was unable to be located or accounted for after being laundered, there was no documented evidence that an investigation was completed. This is evidenced by: The facility policy titled Misappropriation of Property dated 07/2019 documented on admission a list personal items on personal property including clothing was to be documented on the personal property list form. If a resident claims their property has been lost or misappropriated staff was to conduct an investigation. Resident #42 Resident #42 was admitted to the facility with diagnoses of Toxic encephalopathy (a brain and memory disorder), Type 2 Diabetes Mellitus (chronic high blood sugar levels) and Depression (persistent feeling of sadness). The Minimum Data Set (an assessment tool) dated 02/04/2026, documented they could be understood, understand others, and was cognitively intact. Record Review: Review of Personal Property form dated 11/17/2025 did not document clothing Resident #42 had upon admission. There was no documented evidence of an investigation report or grievance completed for residents missing clothing. There was no documented evidence of a search for, or the location of clothing reported missing. Interviews: During an interview on 03/10/2026 at 1:56 PM, Family Member #1 stated they visited at least every other day. When the resident was admitted to the facility, they had brought the residents clothing which was collected by staff. There had been clothes missing a little over a month, to the best of their recollection it was a few sweaters and long sleeve tops. They had spoken to someone (unnamed staff), they had checked laundry area in the facility with the staff member, and the clothing was not located. There was no follow up on the missing clothing after laundry area was checked. They stated they then started doing the residents' laundry instead of having facility do it. During an interview on 03/12/2026 at 1:30 PM, Registered Nurse #4 stated if clothing or items go missing, they called laundry to see if the items could be located. They were not aware of any missing item forms that would have been filled out for missing clothing. They would not go further than looking for the missing clothing or items unless a grievance form was completed. They stated they were aware that Resident #42 had missing clothing that had not been located. Family Member #1 had since started doing the residents' laundry, and there had been no further complaints about missing clothing for the resident. During a subsequent interview on 03/17/2026 at 10:50 AM, they stated Certified Nursing Assistants were responsible for filling out personal property forms. During an interview on 03/16/2026 at11:40 AM, Director of Social Services #1 stated for missing items such as clothing, they would go to laundry area to try and locate the missing item. They stated there were no forms that were filled out for missing clothing, it was verbally communicated through the facility when clothing was missing. The process was to have all items labeled. They had educated staff, residents, and family members on the process for labeling. There was a bin at the front desk that clothing was to be placed in to be labeled by the facility. During an interview on 03/16/2026 at 2:41 PM, Administrator #1 stated the process for missing clothing was to notify laundry with a description of the missing item/s. They stated they have had issues in the facility with family labeling clothing; these labels tended to be washed off during laundering. They have educated families about the preferable method of having laundry labeled in house rather than labeling items themselves. There was a bin at the front desk for clothing to be placed in, the clothing in the bin was sent to be labeled in house. There was an unclaimed clothing rack in laundry for items that were not labeled, clothing is not disposed of it would remain until claimed. There was a separate rack for clothes that had been donated to the facility, the two racks were not in the same area and unlabeled clothing would not go on the donate rack. There were no missing items forms for missing clothing; missing clothing was communicated verbally in the facility. Grievance forms were filled out for other missing items and investigations were started for missing money. During an interview on 03/17/2026 at 11:05 AM, Certified Nursing Assistant #9 stated they would fill out personal property form when a resident entered the facility, they would include things such as wallets, clothing, money, and everything that belong to the resident. They would ask if clothing needed to be labeled and if family or the facility would do the residents' laundry. If they were made aware of a missing item such as clothing, they would get a description of the item and begin to look for the item. They would report the missing item with the description to the nurse. They were unaware of any missing item forms or any form that a Certified Nursing Assistant would fill out for missing clothing. During an interview on 03/17/2026 at 11:12 AM, Certified Nursing Assistant #8 stated they filled out personal property forms for residents. All personal items including clothing were to be listed on the form. They would ensure clothing was labeled or was sent to be labeled. If they were made aware of missing clothing, they would go to the laundry area to find the item personally and report the missing item to the nurse as well as the unit manager. 10 New York Codes, Rules, and Regulations 415.12(h)(1)(2)

Based on observation, record review, and interviews conducted during a survey, the facility failed to ensure that its medication error rate did not exceed five (5) percent for three (3) (Resident #s 57, 67, and 137) of four (4) residents observed during a medication pass for a total of 27 observations. This resulted in a medication error rate of eleven (11) percent. This is evidenced by: The facility's policy and procedure titled, Medication Pass Policy, revised 9/23/2024, documented, acceptable medication pass time is one (1) hour before and one (1) hour after the scheduled time for most medications. Always observe residents until they have swallowed all medications that have been administered. Do not leave medication in medication cup at the bedside or on tableside. Remember the six (6) rights of medication pass: Right Resident, Right Drug, Right Dose, Right Dosage Form, Right Route, Right Time. Resident #57 was admitted to the facility with the diagnoses of atrial fibrillation (a rapid uncontrolled heart rate), hip fracture, and depression. The Minimum Data Set, dated [DATE], documented the resident was able to be understood, understood others and was significantly cognitively impaired. Resident #67 was admitted to the facility with the diagnoses of atrial fibrillation (a rapid uncontrolled heart rate), orthostatic hypotension (a sudden drop in blood pressure occurring when standing up from a sitting or lying position), and dementia (a progressive degenerative neurological disease causing memory problems). The Minimum Data Set, dated [DATE], documented the resident was able to be understood, understood other and was severely cognitively impaired. Resident #137 was admitted to the facility with diagnoses of atrial fibrillation (a rapid uncontrolled heart rate), chronic pain (unrelieved pain), gastro-esophageal reflux disease without esophagitis (a form of heartburn without visible damage to the esophagus). The Minimum Data Set, dated [DATE], documented the resident had could make themselves understood, understood others and was cognitively intact. During an observation on 3/12/2026 at 9:38 AM, Licensed Practical Nurse #5 reviewed Resident #137's Medication Administration Record. They stated Resident #137 was to receive carboxymethylcellulose sodium Ophthalmic Solution [TheraTears] at 9:00 AM, pulled a bottle of eye drops from medication cart, and then showed the surveyor. Upon observation, it was noted the eye drop bottle pulled was Lumigan eye drops. The surveyor pointed out discrepancy to Licensed Practical Nurse #5 at the time of observation. During an interview on 3/12/2025 at 9:40 AM, Licensed Practical Nurse #5 stated they picked up the wrong medication in error and replaced the Lumigan eye drops. During an observation on 3/12/2026 at 9:50 AM, Licensed Practical Nurse #5 reviewed Resident #57's Medication Administration Record. They stated Resident #57 was to receive metoprolol tartrate oral tablet at 9:00 AM, pulled the medication card from medication cart, and then showed the surveyor. Licensed Practical Nurse #5 had taken Resident #57's vital signs prior to preparing the medication and their blood pressure was noted to be 99/66. The surveyor asked as Licensed Practical Nurse #5 prepared to pop the pill from the card, if there were parameters required checking before administration of metoprolol. Licensed Practical Nurse #5 looked at the order again and noted that the parameters in the order stated hold for systolic blood pressure less than 100. Licensed Practical Nurse #5 stated that Resident #57 should not receive the metoprolol because of their blood pressure, stopped attempting to pop the pill out of the card, and replaced it to the cart and documented held for blood pressure parameters. During an observation on 3/13/2026 at 9:17 AM, Licensed Practical Nurse #2 reviewed Resident #67's Medication Administration Record. They stated Resident #67 was to receive midodrine hydrochloride 2.5 MG Oral Tablet at 7:30 AM, pulled the medication card from medication cart, and then showed the surveyor. Licensed Practical Nurse #2 administered the medication without error. Upon returning to the medication cart, Licensed Practical Nurse #2 started to change the administration time for Midodrine to 7:28 AM instead of the administered time at 9:17 AM. The Surveyor stopped Licensed Practical Nurse #2 from doing so. During an interview on 3/13/2026 at 9:30 AM, Licensed Practical Nurse #2 stated without prompting or asking that they were told to back date to the time the medication was due if it was late. When asked who told them to do that, Licensed Practical Nurse #2 stated that the previous Director of Nursing told the nurses to do that, but they had left the facility a month ago. When asked if that rule was reinforced by anyone since the previous Director of Nursing left, Licensed Practical Nurse #2 stated no. During an interview on 3/13/2026 at 10:30 AM Licensed Practical Nurse #3 stated that if a medication was being given outside the time parameters, they would let the provider know and let the nurse manager know. Licensed Practical Nurse #3 stated they did not change the time of medication administration. They would ask the provider what they were supposed to do for the next dose of the medication. During an interview on 3/13/2026 at 10:56 AM, Licensed Practical Nurse #6 stated that they were orienting with Licensed Practical Nurse #5 and that if a medication was given late, they would not change the time, they would document when the medication was given. During an interview on 3/13/2026 at 10:46 AM, Licensed Practical Nurse #7 stated that they documented when a medication was given and if they gave a medication late, they would let the Nurse Manager and Medical Provider know. During an interview on 3/18/2026 at 10:10 AM, Registered Nurse #1 stated that no one had ever told them to alter medication times to fit the time they were due. Registered Nurse #1 stated that if medication was late, the staff should tell the provider and the Unit Manager, document the correct time and ask the provider if there were alternate orders they wanted to give. During an interview on 3/19/2026 at 11:15 AM, Director of Nursing #1 stated that nurses needed to check the orders and administer the medications according to the parameters. They should not alter times in the electronic record. During an interview on 3/18/2026 at 12:17 PM, Administrator #1 and Director of Nursing #1 stated that they had educated Licensed Practical Nurse #2 and started house wide education of nurses about the importance of accuracy with medication records. 10 New York Codes, Rules, and Regulations 415.12 (m)(1)

Based on observations, record reviews, and interviews during a survey, the facility failed to ensure residents were treated with dignity and respect for two (2) (Residents #29 and #67) of 30 residents reviewed for dignity. Specifically, for Residents #29 and #67, catheter drainage bags were not covered for privacy. This is evidenced by: The policy and procedure titled Urinary Catheterization, dated 4/24/2024, stated urinary catheter drainage bags should always be covered for privacy. Resident #29 Resident #29 was admitted to the facility with the diagnoses of nondisplaced intertrochanteric fracture (a fracture where the bone is cracked but remains in proper alignment) of right femur, displaced fracture of upper end of left humerus (a break in the left upper arm bone that has moved out of its normal alignment), and retention of urine (inability to fully empty the bladder). The Minimum Data Set (an assessment tool) dated 03/09/2026, documented the resident was able to be understood, understood others, and was severely cognitively impaired. A physician order dated 03/04/2026 documented that Resident #29 was to have an indwelling Foley catheter (a flexible tube inserted into the bladder to drain urine, held n place by a water-filled balloon) to straight drainage for retention. During an observation on 03/10/2026 at 12:22 PM Resident #29 was observed to be in the hallway with their urinary catheter drainage bag hanging under their wheelchair without a privacy cover. During an observation on 03/12/2026 at 9:49 AM Resident #29 was observed to be in the hallway with their urinary catheter drainage bag hanging under their wheelchair without a privacy cover. During an observation on 03/12/2026 at 2:00 PM Resident #29 was observed to be in the physical therapy gym with their urinary catheter drainage bag hanging under their wheelchair without a privacy cover. Resident #67 Resident #67 was admitted to the facility with the diagnoses of atrial fibrillation (a rapid uncontrolled heart rate), orthostatic hypotension (a sudden drop in blood pressure occurring when standing up from a sitting or lying position), and dementia (a progressive degenerative neurological disease causing memory problems). The Minimum Data Set, dated [DATE], documented the resident was able to be understood, understood other and was severely cognitively impaired. During an observation on 03/10/2026 at 11:21 AM, Resident #67's urinary catheter drainage bag was not covered with a dignity bag. During an observation on 03/10/2026 at 12:06 PM, Resident #67's urinary catheter drainage bag was uncovered on the wheelchair. During an observation on 03/16/2026 at 10:00 AM, Resident #67's urinary catheter drainage bag was uncovered under the chair and touching the floor. During an interview on 03/17/2026 at 10:00 AM Registered Nurse #4 stated that urinary catheter drainage bags should be in a privacy bag. During an interview on 03/17/2026 at 10:21 AM, Licensed Practical Nurse #8 stated urinary catheter drainage bags were supposed to be covered with a privacy bag, to avoid being seen. Leg bags could also be used. They were blue. During an interview on 03/18/2026 at 10:10 AM Registered Nurse #1 stated that urinary catheter drainage bags should be covered so that urine could not be seen. During an interview on 03/18/2026 at 11:15 AM Director of Nursing #1 stated urinary catheter drainage bags needed a privacy cover bag. Some residents messed with their urinary catheters, so it was harder to keep them covered 10 New York Codes, Rules, and Regulations 415.3(c)(1)(i)

Based on observation and interviews during the recertification survey dated 03/16/23 through 03/22/23, the facility did not ensure food was stored, prepared, distributed or served in accordance with professional standards for food service safety for three (3) of 3 resident unit kitchenettes and the main kitchen. Specifically, in the main kitchen, the microwave oven, slicer, mixer, thermometer holder, ceiling and ceiling lights, wall by kitchen door, and fire extinguishers were soiled with food particles; the framing around the window by the 3-compartment sink was peeling; and the walls behind and around the dishwashing machine were peeling and soiled with black mold. In the 2nd floor, 3rd floor, and 4th floor kitchenettes, the refrigerator door gaskets were soiled with food particles. In the 2nd floor kitchenette, the cabinets, wall by sink, and floor below refrigerator were soiled with food particles; the windows had cobwebs; one spray bottle of disinfectant, a toxic cleaning substance, was stored on top of the refrigerator; and the laminate on the cabinets was peeling. This is evidenced as follows: During observations on 03/16/23 at 10:24 AM, in the main kitchen, the microwave oven, slicer, mixer, thermometer holder, ceiling and ceiling lights, wall by kitchen door, and fire extinguishers were soiled with food particles; the framing around the window by the 3-compartment sink was peeling; and the walls behind and around the dishwashing machine were peeling and soiled with black mold. In the 2nd floor, 3rd floor, and 4th floor kitchenettes, the refrigerator door gaskets were soiled with food particle. In the 2nd floor kitchenette, the cabinets, wall by sink, and floor below refrigerator were soiled with food particles; the windows had cobwebs; one spray bottle of disinfectant, a toxic cleaning substance, was stored on top of the refrigerator; and the laminate on the cabinets was peeling. During interviews on 03/16/23 at 11:27 AM, the Administrator and Food Service Director stated that the items found will be cleaned, the walls will be repaired, the mold will be addressed, and staff will be re-educated on calibrating thermometers and the cleaning checklist. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14

Based on observation, record review and interviews during the recertification survey, the facility did not ensure preadmission screening for individuals with a mental disorder and individuals with intellectual disability was performed for 1 (Resident #13) of 2 residents reviewed for Preadmission Screening and Resident Review (PASRR). Specifically, for Resident #13, the facility did not ensure a comprehensive Level 2 assessment and determination/recommendations were completed prior to admission to the facility, following a positive Level 1 determination on the DOH-695 Preadmission Screen form on 11/16/2021. This was evidenced by: Resident #13 Resident #13 was admitted to the facility with diagnoses of bipolar disorder, schizoaffective disorder, and chronic kidney disease. The Minimum Data Set (MDS - an assessment tool) dated 11/22/2021, documented the resident was able to make themselves understood, able to understand others, and was cognitively intact. The undated Policy and Procedure (P&P) titled PASRR Review, documented it was the policy of the facility to screen all individuals for new admission for serious mental illness or mental retardation/developmental disability per New York State Department of Health (NYSDOH) regulations. All applicants who were positive for Level 1 criteria will have a comprehensive Level 2 assessment and determination/recommendations completed prior to admission to the facility. If no Level 2 referral was indicated, the resident could be admitted to the facility. The DOH-695 Preadmission Screen form, dated 11/16/2021, documented: - Question #23 (Level 1 Review for Possible Mental Illness (MI) Does this person have a serious mental illness?: Answer - Yes - Guideline: If item 23 or any of the Items 24 - 26 were marked Yes, proceed to Categorical Determinations (Items 27 - 30). Answers to Items 27 - 30 were not documented. - Guideline: If any of the Items 27 - 30 were marked Yes, proceed to Danger to Self or Others Qualifiers (Item 31). If all were marked No, proceed to Level 2 referrals (Item 33). Answers to either Items 31 or 33 were not documented. During an interview on 03/21/23 at 02:44 PM, the Director of Social Work (DSW) stated prior to admission, the SW department performed a brief review of preadmission screens. If the screen was incomplete, or there was information missing, they would report this to the Director of Nursing (DON). The preadmission screen for Resident #13, dated 11/16/2021, documented the resident had a serious mental illness for Item 23. Based on the screen instructions, Items 27 - 30 should have been completed to determine whether the resident was a danger to themselves or others, or if a Level 2 screen was required; this was not done. That should have been caught by whomever reviewed the screen and reported to the DON. During an interview on 03/22/23 at 10:14 AM, the DON stated the Clinical Evaluator (CE) was responsible for initially reviewing preadmission screens; when social work reviewed the screens, they would be secondary reviewers. The preadmission screen for Resident #13 from 11/16/2021 should have been reviewed by the CE, and it should have been identified that there were questions on the screen that had not been addressed. The hospital should have been contacted, and any incomplete questions should have been completed prior to the resident's admission. They had not been informed of any issues related to the screen at the time it was received. During an interview on 03/22/23 at 3/22/2023 at 10:49 AM, CE #1 stated they were responsible for initial review of preadmission screens for residents prior to admission. This review typically consisted of a conversation with the hospital screener, and if they were told that the screen was completed they did not always review the screens themselves. When they do review the preadmission screens, they did not typically review all the questions on the preadmission screen forms for completion. If there was an issue with a preadmission screen form, or the form was incomplete, they would need to have a conversation with the care manager responsible for completing the form. They did not recall the specific screen for Resident #13 from 11/16/2021 but was familiar with the screener who signed the form. Whenever they told them they completed a screen, they did not question them or conduct any further review of their preadmission screens. During an interview on 03/22/23 at 11:04 AM, the DON stated the CE was responsible for reviewing all preadmission screens, whether they were informed by hospital screener they were completed or not. During an interview on 03/22/23 at 12:00 PM, the Administrator stated the CE should have reviewed and addressed any issues related to completion of the preadmission screen for Resident #13 on 11/16/2021, to ensure the resident was appropriate for admission and going to receive all the necessary services they required. At the time Resident #13's screen dated 11/16/2021 was received, no issues or concerns were reported to them regarding the screen. 10 NYCRR 415.11(e)

Based on observation and interviews during the recertification survey dated 03/16/23 through 03/22/23, the facility did not ensure garbage and refuse was disposed properly. Specifically, the metal plate back piece and metal plate bottom piece of the large dumpster was pulled away creating two 2-foot by 3-inch holes and the drain plug was missing in the small dumpster. This is evidenced as follows: During observations on 03/16/23 at 11:44 AM, the metal plate back piece and metal plate bottom piece of the large dumpster was pulled away creating two 2-foot by 3-inch holes; the drain plug was missing in the small dumpster. During an interview on 03/16/23 at 11:47 AM, the Administrator stated that the vendor will be contacted to replace the large dumpster and to provide a drain plug for the small dumpster. 10 NYCRR 415.14(h)

Based on observation, record review and interviews during the recertification survey the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents rights, that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 6 (Resident #'s 29, 34, 60, 71, 78 and #91) of 22 residents reviewed for comprehensive care plans (CCPs). Specifically, for Resident #29, the CCP for anticoagulation therapy did not include an indication or [DIAGNOSES REDACTED].#34, the CCP for a communication problem did not include the services needed for the resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being related to hearing loss; for Resident #60, the CCP did not include safety interventions for the resident with [MEDICAL CONDITION] following a hot food spill; for Resident #71, the facility did not ensure a CCP titled PICC included indication for use and interventions for the IV antibiotic use for infection; for Resident #78, the CCP for anticoagulation therapy did not include an indication or [DIAGNOSES REDACTED].#91, the CCP did not include a care plan for urinary tract infection [MEDICAL CONDITION]. This was evidenced by: The Policy & Procedure (P&P) undated and titled Care Planning Instructions documented, care plans are initiated upon a resident's admission, with change in status or condition, medications, etc. Care plan process included: Care plans are labeled with resident's name, unit and room number; date of care plan initiated; problem/need/strength; measurable goal for resident; interventions individualized for resident; care plans must be updated with any change in plan of care. Resident #71: Resident #71 was admitted to the facility with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 10/15/20, documented the resident had severely impaired decision making and received IV medications. The physician's orders [REDACTED]. The order was continued on 11/4/20 to continue through 12/9/20. The CCP for a PICC line was not individualized to the resident, did not include indication for use, and did not include interventions specific to the use and care of administering medications and/or flushes. During an interview on 11/12/20 at 11:17 AM, Registered Nurse Unit Manager #4 stated Resident #71's left heel wound had worsened from a stage 2 or a deep tissue injury. The PICC line in her right chest was placed on 9/25/20. The care plan should have been updated to address the PICC line and the IV medications. During an interview on 11/12/20 at 1:45 PM, the Director of Nursing stated the care plan should have been updated to include the PICC line and antibiotic administration. Resident #78: Resident #78 was admitted to the facility with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 9/22/20, documented the resident was cognitively intact, could understand others and could make self understood. The CCP for anticoagulation therapy dated 4/21/20, documented the resident had the potential for untoward effects due to anticoagulation therapy- Xarelto (a blood thinner medicine- anticoagulant). The CCP did not include an indication or [DIAGNOSES REDACTED]. During an interview on 11/12/20 at 9:37 AM, Registered Nurse (RN) #2 stated the admission nurse initiated the care plans when residents were admitted , and the RN Unit Manager helped to maintain and build on the care plans throughout the resident's stay in the facility. He stated he could certainly add the [DIAGNOSES REDACTED]. Resident #91: Resident #91 was admitted to the facility with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 9/20/20 documented, the resident had moderate cognitive impairment. The physician's progress note dated 10/12/20 documented; Foley in place, milky white urine in bag, pyuria (elevated number of white blood cells in the urine, which can cause the urine to appear cloudy or contain pus), start Fluconazole (treat and prevent fungal infections) 100 mg x 7 days and repeat C&S (culture and sensitivity), change Foley (a sterile tube that is inserted into your bladder to drain urine) today. A nursing progress note dated 11/6/20 documented; resident noted to be confused overnight and this morning. Urine in resident's Foley bag is noted to be creamy yellow in color. Physician updated and new order to change Foley catheter and collect urinalysis and culture and sensitivity. The CCP for indwelling catheter dated 6/22/18, documented the resident had [MEDICAL CONDITION] and obstructive reflux [MEDICAL CONDITION]. The CCP did not include a care plan for urinary tract infection [MEDICAL CONDITION]. During an interview on 11/12/20 at 11:17 AM, Registered Nurse Unit Manager #4 stated the resident had a urinary tract infection in October 2020. A urine was collected on 11/9/20 and we are waiting for the culture and sensitivity to come in. The care plan should have been updated to include the urinary tract infection. During an interview on 11/12/20 at 1:45 PM, the Director of Nursing stated the care plan should have included urinary tract infection. 10 NYCRR 415.11(c)(1)

Based on interviews and record review conducted during the recertification survey, the facility did not provide proper treatment and assistive devices to maintain the hearing ability for 1 (Resident #34) of 1 resident reviewed for communication. Specifically, for Resident #34, the facility did not ensure the resident, who had impaired hearing, was provided with an audiologist consultation to be evaluated for hearing aids. This is evidenced by: Resident #34: Resident #34 was admitted to the facility with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 8/19/20, documented the resident had moderately impaired cognition, could usually understand others and could make self understood. The Minimum Data Set (MDS) documented the resident had moderate difficulty hearing. The facility did not provide a Policy and Procedure related to communication or hearing impaired residents. The Comprehensive Care Plan for a Communication Problem, last revised 5/21/20, documented the resident was deaf in the left ear. The interventions included; to be conscious of resident's position when in groups, activities, dining room to promote proper communication with others, to allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, face when speaking, make eye contact, and use alternative communication tools as needed. A review of progress note entries by the Physician Assistant (PA) documented: -7/31/2020 - that the PA was asked to see the resident regarding left ear pain and difficulty hearing. The resident stated intermittently losing hearing in left ear for no reason and thought there was wax in it. The resident reported being deaf in the right ear due to a history of [DIAGNOSES REDACTED] on that side. The resident reported having hearing aids before but got frustrated because they were not working right so he/she threw them in the garbage. The resident was wondering about getting new ones. The PA documented hearing loss; had hearing aids in the past, not anymore, wants to see audiologist to get new ones, will refer. -8/10/20 - left side hearing loss. The resident still had cerumen impaction on left side and will try [MEDICATION NAME] (ear wax removal treatment) and ear flush again. Audiology referral placed. -9/11/20 - the PA was asked to see the resident regarding continued hearing loss and concern for ear wax. The PA documented she had seen the resident several times lately for concerns over hearing loss and ear wax, most recently on 8/10/20. The note documented at that visit she again ordered [MEDICATION NAME] for 3 days and then ear flush, however this had not helped and the resident still could not hear well. The PA documented the resident had been referred to audiologist for consideration of hearing aids, but it had not been set up yet. During a record review, the medical record did not include documentation that an appointment had been made for the resident to seen an audiologist. During an interview on 11/05/2020 at 12:05 PM, Resident #34 stated he/she had hearing loss in the left ear and was supposed to see audiologist, but the appointment had not been arranged yet. The resident stated the appointment was supposed to be arranged a while ago. During an interview on 11/12/20 at 10:11 AM, Registered Nurse #1 (RN) stated an audiology appointment was not made for the resident. She stated it never got conveyed to her that the resident needed an audiology appointment. She stated the PA wrote a note on 7/31/20, 8/10/20 and 9/11/20, but she was unaware the PA had documented a referral for an audiology appointment. The RN stated she did not regularly review the PA progress notes. She stated when the RN Supervisor received the orders from the PA, the RN Supervisor should have put a physician order [REDACTED]. She stated if an order had been put in the EMR, she would have seen a referral had been made by the PA and would have filled the appointment sheet out for the Unit Secretary to follow through on. During an interview on 11/12/20 at 11:53 AM, the Director of Nursing DON stated the RN Supervisor who received the orders from the PA was not aware the orders for the audiologist referral needed to be put in the EMR under physician orders [REDACTED]. The audiologist appointment was not made for the resident. She stated the same RN Supervisor received the orders from the PA for an audiologist referral in July, August, and September and did not make the connection that an appointment still had not been made for the resident. 10NYCRR415.12(3)(b)

Based on observation, staff interview, and record review during the recertification survey, the facility did not adhere to adopted food safety regulations. The safe and sanitary operation of a professional kitchen is to include particular methods of operation. Automatic dishwashing machines are to operate in accordance with manufacturer specifications, and floors are required to be kept clean and in good repair. Specifically, the automatic dishwashing machine was not operating within the manufacturer's specifications required to sanitize food contact surfaces, and floors were covered in food debris and missing grout. This is evidenced as follows. The main kitchen was inspected on 11/05/2020 at 09:48 AM, revealing the automatic dishwashing machine final rinse was 160 Fahrenheit (F) at 28 pounds per square inch (psi) water pressure, and the kitchen floors were missing grout and covered in food debris. Record review on 11/05/2020 revealed that the automatic dishwashing machine information plate stated that the minimal final rinse water temperature is to be 180 F at 20 psi. The Director of Food Services stated in an interview on 11/05/2020 at 10:24 AM that he was unaware that the high temperature automatic dishwashing machine's final rinse was only reaching 160 F, and he will contact the service company. Additionally, he stated that the kitchen floor will be cleaned and re-grouted. 10 NYCRR 415.14(h); State Sanitary Code Subpart 14-1.32, 14-1.85, 14-1.110, 14-112(c), 14-1.170

Based on record review and interview during a recertification survey, the facility did not ensure as needed (PRN) orders for [MEDICAL CONDITION] drugs were limited to 14 days, unless the attending physician or prescribing practitioner believed it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order for 1 (Resident #28) of 5 residents reviewed for unnecessary medications. Specifically, for Resident #28, the facility did not ensure a PRN antianxiety medication ([MEDICATION NAME]) was not ordered for more than 14 days without a documented rationale from the attending physician or prescribing practitioner. This is evidenced by: Resident #28: Resident #28 was admitted to the facility with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 10/21/20, documented the resident had moderately impaired cognition, could usually understand others and could usually make self understood. The Policy and Procedure titled PRN [MEDICAL CONDITION] Medications, dated 3/2018, documented residents did not receive PRN [MEDICAL CONDITION] medications unless the medication was necessary to treat a specific condition that was documented in the clinical record and all PRN orders for [MEDICAL CONDITION] medications would not exceed 14 days, including those residents on Hospice. The Comprehensive Care Plan for [MEDICAL CONDITION] Medications, last updated 9/23/20, documented the resident received [MEDICAL CONDITION] medications related to anxiety before [MEDICAL TREATMENT]- [MEDICATION NAME]. The care plan interventions included: To administer medications ([MEDICATION NAME]) as ordered by physician; monitor for side effects and effectiveness; monitor/document/report PRN any adverse reactions; and discuss with physician and family regarding ongoing need for use of medication. A physician order [REDACTED]. A physician re-admission note dated 9/24/20, documented the resident had dementia with agitation including aggressive behaviors towards the physician and nursing staff and to continue [MEDICATION NAME] (antipsychotic medication) and [MEDICATION NAME] ([MEDICATION NAME]). The note documented to consult with psychiatrist if the resident accepted. A Psychiatry Diagnostic Evaluation dated 9/28/20, documented to consider routine [MEDICATION NAME] ([MEDICATION NAME]) prior to [MEDICAL TREATMENT] treatment and to continue [MEDICATION NAME]. The medical record did not include a medical justification documented by the attending physician or prescribing practitioner for continuing the PRN [MEDICATION NAME] order for more than 14 days after it was ordered on [DATE]. During an interview on 11/12/20 at 9:37 AM, Registered Nurse (RN) #2 stated he was aware of the regulation for PRN [MEDICAL CONDITION] medication orders and stated the PRN [MEDICAL CONDITION] were ordered for 14 days with review by the physician on the 13th or 14 day to determine whether or not to extend the order. He stated the resident's PRN [MEDICATION NAME] order had been reviewed by the physician and the rationale for extending the order past 14 days should be written in the provider progress notes. RN #2 reviewed the progress notes and stated there were physician notes dated 9/24/20 and 11/11/20, but there was not a provider note documenting a rationale to extend the PRN use past 14 days after the PRN [MEDICATION NAME] was ordered on [DATE]. He stated the resident typically received the PRN [MEDICATION NAME] before [MEDICAL TREATMENT] since the resident's anxiety seemed to revolve around going to [MEDICAL TREATMENT]. During an interview on 11/12/20 at 11:49 AM, Director of Nursing (DON) for PRN [MEDICAL CONDITION] medication orders there needed to be a 14-day review. She stated all PRN orders were looked a couple times a week and a provider justification should be written in a provider progress notes. She stated the Unit Manager should let the providers know when a PRN medication order needs to be reviewed then the providers write a justification for extending for extending the order. She stated the provider should have written a note 14 days after the PRN was ordered. She stated Nurse Managers and the facility providers were aware of the regulation. 10NYCRR 415.12(1)(2)(ii)

Based on observation, record review, and interviews during the recertification survey, the facility did not ensure acceptable parameters of nutrition were maintained for 1 (Resident # 87) of 4 residents reviewed for nutrition. Specifically, for Resident #87, the facility did not ensure re-weights were obtained per facility protocol, the physician was notified of the resident's significant change in weight, and the nutrition care plan included person-centered approaches to maintain acceptable parameters of the resident's nutritional status. This is evidenced by: Resident #87: Resident #87 was admitted to the facility with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 9/29/20 documented the resident was cognitively intact, could understand others and could make self understood. The Policy and Procedure titled Weight, last revised 8/2018, documented new admissions would be weighed weekly for 4 weeks and if weight remained stable the resident would be weighed monthly. Weights would be obtained and recorded per physician order. If a weight loss was noted (5% in one month, or 3 pounds in one week and weight loss was not planned or anticipated) the charge nurse would notify the nursing supervisor, physician, dietician, and responsible party. If there was a 3 pound weight difference from the last weight, a re-weight was to be done the next day with the nurse or dietician present. The Comprehensive Care Plan for Nutrition, last revised 10/22/20, documented the resident had an actual/potential nutritional problem: Increased nutrient needs r/t increased demand for calories as evidenced by recent diagnosis. The goal was the resident would maintain adequate nutritional status as evidenced by maintaining weight, no signs or symptoms of malnutrition, and consuming at least 50% of at least 2 meals daily through review date. Interventions included: To provide and serve diet as ordered; monitor intake and record every meal; RD to evaluate and make diet change recommendations PRN; and to weigh as ordered by MD/physician. The care plan did not include person-centered goals or approaches to maintain acceptable parameters of resident's nutritional status. Physician orders did not include an order to obtain the resident's weight. A review of the resident's weight record documented: 9/28/20- 113.4 pounds (lbs.) (this weight was subsequently struck out by RN #1 on 10/28/20) 10/05/20- 101.5 lbs. (10.49% weight loss x 1 week) (this weight was subsequently struck out by RN #1 on 10/28/20) 10/12/20- 95 lbs. (6.40% weight loss x 1 week) 10/13- 97 lbs. 10/14- 99 lbs. (this weight was subsequently struck out by RN #1 on 11/10/20) 10/19- 95 lbs. 10/20- 93 lbs. 10/28- 96.5 lbs. The Patient Review Instrument (PRI) completed in the hospital dated 9/24/20, documented the resident weighed 53 kg (116.6 pounds). The hospital discharge summary dated 9/28/20, documented no leg [MEDICAL CONDITION]. A nursing admission note dated 9/28/20, documented the resident stated his/her legs were very swollen; some [MEDICAL CONDITION] noted to legs and bilateral ankles. The facility admission history and physical dated 9/29/20, documented the resident had no [MEDICAL CONDITION]. A Nutrition assessment dated [DATE], documented the resident weighed 113.4 lbs. The resident reported his/her usual body weight was approximately 100 pounds. The assessment documented the resident had significant weight gain and the resident reported the weight gain was from increased [MEDICAL CONDITION] in his/her legs. Weight loss was expected from fluid shifts. A nursing note on 10/3/20 documented while assisting the resident into bed, noted that his/her bilateral legs were shiny, with plus 2 [MEDICAL CONDITION]. During a record review on 11/10/20, the medical record did not include documentation that re-weights were obtained when there was a weight difference of 3 or more pounds in accordance with the facility policy. The medical record did not include documentation the physician was notified of the resident's significant changes in weight since admission on 9/28/20. During an interview on 11/12/20 at 10:22 AM, Registered Nurse (RN) #1 stated Resident #87 was admitted to a different unit and was moved up to her unit, but when any resident was admitted to the facility they were weighed weekly for 4 weeks, then it was up to the physician how frequently to weigh the resident. She stated the resident was currently being weighed weekly. She reviewed the resident's physician orders and stated there was not an order to weigh the resident and there should be. The RN stated she crossed out the weights dated 9/28 and 10/5 in the resident's medical record because the resident told her on 10/28 the weights were not accurate. She stated she weighed the resident on 10/28 to get an accurate weight. The RN stated when there was a 3 pound or greater difference in a resident's weight, the protocol was re-weigh the resident within 24 hours. She stated because a re-weight was not obtained, she did not know if the admission weight of 113 lbs. was accurate at the time of admission. She stated on her unit, the staff obtained the weights and brought the weights to her to review and to input into the medical record that way she reviewed all the weights and could determine if a re-weight was needed. She stated when the resident was weighed at 101 pounds after a weight of 113lbs last week, there should have been a re-weight. The resident should be re-weighed any time there is a 3 pound discrepancy in weight. She stated the RD and physician should have been made aware, but based on the documentation in the medical record it did not appear either had been notified of the resident's weight loss. During an interview on 11/12/20 at 10:47 AM, the RD stated she was not the RD at the facility when the resident was admitted . She stated she would have done a re-weight because a lot of times after a hospitalization residents were admitted with excess fluid or [MEDICAL CONDITION] but with a drastic weight loss like this resident had, a re-weight should have been obtained to determine if the admission weight was an error. She stated the RD should have been made aware when the resident's weight went from 113 lbs. to 101 lbs. and then to 95 lbs. She stated the team had weekly weight meetings so discrepancies in weight could be picked up. She was unsure if this resident had been discussed in the weekly weight meeting. She stated the Nurse Managers also reviewed weights weekly and ordered re-weights as needed. She stated after the weekly weight meeting, if there was a concerning weight change the nurse would notify the Doctor of the weight change and the Nurse and Doctor would document if there was [MEDICAL CONDITION] and visually verify if [MEDICAL CONDITION] was present. She stated she would have tried to find information on the resident's normal weight and stated she did not know if she could say the resident's weight change was related to [MEDICAL CONDITION] since the change in weight was so significant. She stated the team needed to determine if the admission weight was incorrect at the time of admission, and if it was determined to be incorrect, then it would get crossed out in the medical record after a re-weight was obtained. The RD reviewed the resident's nutrition care plan. She stated the care plan needed to be more person centered and to include nutritional interventions such as supplements, unintended risk for fluid, and weekly weights. She stated the care plan needed to be more individualized and specific to the resident. During an interview on 11/12/20 at 11:59 AM, the Director of Nursing (DON) stated the facility protocol for a weight discrepancy was to obtain a re-weight in order to determine if the initial weight was accurate. She stated if the resident was weighed at 113 pounds and then weighed at 101 pounds, the staff should have gotten the physician and RD to review the weights and to see the resident. She stated she would expect there to be a dietary note addressing the discrepancy in the resident's weight and there was not a note from the RD until 10/23/20. She stated she would expect the unit manager to write a progress note that the physician was notified of the weight discrepancy if the physician had been notified. She reviewed the resident's physician orders and stated she would expect to see an order for [REDACTED]. 10NYCRR415.12(i)(1)

Based on record review and staff interviews during an abbreviated survey (Case #NY 544), the facility did not immediately consult with the resident's physician when there was a significant change in the resident's physical condition for 1 (Resident #2) of 3 residents reviewed. Specifically, the physician was not notified when Resident #2 had a sudden onset of abdominal pain beginning on [DATE] at 6:30 PM, then had brown emesis, diarrhea and abdominal pain on [DATE] at 12:35 AM, and progressed to abdominal tenderness and absence of bowel sounds on [DATE] at 3:08 AM. Subsequently, the physician was notified on [DATE] at 6:10 AM. Resident #2 was sent to the hospital. Resident #2 was diagnosed with [REDACTED]. This resulted in actual harm that is not immediate jeopardy. This was evidenced by: Resident #2: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severe cognitive impairment, was usually understood, and could usually understand others. The Policy and Procedure for Physician Notification/Family Notification with a revision date of ,[DATE] documented the staff must immediately consult with the resident's physician (MD) when there was a significant change in the resident's physical status. The MD was to be notified by a Registered Nurse Supervisor (RNS), an RN Manager (RNM), or designee of a resident's change in condition after the RNS or RNM conducted a complete physical assessment. Examples of a change in condition included diarrhea and vomiting. The Policy and Procedure for Bowel Regimewith a revision date of ,[DATE] documented the absence of bowel sounds could indicate intestinal obstruction. The MD must be notified. The Comprehensive Care Plan (CCP) for Advance Directives dated [DATE], documented the resident wanted to go to the hospital if necessary. The CCP intervention documented the Advance Directives were to be honored. The Medical Orders for Life Sustaning Treatment (MOLST) dated [DATE], documented the resident wanted to be sent to the hospital if necessary. The Order Summary Report for active orders as of [DATE], documented the resident was to be sent to the hospital if necessary. The CCP for Constipation dated [DATE], documented the resident was to be monitored and staff were to report resident complaints of abdominal pain, nausea and vomiting. A Nurse's Note dated [DATE] at 10:09 PM, written by Licensed Practical Nurse (LPN) #1, documented that at 6:30 PM, the resident complained of (c/o) abdominal pain. The resident had hyperactive (noisy, overactive) bowel sounds. [MEDICATION NAME] (Tylenol) was offered but the resident declined. LPN #1 notified RNS #1. A Nurse's Note dated [DATE] at 3:16 AM, written by LPN #2, documented that at 12:35 AM, the resident c/o abdominal pain. She had vomited a moderate amount of brown emesis, on her gown and bed linens and the bathroom floor was covered with brown colored stool. RNS #2 was called to the unit to assess the resident. The ,[DATE] Medication Administration Record [REDACTED]. A Nurse's Note dated [DATE] at 3:08 AM, written by RNS #2, documented the resident complained of pain in the right lower side of her abdomen and it was tender when the nurse touched the area. The resident and staff both stated she had vomited what appeared to be fecal matter (brown emesis) at the end of the evening shift and that diarrhea was leaking out of her rectum. RNS #2's 3:08 AM assessment documented the resident had abdominal pain in all areas of her upper and lower abdomen and there were no audible bowel sounds (BS- the absence of bowel sounds is an abnormal finding). RNS #2 was going to have the medical provider see the resident in the morning. A Nurse's Note dated [DATE] at 3:19 AM, written by LPN #2, documented the resident stated the Tylenol was not helpful in relieving her pain. The Emergency Department (ED) MD note dated [DATE] at 7:41 AM, documented the resident had a distended, tender abdomen with a firm mobile mass, absent bowel sounds, and the suprapubic (the area of the abdomen below the navel) region of the abdomen had a mottled appearance. The mass was a large inguinal hernia (a hernia in the groin area) and the MD was able to easily push it back into the resident's abdomen, however the resident did not show improvement in her condition. A CT scan was completed, and the report documented the resident had [MEDICATION NAME] ischemia ([MEDICATION NAME] ischemia is a medical condition in which injury to the intestine occurs due to not enough blood supply) secondary to superior [MEDICATION NAME] artery occlusion (blockage), air in the membrane that lines the abdominal cavity, and liver infarction (tissue death due to inadequate blood supply to the liver). She was in critical condition. The hospital Discharge Summary dated [DATE] at 4:06 PM, written by the Physician Assistant, documented the resident's primary discharge diagnosis/cause of death was superior [MEDICATION NAME] artery [MEDICAL CONDITION], acute ischemic [MEDICAL CONDITION], peritoneal free air, liver infarction, [MEDICAL CONDITION]. It documented the resident died on [DATE] at 7:38 PM. During an interview on [DATE] at 12:02 PM, RNS #1 stated she was called on [DATE] at 6:30 PM by LPN #1 regarding Resident #2, and arrived on the unit approximately 10 minutes later. LPN #1 reported the resident c/o a stomachache and reported the resident's vital signs were stable. When RNS #1 assessed the resident, her BS were hyperactive throughout the abdomen and the resident told her that her stomach hurt. She stated she thought maybe the resident's stomach issues were because there had been a stomach bug in the facility at that time, and/or the resident may have needed to have a BM (bowel movement). RNS #1 did not receive any further reports regarding the resident unitl she was called back to the unit on [DATE] at 12:35 AM because the resident had vomited. She reassessed the resident who still c/o abdominal pain. RNS #1 stated she smelled the vomit and it smelled like bile. She reported to RNS #2 that the resident had vomited. RNS #1 stated that when she assessed the resident at 12:35 AM, the resident was agitated and walking around the room, so she was unable to listen to her bowel sounds. During an interview on [DATE] at 1:15 PM, RNS #2 stated that on [DATE] at 1:00 AM, she received report form RNS #1. RNS#1 did not report the resident's abdominal pain but reported the resident had vomited and eaten chocolate. LPN #2 reported that at 2:16 AM the resident was complaining of abdominal pain, and she had given the resident Tylenol. RNS #2 also stated that between the report from LPN #2 and RNS #1, she did not rush to the unit because she was in the process of sending another resident to the hospital. She assessed the resident at 3:08 AM on [DATE]. The resident did not appear to be in a lot of pain, bowel sounds were not present and when she palpated the resident's abdomen, Resident #2 said Ow! but the resident said she was not in pain. She thought the resident was on comfort care, so she did not check the resident's chart for Advance Directives for the resident's wishes concerning transfers to the hospital. She assessed the resident a second time, prior to 5:00 AM, but did document the assessment. She stated the resident did not appear to be in acute distress but had hypoactive BS at that time. She did not feel the MD needed to be contacted. At 6:00 AM, the resident started to have mottling (blotchy, red-purplish marbling of the skin caused by the heart no longer being able to pump blood effectively) and she was concerned the resident could have a bowel obstruction. RNS #2 checked the chart and saw that the resident was not comfort care and that the MOLST documented the resident's wish to be sent to the hospital. She then called the MD and reported her assessment findings, and the MD ordered the resident to be sent to the hospital. She stated she should have checked the resident's Advance Directives when she assessed her at 3:08 AM. During an interview on [DATE] at 1:35 PM, LPN #2 stated, on [DATE] at 12:35 AM the resident vomited what appeared to have been fecal matter and complained of stomach pain. At 2:16 AM, Tylenol was given and at 3:19 AM Resident #2 reported the Tylenol was not effective in relieving her pain. RNS #1 told LPN #2 that she thought the abdominal pain was from something Resident #2 ate and that the resident's BS were hyperactive. RNS #1 saw the resident at approximately 6:30 PM and again at 12:30 AM but did not document either assessment. When RNS #2 assessed the resident, she told LPN#2 that the resident had no bowel sounds and was RNS#2 was concerned about the resident. RNS#2 reassessed the resident again at 5:00 AM, and the resident was sent to the hospital at approximately 7:00 AM. During an interview on [DATE] at 3:04 PM, the Director of Nursing (DON) stated she had been told that on [DATE] Resident #2 had been sent to the hospital and had died later that day. On [DATE] she reviewed the resident's medical record and noticed there was LPN documentation that she had notified RNS #1 of the resident's condition. There was no documentation from RNS #1. RNS #1 told her she did not document her assessments of Resident #2 on [DATE] at 6:30 PM and [DATE] at 12:35 AM. The DON stated RNS #1 felt the the resident had eaten something that did not agree with her and had an upset stomach. She went back a second time to the resident's room at 12:35 AM and saw that the resident had vomited and had diarrhea. RNS #1 gave report to RNS #2 regarding the resident prior to leaving work. After reviewing the Nurses Notes, the DON stated RNS #2 assessed the resident at 3:08 AM, and RNS #2 should have called the physician (MD) at 3:08 AM when she documented there was an absence of bowel sounds. RNS #2 also should have checked the resident's chart at 3:08 AM to determine her advance directives, and should have documented her [DATE] 5:00 AM assessment of the resident. During an interview on [DATE] at 9:28 AM, LPN #3 stated that on [DATE] she received report that the resident had not felt well during the night. At 6:10 AM, the resident was still in bed, but shortly after that the resident came out into the hallway and stated her belly hurt. She notified RNS #2 who told her she had just called the MD and had an order to transport the resident to the hospital. The hospital transfer paperwork was completed, and the resident was transported to the hospital by ambulance at 7:00 AM. During a subsequent interview on [DATE] at 12:28 PM, the DON stated the CCP defined how nursing should be caring for the residents and contained individualized interventions for each resident. She reviewed the resident's CCP for constipation and stated staff were supposed to monitor, document, and report nausea, vomiting, and abdominal pain. The nursing staff should have assessed, documented and notified the MD of their assessment findings in a timely manner, but they did not. During an interview on [DATE] at 8:21 AM, the Medical Director stated the nurse paged him on [DATE] at approximately 6:10 AM, and reported the resident had vomited what may have been fecal matter. The nurse did not sound concerned and did not sound like the situation was an emergency. It was more like she was just reporting the appearance of the vomit and wanted to know if he had any orders for the resident. He told her that if she thought it was fecal, then the resident had to be evaluated because she may have had a bowel obstruction. He gave an order to send the resident to the hospital. After reviewing the resident's facility medical record, the MD stated it appeared the resident had been in pain for some time, starting with the evening shift, and it would have helped him in piecing together the timeline of the resident's change in condition if the RNS #s 1 and 2 had documented their assessments. The MD stated he should have been notified at 12:35 AM, when the resident continued to be in pain, and had emesis suspicious of fecal matter, as this constituted a medical emergency. It was not a nursing judgement to determine if the vomit was fecal matter or not and that should have been discussed with the MD. The MD stated whatever the resident's emesis was, coupled with her pain, he should have been called. Staff should have checked the resident's advance directives. He did not understand why the nurses did not call him sooner, because they call him about other residents when they had vomiting or diarrhea. He could not determine if there would have been a better outcome for the resident, but she would have been seen sooner and had the opportunity to see a specialist. There could have been more done for the resident and there would have been a discussion at that time with the family and resident about treatment. Treatment could have been started, or an alternative treatment plan such as comfort care depending on the prognosis. The MD stated the resident should have been sent to the hospital when she became symptomatic at 12:35 AM so she could have had a chance for treatment. He reviewed the MD notes from ,[DATE] through ,[DATE] and the resident had no abnormal gastrointestinal findings. 10 NYCRR 415.3(e)(2)(ii)(b)

Based on record review and staff interviews during an abbreviated survey (Case #NY 544), the facility did not maintain medical records on each resident that were complete and accurately documented for 1 (Resident #2) of 3 residents reviewed. Specifically, Registered Nurse Supervisor (RNS) #1 and RNS #2 did not document their assessments of the resident's abdominal pain, vomiting, diarrhea, and hypoactive bowel sounds in the Nurses Notes for [DATE] at 6:30 PM, [DATE] at 12:35 AM (RNS #1), and [DATE] at 5:00 AM (RNS #2). Subsequently vital assessment documentation was missing from the resident's medical record. This was evidenced by: Resident #2: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severe cognitive impairment, was usually understood, and could usually understand others. A Nurse's Note dated [DATE] at 10:09 PM, written by Licensed Practical Nurse (LPN) #1, documented that at 6:30 PM, the resident complained of (c/o) abdominal pain. The resident had hyperactive (noisy, overactive) bowel sounds. [MEDICATION NAME] (Tylenol) was offered but the resident declined. LPN #1 notified RNS #1. A Nurse's Note dated [DATE] at 3:16 AM, written by LPN #2, documented that at 12:35 AM, the resident c/o abdominal pain. She had vomited a moderate amount of brown emesis, on her gown and bed linens and the bathroom floor was covered with brown colored stool. RNS #2 was called to the unit to assess the resident. During an interview on [DATE] at 12:02 PM, RNS #1 stated she was called at 6:30 PM by LPN #1 regarding Resident #2 and arrived on the unit approximately 10 minutes later. LPN #1 reported the resident was c/o a stomachache and reported the resident's vital signs were stable. When RNS #1 assessed the resident, her BS were hyperactive throughout the abdomen and the resident told her that her stomach hurt (she did not document the assessment). She did not receive any further reports regarding the resident until she was called back to the unit at 12:35 AM because the resident had vomited. She reassessed the resident who was still c/o abdominal pain. RNS #1 stated she smelled the vomit and it smelled like bile, but did not document the assessment. During an interview on [DATE] at 1:15 PM, RNS #2 stated that on [DATE] at 5:00 AM, she re-assessed the resident. She had hypoactive bowel sounds at that time, but she did not document the assessment. She stated she must have gotten busy and forgotten to document the assessment. During an interview on [DATE] at 3:04 PM, the Director of Nursing (DON) stated she had been told that on [DATE] Resident #2 had been sent to the hospital and had died later that day. On [DATE] she reviewed the resident's medical record and noticed there was LPN documentation that she had notified RNS #1 of the resident's condition, but there was no documentation from RNS #1. RNS #1 told her she did not document her assessments of Resident #2 on [DATE] at 6:30 PM and [DATE] at 12:35 AM. The DON stated RNS #2 also should have documented her [DATE] 5:00 AM assessment of the resident. During an interview on [DATE] at 8:21 AM, after reviewing the resident's medical record, the Medical Director stated that it appeared the resident had been in pain for some time, starting with the evening shift, and it would have helped him in piecing together the timeline of the resident's change in condition if RNS #s 1 and 2 had documented their assessments. 10 NYCRR 415.22(a)(,[DATE])

Based on observation and staff interview, it was determined during the extended recertification survey that the facility failed to store and serve potentially hazardous food under sanitary conditions. Specifically, the facility failed to recognize that the walk-in cooler, the kitchen's sole source of refrigeration, was not operating properly and that food items were warm. Meatballs were found to be 55 degrees Fahrenheit (F) after being held in the walk-in cooler for 3 days. The facility's temperature monitoring of the walk-in cooler was inconsistent and there was no calibration process for the walk-in cooler's thermometer. The ambient temperature of the walk-in refrigerator was measured at 60 F while the facility-provided thermometer read 46 F. Additionally; the kitchen staff did not monitor and log refrigerated food temperatures consistently to ensure food was cooled to 41 degrees F with in six hours. The facility did not clearly mark cold-held food to indicate the date by which the food shall be consumed or discarded (consume by date) as required. This has the potential to effect 104 of 105 residents. This resulted in no actual harm but had the potential for more than serious harm that is Immediate Jeopardy to the health and safety of the residents. This is evidenced by the following: The Immediate Jeopardy was removed on 4/16/14 prior to the survey exit. The facility discarded all food from the walk-in refrigerator and from throughout the facility. The facility in-serviced staff on the required food cold-holding temperatures, thermometer calibration and food temperature monitoring, and internal reporting procedures for faulty equipment. The facility replaced the compressor servicing the walk-in refrigerator, thoroughly cleaned the interior, and returned the walk-in refrigerator to operation with 100% fresh food stock. The facility purchased and put into service a new 2-door reach-in refrigerator to minimize traffic in and out of the walk-in refrigerator. To monitor food storage temperatures and the walk-in refrigerator ambient temperature, the facility placed a calibrated metal stem probe thermometer (probe thermometer), pierced through the cap of a gallon water container, in the walk-in refrigerator and installed 2 new calibrated shelf thermometers. The facility implemented monitoring programs for cold-holding foods and thermometer calibration. Accepted safe food handling practice dictates that food be cold-stored at 41 F or less and requires that facilities provide refrigeration sufficient in number and capacity to cold-hold food at 41 F or less. Thermometers shall be calibrated. Additionally, the facility did not cool food within 6 hours total to 41 F as required and the facility did not clearly mark cold-held food to indicate the date by which the food shall be consumed or discarded (consume by date) as required. On 04/14/2014 at 8:50 AM, cold held foods in the walk-in refrigerator were found to be marked with the prepared date only. During the tour of the main kitchen on 04/14/2014 at 9:20 AM the probe thermometer used by Cook #1 was found to be 20 F when checked for calibration in an ice bath. A new probe thermometer was found to be accurately calibrated and was used at 9:30 AM to measure meat balls in sauce to be 55 F. The date label on the pan of meatballs read that this item was prepared on 04/11/2014, 3 days prior to the survey temperature measurement. During an interview on 04/14/2014 at 9:30 AM Cook #1 stated that on 04/11/2014 he cooled the meatballs ( the meatballs that were measured at 55 F on 4/14/14) in sauce, by filling a 10-inch by 12-inch by 6-inch deep pan and placing it in the refrigerator and did not monitor the cooling times and temperatures. Further, Cook #1 stated that he had not cooled the meatballs correctly and that the meatballs were above the required minimum temperature. The new calibrated probe thermometer was used in all subsequent food temperature measurements. On 04/14/2014 at 1:50 PM, egg salad was found to be 57 F. At 2:00 PM ham was found to be 56 F, roast beef was 56 F, and prepared pineapple was 56 F; the ambient temperature of the walk-in refrigerator was measured at 60 F while the facility-provided thermometer read 46 F. During an interview conducted on 04/14/2014 at 1:50 PM the Food Service Director stated that for the past month, the walk-in refrigerator was sometimes having problems maintaining temperature; the facility needs a reach-in refrigerator to decrease traffic through the walk-in; the walk-in ambient temperature was not adequately monitored over the past weekend; and the temperature of food stored in the walk-in refrigerator was not monitored. 10 NYCRR 415.14(h)

Based on medical record reviews and staff interviews during a complaint investigation (Case # NY 982) the facility did not ensure that each residents drug regimen was free of drugs without adequate monitoring during its use for one (Resident #1) of four residents reviewed. Specifically when the resident was admitted to the facility from the hospital on [DATE] and ordered to receive intravenous [MEDICATION NAME] through a PICC ( peripherally inserted central catheter) as he had in the hospital, the facility did not order peak and trough ( used to determine safe levels of the [MEDICATION NAME]) levels to be drawn. On 1/8/14, the resident was noted to have a [MEDICATION NAME] trough level of 42.9 mcg/ml (micrograms per milliliter), above the desirable range of 10 to 15 mcg/ml. Subsequently, the resident was noted to have a elevated creatinine and blood urea nitrogen (BUN) ( both are tests that determine kidney function). This was an isolated incident that resulted in actual harm that is not immediate jeopardy. This is evidenced by the following: Resident # 1 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set assessed the resident to have long and short term memory impairment. Resident # 1's physician order [REDACTED]. Resident # 1's "Physicians Orders" throughout his admission at the nursing home, an order was not written for a [MEDICATION NAME] peak or trough level to be drawn until 1/9/14. Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Nurse's notes entered on 1/2/14 at 5:00pm, a nurse documented that blood was drawn from the PICC line for International Normalized Ratio( INR- a test used to determine blood coagulation time) and blood sugar. In a late entry on 1/8/14 for 1/7/14, a nurse documented that the resident was sent out to the Infusion Center for treatment of [REDACTED]. On 1/8/14 at 5:00pm, a nurse documented that a [MEDICATION NAME] trough level was drawn at 2:00pm and the hospital lab called to advise staff that Resident # 1's trough level was critically high at 42.9 mcg/ml. A note entered on 1/9/14 at 4:00pm, documented that a physician's assistant had given an order to hold Resident # 1's dose of [MEDICATION NAME] until seen by the physician. The final note is written at 5:00pm on 1/9/14 when the nurse documented that the resident passed a stool that was positive for blood and was being sent out to the local emergency room for evaluation. During an interview on 1/14/14 at approximately 10:00am, a registered nurse unit manager (RNUM) stated that Resident #1 was admitted to the facility on [DATE] with a PICC line and was to receive intravenous [MEDICATION NAME] 1500 mg each day for 42 days. On 1/8/14 when arrangements were being made for discharge, the home care agency asked what the resident's recent [MEDICATION NAME] peak and trough levels had been. It was then that staff realized that the levels had not been previously drawn, an order was obtained and a trough level was drawn. The RNUM recalled that later in the day on 1/8/14, a call was received from the lab advising the staff that the resident's trough level was critically high at 42.9 mcg/ml. During an interview on 1/14/14 at approximately 2:00pm, the Medical Director (Med Dir)stated that it is desirable to have [MEDICATION NAME] trough levels drawn on a weekly basis and that is what he would have expected to see for Resident # 1. The Med Dir added that not drawing the resident trough levels was a "typical hand-off mistake." He explained that the discharging physician at the hospital had not advised in the discharge summary that the [MEDICATION NAME] trough levels should be drawn. The physician at the nursing home had overlooked that the trough levels should be drawn and the nursing staff at the nursing home did not recognize that the trough levels had not been ordered or drawn. The Med Dir stated that the resident had critically high [MEDICATION NAME] trough levels when he was admitted to the hospital for a [MEDICAL CONDITION] on 1/9/14 and this had caused the resident's BUN and creatinine to become elevated. The Med Dir stated that he had been following the resident's progress while in the hospital and the resident's blood work (BUN and Creatinine) were improving and he was hopeful that this trend would continue and the resident would not have permanent kidney damage. 10NYCRR 415.12(l)(l) .

Based on medical record review, observation and staff interview the facility did not ensure that the resident received modification to the wheelchair to prevent accidents for 1(#5) of 5 residents reviewed during a post survey revisit. Specifically, after Resident #5 stood in his wheelchair, fell forward, landed on his right side, hit his head and the wheelchair fell on top of him, the registered nurse documented actions taken for prevention included: reapply anti-tipping device, and apply sandbags to the chair. There was no documented evidence Physical Therapy(PT) or Occupational Therapy(OT) were notified of these recommendations, a PT or OT assessment was completed and recommendations were made. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. This is evidenced by: Resident #5 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident ' s Brief Interview for Mental Status score (BIMS) was 3/15 (severely cognitively impaired). This same MDS assessed the resident had a fall within a month prior to admission and one fall since admission. The Episodic Screening/Referral Request dated 2/11/13 documented the resident ran over his right 4th toe with his wheelchair (w/c) causing injury to the toe. The bottom of this form, which was signed and dated by the Certified Occupational Therapy Assistant on 2/12/13 documented the recommendations included: the resident would benefit from front anti-tippers to decrease w/c tipping forward and also aid in keeping the resident ' s feet from coming close to the wheels to increase safety. The Nurse ' s Notes dated 3/19/13 at 10:15am documented the nurse was called to the floor to assess the resident who flipped over in his w/c, landed on his right side and hit his head. This note documented the resident ' s range of motion and neurological (neuro) status was within normal limits, and the resident was noted to have a 4cm reddened area to the right side of his forehead. The note also documented the Nurse Practitioner was notified, and ordered neuro checks per protocol, and send to the emergency room if symptoms of pain or altered mental status occur. The " Accident/Incident Report " (A&I) dated 3/19/13 at 10:15pm documented the resident stood in the w/c, fell forward, landed on his right side, hit his head and the w/c landed on top of him. The " Investigation of Bruise/Skin Tear/Abrasion Form dated 3/19/13, which was attached to the above A&I, documented the actions taken for prevention included: reapply the anti-tipping device to the w/c, obtain alternate footwear the resident cannot easily remove and apply sand bags to the chair. The Comprehensive Care Plan (CCP) for Falls/Safety initiated 1/11/13 and most recently updated on 3/19/13 documented front anti-tippers were added to the resident ' s w/c on 2/12/13 and discontinued on 3/18/13. This same care plan documented on 3/19/13 the resident stood in the w/c with the seatbelt attached, fell forward, fell on his right side hit his head and the w/c landed on top of him. This CCP documented the resident sustained [REDACTED]. Interventions documented antitippers to chair and sand bags to weigh chair down. The Nursing Assistant Care Card last updated on 3/19/13 and identified by the registered nurse unit manager as current for 3/20/13, documented the resident had anti tippers on the back of the w/c. There was no documented evidence the front anti tippers and the sand bags were to be utilized for this resident ' s w/c. On 3/20/13 at 11:00am the resident was observed sitting in his w/c with no front anti-tippers or sand bags on the w/c. During interview on 3/20/13 at 11:30am the Physical Therapist who was in charge of the therapy department for 3/20/13, stated if the nursing staff wants to request a change to the resident ' s w/c they should notify the therapy department by submitting an Episodic Screen Form. The therapist will then assess the resident, and if any changes are recommended for the resident ' s w/c, the request will be documented on a Maintenance Log Sheet, and maintenance will make the changes. The Physical Therapist also stated she had no documented evidence of any Episodic Screen Forms for this resident since 3/11/13. The Physical Therapist stated there she had no Episodic Screen Form from 3/19/13. 10NYCRR415.12(h)(1)

Based on record review and staff interview, the facility did not ensure that the resident receives assistance devices to prevent accidents during an abbreviated survey ( Case # 642). Specifically, for one ( Resident #1) of five reviewed, the facility did not provide anti tippers or a counter weight ( used to assist in preventing tipping) to the resident wheelchair as recommended by physical therapy (PT). Subsequently, the resident fell backwards while in his wheelchair and was hospitalized for [REDACTED]. This resulted in actual harm that is not immediate jeopardy. This is evidenced by the following: Resident #1 The resident was admitted to the facility on [DATE] diagnosed with [REDACTED]. Comprehensive Care Plan for Behaviors initiated on 9/25/12 documented the resident wanders into other resident's rooms and on 11/20/12, an intervention was added to include piping added to back of wheelchair to prevent going into others rooms. Nursing Assistant Care Card (utilized by Certified Nurse Assistants to determine all assistive and safety devices and care instructions) updated 11/27/12 documented that the resident' protective devices, cushions and mattresses included, poseyrolls, 2 blue fall mats, a bed alarm and one hour checks of the resident. An update on 12/16/12 documented a pressure redistribution mattress and a ROHO cushion in wheelchair. Nurse ' s note dated 12/10/12 (untimed) documented that the resident fell out of his wheelchair in the dining room at 4:45 pm, no injuries were noted and the supervisor was made aware. Nurse ' s note dated 12/28/12 at 12:00 pm, documented that at 9:10 am the resident was found flipped over in this wheelchair on the ground, the physician was notified for questionable mental status changes and new orders were obtained to transfer the resident to the hospital for evaluation and a CT scan. Nurse ' s note dated 12/28/12 at 3:30 pm documented that the resident was admitted to the hospital diagnosed with [REDACTED]. Incident and Accident Report dated 12/28/12 at 9:10 am documented that the resident was found with his wheelchair flipped over on the ground. The attached fall investigation documented that the environmental factors included a T bar on wheelchair and documented that the " T " bar hit the corner of edge of wall going to the shower and flipped backward in his wheelchair. Nursing Assistant Care Card updated 12/31/12 documented that the resident ' s protective devices, cushions and mattresses included, poseyrolls, 2 blue fall mats, a bed alarm and one hour checks of the resident, pressure redistribution mattress. When roaming in the hallway, apply a " T " bar to wheelchair - anti-tipper on back of wheelchair - weight bottom wheelchair, clip and bed alarms. An investigative statement signed by the Registered Nurse Manager (RNM) documented on 12/10/12, the resident was placed in a wheelchair with a " T " bar on back of his wheelchair to prevent resident from entering other resident ' s rooms, counter weights and non-tippers were also applied. On 12/8/12 resident had skin breakdown and ROHO cushion was placed in wheelchair. The resident was unable to self propel in wheelchair because of the wheelchair cushion made him too high and his feet did not touch. Resident was placed in a lower wheelchair " T " bar reapplied but the counter weights and non-tippers were not reapplied to the smaller wheelchair. The investigative summary coordinated by the Administrator documented in conclusion that the resident' wheelchair should have had anti-tippers with the T bar to reduce the risk of the wheelchair tipping backwards. The conclusion also documented that maintenance staff applied anti-roll backs instead of anti tippers and the RNM didn't recognize the difference until the reenactment of the fall. During an interview on 1/3/13 at 11:30 am, the Maintenance Manager (MM)stated that he attended an Interdisciplinary team meeting in which Resident #1 ' s wandering behavior was discussed. The MM stated that during that meeting the Administrator, PT Director and other team members decided to construct a device to be placed on the resident's wheelchair to prevent him from entering other resident's rooms. The MM stated that the device was made of PVC pipe in the form of a " T " and was applied to the resident ' s wheelchair on 11/20/12. The MM stated he also applied anti rollers to the resident ' s wheelchair as discussed in the same meeting. The MM stated that he was called to the nursing unit again between 12/10 and 12/11/12 to obtain a smaller wheelchair for the resident and he moved the " T " bar and anti rollers onto the new wheelchair. The MM stated that after the resident's fall on 12/28/12, he learned that anti tippers should have been applied on 11/20/12 when the " T " bar was affixed to the wheelchair. During an interview on 1/3/12 at 1:30 pm, the RNM stated that if nursing staff determine there is a need for a new positioning device for a resident, a Physical Therapy Screen should be sent by nursing to the PT department. The RNM stated that during a team meeting, a decision was made to add a " T " bar and anti tippers to the resident's wheelchair to prevent him from wandering into other resident's rooms. The RNM stated that MM applied the " T " bar and anti tippers on 11/20/12 and advised her of such. The RNM stated that she observed both of the devices on 11/20/12, and stated " but now I realize I made a mistake, I thought that the anti rollers were anti tippers." The RNM stated that on 12/10/12, the wound nurse advised her that the resident had a new pressure area and wanted to add a ROHO cushion to the wheelchair, to which she agreed and the wound nurse applied it. The RNM stated later that day, the resident fell forward out of his wheelchair while in the dining room. The RNM stated on 12/11/12, the team decided to change to a smaller chair. The RNM stated that all of the devices were added to the new smaller chair and issued to the resident. The RNM stated that she looked at the smaller chair and observed the same anti tipper device that was placed on the original chair. The RNM stated that it was not until after the resident's fall on 12/28/12, the Director of PT came to the nursing unit and immediately identified that the device on the resident' chair was anti roll backs and not anti- tippers. The RNM stated that she had not requested that PT screen or evaluated the resident as these new devices were being added to the wheelchair. The RNM stated that PT would be the discipline responsible to determine if the resident was safely positioned in his chair. The RNM further stated that she is responsible for updating the care card utilized by CNAs, and that she never added the " T " bar or anti tippers to the care card, " so they would not have known to look at them. " During an interview on 1/3/13 at 4:15 pm, the Director of Physical Therapy (DPT) stated that the PT department is responsible for evaluations and assessments of residents and assistive devices to determine the safest situation for the resident. The DPT stated that he recalls the discussion in IDT that the resident was entering other resident ' s rooms and it was agreed upon that maintenance would construct a device to be attached to the resident ' s wheelchair. The DPT stated that the team also discussed at length the need for anti tippers to be attached along with the " T " bar to ensure the resident ' s safety. The DPT stated that at some point, the wound nurse requested a ROHO cushion from him for the resident but that he did not evaluate or assess the ROHO in the resident ' s chair because " I assumed the safety of the added cushion would have already been assessed. " The DPT stated he was not aware of the fall on 12/10/12 after the ROHO was placed or of the smaller wheelchair given to the resident. The DPT stated that nursing should have submitted a request for a screen by PT when changing the wheelchair. The DPT stated that after the fall on 12/28/12, he observed the resident ' s wheelchair and the first thing he noticed were the anti rollers and asked, " why are the anti tippers not on? " The DPT stated that during the discussion of adding the " T " bar, " this was my biggest issue, the chair had to have anti tippers. This is the exact scenario that we were worried about. " The DPT stated, " I am at a loss for where this broke down. " The DPT stated, " sometimes we get a screen from nursing and sometimes we don ' t, this is something we are working on with the Administrator. " During an interview on 1/3/13, the Administrator stated that the facility is working on a new process of communication between nursing and PT as a result of this incident. Regarding Resident #1, the Administrator stated, " we missed the fact that the anti tippers weren't there " and because the " T " bar and anti tippers were not added to the CNA care card, the CNAs wouldn't have seen that the wrong device was on the wheelchair. 10NYCRR 415.12(h)(2)

Based on medical record review and staff interviews during an abbreviated survey (Case #NY 669) it was determined that for one (Resident #3) of five residents reviewed, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, the resident was receiving an anticoagulant (slows clotting time of blood), the facility did not ensure adequate monitoring of the residents blood coagulation, and did not adequately to signs and symptoms. The INR ( International Normalized Ratio) was documented by the facility 21 days after admission. The facility used a coagulation machine that only read to greater than 8. The resident was noted to have an elevated INR, three days later, which required hospitalization . This resulted in actual harm that is not immediate jeopardy. This is evidenced by the following: The facility policy titled "Anticoagulation Flow Record" dated 8/2005, documented as their standard, the anticoagulation flow sheet is utilized to record results of blood coagulation tests. Documented as their policy, physicians orders specify blood coagulation tests; physician is notified of blood coagulation study results; physician is notified of last written anticoagulation order; new orders are obtained from the physician and written on the physician order [REDACTED]. Documented as the procedures: blood coagulation study results are obtained from the laboratory; the Registered Nurse (RN) supervisor obtains the clinical record and verifies the previous physician order [REDACTED]. Resident # 3: The resident was admitted to the facility 12/7/12 with [DIAGNOSES REDACTED]. The admission Minimum Data Set assessed the resident had intact cognition. The hospital discharge summary dated 12/7/12 documented that the resident was receiving [MEDICATION NAME] 2.5 milligrams (mg.) every Monday, Wednesday & Friday; and [MEDICATION NAME] 5 mg. on Sunday, Tuesday Thursday and Saturday. The residents [MEDICATION NAME] can be adjusted accordingly. It may have to be decreased. Hemoglobin dated 12/6/12 11.0 (normal 12-16) & hematocrit 30.9 (normal 35- 45). The INR dated 12/7/12 was 2.7 (normal range 2-3 for [MEDICAL CONDITION] on [MEDICATION NAME]). Physician orders [REDACTED]. Nurse's notes documented the following: 12/7/12 at 11:00 pm the resident was admitted post lysis for persistent small bowel obstruction. 12/8/12 at 11:59 pm, bilateral [MEDICAL CONDITION] to lower extremities. 12/9/12 at 3:00 pm, complained of shortness of breath, stated he used oxygen at the hospital. Sputum brown & yellow tinge (normal color clear). 12/15/12 at 2:00 pm resident had dry heaves. 12/18/12 (untimed) complained of shortness of breath this morning and nausea. Noted to be dry heaving with production of scant amount of brown colored sputum. 12/19/12 (untimed) coughing up brown sputum. 12/23/12 (untimed) complained of nausea and stomach upset. 12/24/12 (untimed) complained of right leg [MEDICAL CONDITION] and discomfort; spongy feeling to area on back of right leg. 12/26/12 at 5:00 am complained of right thigh knee discomfort, with a 15 centimeter (cm) bruise on posterior thigh/knee. 12/26/12 (untimed) INR greater than 8 (on the coagulation machine), hold [MEDICATION NAME]. Large bruise on back of right thigh; bruise purple in color; resident very shaky and unsteady on feet. Complained of nausea and vomiting; sputum with brown blood tinge. 12/27/12 at 5:00 am anxious stating he was having difficulty moving/breathing. Right posterior thigh observed to be purple/black in color traveling down upper calf (just below knee bend). 5:07 am large area of hematoma right posterior thigh extending down to posterior knee area. Warm to touch. The physician made aware of coagulation check, INR on the coagulation machine registered greater that 8. INR already ordered. 12/28/12 at 11:00 am, the physician was made aware of INR greater than 8; new order to send to the emergency room for further evaluation. physician progress notes [REDACTED]. 12/17/12 lower extremities are 2 - 3 plus [MEDICAL CONDITION].(scale used to describe depth of swelling), in the left extremity which extends mid shin. No [DIAGNOSES REDACTED], no tenderness. 12/24/12 asked to see the resident regarding right upper thigh discomfort since this morning. The resident reports swelling on the right posterior thigh as well as tenderness to touch. The resident states that the right thigh pain is due to pressure that was put on the right leg throughout the night. 12/27/12 the resident's INR has climbed significantly high. Today it is greater than 8. Right lower extremity exhibits a very large ecchymotic area extending all the way from his inferior right buttock down to his superior calf all along the posterior edge of his right lower extremity. The area is approximately 25 - 30 cm. in length and between 5 - 15 cm, in width. It is tender without guarding. 12/28/12 to review an INR today, which is greater than 8 despite holding the [MEDICATION NAME] for three days. In addition he has a very large right lower extremity ecchymosis. The resident is uncomfortable with pain and shortness of breath and appears pale. The MAR for the month of December documented that the resident had ice packs to the right posterior thigh three times a day starting on the evening shift on 12/24/12 through the day shift on 12/26/12. A laboratory slip dated 12/26/12 at 7:35 pm documented the specimen was insufficient quantity, please redraw. There was no documentation of another laboratory INR drawn at that time. The facility sheet titled "Anticoagulation Flowsheet" dated 12/26/12 documented an INR of greater than 8; next INR to be drawn 12/27/12. Documentation on 12/27/12 revealed the INR is greater than 8, the [MEDICATION NAME] is on hold and next INR to be drawn on 12/28/12. Documentation on 12/28/12 documented that the INR is greater than 8, the [MEDICATION NAME] is on hold and the next INR is to be drawn on 12/29/12. There was no other documentation of a repeat INR. The facility form titled "Transfer form" dated 12/28/12 (untimed) documented that the resident was being transferred to the hospital because of an INR greater than 8 for seventy-two hours and worsening bruise. Documentation from the hospital dated 12/28/12 at 4:50 pm documented that the resident was being admitted due to an elevated INR (6) with symptomatic severe [MEDICAL CONDITION] and decreased mental status. The INR was elevated greater than 8 for the past seventy-two hours. The RN manager was interviewed on 1/3/13 at approximately 12:40 pm who stated she became aware of the resident's INR about 12/26/12 when the area was noted behind the resident's right knee upper hip area. It was realized then that the INR was not charted after the 12/8/12 INR and therefore the physician probably didn't re-order an INR. The nurse practitioner was made aware on 12/27/12 and she wanted an accurate reading, so the specimen was taken. The specimen was insufficient quantity. The next day the physician discontinued the [MEDICATION NAME] and ordered vitamin K (promotes clotting) to be administered. The resident went to the hospital on [DATE]. 10 NYCRR 415.12

Based on medical record review and staff interviews during a complaint investigation (Case #NY 998), the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for one (Resident #1) of one resident reviewed, the facility did not ensure that all staff were aware that the resident was not to be left unattended in the bathroom because of her decreased safety awareness. This resulted in actual harm that is not immediate jeopardy. This is evidenced by the following: Resident # 1 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent minimum data set ((MDS) dated [DATE], assessed the resident to have long and short term memory impairment. An incident/accident report dated and timed for 12/15/11 at 10:15pm, documented Resident #1 was found on the floor in the bathroom with a laceration to the right forearm; that the fall was un-witnessed and the resident was sent out to the emergency department and received stitches to close the laceration. In an attached statement dated 12/15/11, CNA #1 documented that she left the resident unattended in the bathroom for no longer than 10 minutes and added that she was never told during her training that she had to stay in the bathroom with a resident that had a bed alarm. A record from the local hospital documented that Resident # 1 was admitted to the ED on 12/15/11 at 11:00pm with a laceration to the right forearm. Ten stitches were required to close the wound. Nurses Notes dated 12/15/11 for the 3:00pm - 11:00pm shift, documented that Resident # 1 was found on the bathroom floor and a "deep laceration" was noted on her right forearm. The resident also complained of pain in the back and coccyx area. The resident was assessed, left on the floor, the physician (MD) was called and the resident was sent out to the ED. A fall risk assessment form for Resident # 1, dated 11/18/11 revealed a fall risk assessment score of fourteen. Instructions on this form indicated that a score above ten indicated the resident is at high risk of falling. ( It should be noted that section H on this form instructed that 2 points should be added if the resident was assessed with [REDACTED].# 1's score '16'.) A review of Resident # 1's SCPS, dated 12/13/11, two days before the resident's fall and the sheet printed closest to the date of the fall, revealed staff are instructed to ensure that Resident # 1 has bed, chair and clip alarms in place. The sheet does not instruct staff to not leave the resident unattended in the bathroom. A review of the SCPS for all of Unit 3, revealed there are instructions that nine of thirty-four residents should not be left alone in the bathroom. During an interview on 12/29/11 at approximately 11:00am, CNA #1 stated that she was originally scheduled to work on the second floor on 12/15/11 but after arriving at work that evening she was told that she would be floating to the third floor for the shift. She stated she did not know the residents on the third floor but recalled that she answered Resident # 1's call light at around 10:15pm and took the resident to the bathroom. CNA # 1 stated she had looked at Resident # 1's care card (standard of care provided sheet) earlier in the shift and knew that the resident was a two assist for transfers but did not recall seeing a warning to not leave the resident unattended in the bathroom. She placed Resident # 1 in a wheelchair, brought her into the bathroom and then transferred her to the toilet. She then left the resident unattended in the bathroom and went to assist another CNA with a Hoyer lift transfer. CNA # 1 was at the nurses' station waiting for the resident to put the call light on 5 to 10 minutes later, when she heard that Resident # 1 had been found by another CNA lying on the bathroom floor and bleeding from the arm. CNA # 1 stated she realized she should not have transferred the resident alone because she was a two assist for transfers but thought the resident did well with the transfer and there had not been any problems. During an interview on 12/29/11 at approximately 12:30pm, a certified nursing assistant (CNA #2) stated that she had worked full-time on the third floor for a number of years and knew Resident # 1 well. CNA # 2 stated she would not leave the resident unattended in the bathroom because the resident had fallen several times. CNA # 2 stated that generally a resident who had a bed alarm was not safe in the bathroom unattended. When asked where a staff member would find that information, CNA #2 stated it would be on the SCPS. During an interview on 12/29/11 at approximately 11:50 am a certified nursing assistant (CNA # 3) stated that she worked on unit three full time and she knew Resident # 1 and knew what her needs were. CNA #3 stated the resident was a risk for falling and she would not leave the resident unattended in the bathroom. The CNA stated that if she did not know the resident and needed to know what should be done for a resident she would look at the SCPS or ask one of the nurses. During an interview on 12/29/11 at approximately 3:00pm, the facility Director of Nursing (DON) was asked why the SCPS for Resident # 1 did not instruct that staff should not leave Resident # 1 unattended in the bathroom, just as the form did for other residents who were at risk for falls. The DON responded that she did not know why the form did not advise the CNA's against leaving Resident # 1 unattended. She added that information should be on the SCPS. 10NYCRR 415.12(h)(1)(2)

Based on observation, staff interview and record review during a complaint investigation (NY 816), the facility did not ensure that necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, for 1( Resident #1)of 2 residents reviewed, the facility did not implement a residents care planned interventions, did not administer a treatment in a dignified manner; and did not honor the resident's right to refuse treatment. Additionally, an incident report was not initiated timely and a Registered Nurse did not assess the resident after the resident stated "I broke my finger". The resident sustained [REDACTED]. This caused the resident actual harm that is not immediate jeopardy. This is evidenced by the following: Resident #1 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having severe cognitive impairment with daily decision making. The Comprehensive Care Plan (CCP) , titled Cognitive Status initiated 8/24/10, and last dated 12/5/10, documented the resident strengths as the ability to make her needs known. The CCP, titled Refusal of Care initiated on 8/24/10,and last dated 11/16/10, documented that the resident is able to participate in care plan decisions and that the resident refuses care including, medications. Interventions documented included; attempt at a different time of day and utilize a different staff member to encourage. The facility Policy and Procedure titled Bowel Regime dated 1/08 documented that Certified Nurse's Aides will document any bowel activity in the Bowel Movement Record (BMR) at the end of each shift. The Charge Nurse will review the book at the beginning and ending of each shift for residents who are in need of the bowel regime. Residents who have not had sufficient BMs with in the last 6 shifts will be administered 30 cc of Milk of Magnesia (MOM) at the beginning of the seventh shift. If the MOM is ineffective, the charge nurse will administer a [MEDICATION NAME] 10 mg suppository the following shift (8th shift). Residents not having results after the [MEDICATION NAME] Suppository will receive an enema within 12 hours. The fleets enema is to be administered at the time of day best adapted to resident needs, desires and quality of life. The BMR documented the resident had no BMs for a total of 10 shifts from 12/15/10-12/19/10. The nurses notes (NN) dated 12/18/10 at 6:30 am documented the resident received MOM at 12:00 midnight (8th shift), and there were no results as of 6:30 am. The MOM was not documented as administered on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] The NN dated 12/18/10 at 2:00 pm documented no BM from MOM and a suppository was given with the results pending. The Nurse's Notes (NN) dated 12/18/10 at 10:00 pm documented the resident received an enema according to the BM Protocol with results pending. The same note documented that the resident hit the certified nurses aide (CNA) during care while receiving the enema. The resident stated "I broke my finger". The NN documented there was no bruising noted, and the resident was able to bend the left "pinky" finger without difficulty. The Accident/Incident (A&I) Report dated 12/18/10 at 11:30 pm, documented that "during rounds, CNA noted bruising to the left outer hand, and large dark bruise on top of the right hand." The same A& I documented that on 12/20/10, a left hand x-ray revealed osteopenic bones, and an acute [MEDICAL CONDITION] metacarpal. The NN dated 12/18/10 at 11:30 pm documented the resident's left outer hand was slightly swollen with bruising, the resident was able to bend her fingers, and expressed no complaints of pain. This NN also documented there was a 9 cm by 6 cm bruise on the top of the resident's right hand. The NN dated 12/19/10 at 5:40 am documented that the resident was complaining of discomfort, was holding the side of the left hand. Bruising was increased in size, now 4cm from 3 cm with increased swelling and discomfort. The NN further documented that the Physicians Assistant (PA) was notified and advised to give Tylenol as needed and the PA would see the resident on Monday (12/20/10). The Investigation of Bruise/Skin tear/Abrasion Form dated 12/18/10 (untimed) described the location of the immediate environment as occuring in Resident #1's Room, in bed, with the staff from the 2:00 pm -10:00 pm shift, giving the resident an enema. In a statement prepared for the investigation of the bruising dated 12/19/10 signed by CNA #1, CNA #1 documented that during rounds at 11:00 pm, she and CNA #2 noticed a "big purple bruise on top of her right hand and a smaller bruise on her left hand" and documented that both CNAs informed their charge nurse of the bruises. In a statement prepared for the investigation of the bruising dated 12/19/10 (untimed), CNA #3 documented that "at approximately 9:30 pm, I attempted to give Resident #1 an enema with the assistance of CNA #4. Immediately, she began swinging and hitting at us and turned over on the enema so I called for LPN #1 and she came in and rolled her over so that I could finish. She (the resident) complained that her left pinky finger hurt and I told the LPN and she checked it" In a statement prepared for the investigation of the bruising dated 12/19/10 (untimed), CNA #4 documented that "at approximately 9:30 pm, CNA #3 attempted to give Resident #1 an enema, the resident hit me in the head and my glasses were bent. We tried to give the enema but Resident #1 rolled onto her back. LPN #1 came into the room and rolled her over so that we could give her the enema" An Illness Note dated 12/20/11 (untimed) signed by the PA documented that the resident was being seen for pain and bruising of both hands due to bruising and injury that occurred while the patient was receiving an enema and she was significantly combative to this. The PA further documented that the resident refused to allow the left hand to be touched and x-rays will be ordered. The NN dated 12/20/10 at 3:00 pm documented the resident was seen by the provider, and complained of pain with palpitation to the left pinky. A new order was received for an x-ray of the left hand which was completed and the results were pending. The NN dated 12/20/10 at 4:30pm documented the x-ray revealed a [MEDICAL CONDITION]'s 5th metatarsal (pinky). The Summary of Investigation Report signed by the Assistant Director of Nursing (ADON) on 12/20/10 regarding the 12/18/10 A&I in the section titled Investigation Findings documented "Resident has a history of being combative during care. Resident had been sleeping and was wakened to give enema approximately 2 hours prior". The section titled Changes Made to Plan of Care included "resident to be fully awake when procedure explained and administered, if the resident is combative, leave the resident safe and reapproach." The section titled Conclusion documented "Resident was combative when receiving an enema". The form documented the Director of Nursing's (DON) signature on 12/22/10 and the Administrator's signature on 12/23/10. During an interview CNA #4 on 1/28/11 at 3:15 pm, stated that she and CNA #3 were told at 9:30 pm by LPN #1 that Resident #1 needed an enema. CNA #4 stated that they went into the resident's room, woke her up and told the resident what they were doing (administering the enema). CNA #4 stated that when CNA #3 began to administer the enema, Resident #1 immediately began screaming, protesting the procedure and struck the CNA #4 in the face twice. CNA #4 stated that the resident rolled over onto the enema, they were lucky to get the enema out and that she went to get the LPN. CNA #4 stated that the LPN came in and was talking to the resident and the resident still did not want the enema. The LPN rolled the resident over, the resident still did not want it and began screaming "ouch, ouch" "I am cold". During an interview on 1/28/11 at 3:45 pm the ADON stated that she reviews all A&I's and investigates incidents as needed. The ADON stated that residents have a right to refuse medication and treatments and resident care plans should have documented on them that if a resident is combative with care, staff should reapproach the resident and if they still refuse, the refusal should be documented for follow-up with a physician or family member depending on the medication or treatment being refused. The ADON stated that she conducted an investigation of Resident #1's bruising discovered on 12/18/10 and although she thought that the CNAs should have stopped administering the enema she believed that LPN #1 had stated that the procedure was almost complete, so they just finished. The ADON stated "I thought they used bad judgement, would I have continued?...no". The ADON stated that she did not think that 9:30 pm was a reasonable time for a sleeping resident to be administered an enema. The ADON stated that she reviewed the investigation file and stated that there was no statement from LPN #1 regarding the incident. The ADON stated at the time, she did not believe the incident was abuse and based that conclusion on the information that she had at the time, however, by definition the incident was abuse. During an interview on 1/28/11 at 4:00 pm the DON and the Administrator, both stated that at the time of their respective signatures on the A & I, they believed that abuse, mistreatment and neglect had been ruled out, however, upon review of the investigation today, both had remaining questions about the incident. In a statement prepared for the investigation signed by LPN #1 on 1/29/11, more 41 days after the investigation began, the LPN documented that she was approached by a CNA who told her the resident was combative when the CNA attempted to give the resident an enema. LPN #1 documented that when she entered the room, the resident was lying on her back and was calm. She further documented that she explain to the resident that she was going to roll her over and the CNA was going give her the enema, and that the resident remained calm for the procedure. LPN #1 documented that before leaving the resident's room, the resident said "my finger, my finger". During an interview LPN #1 on 2/16/11 at 3:30 pm, stated that she was made aware at the beginning of her shift that Resident #1 had received a suppository during the last shift and results were pending. LPN #1 stated that between 8:00 pm and 9:00 pm, she asked the CNAs if the resident had had a bowel movement, the CNAs said no, and told the CNAs that the resident needed an enema. LPN #1 stated that a short time later, the CNAs called for help because the resident was being combative. LPN #1 stated she went to the resident's room and observed the resident and she appeared to be calm, okay with receiving the enema and so she rolled the resident over so that the CNA #4 could administer the enema. LPN #1 stated that when the procedure was complete, she assisted the resident to a lying position on her back and the resident yelled that her hand hurt. The LPN stated that she observed the resident's hand, saw no bruising and it appeared that the resident could move her hand. The LPN stated that the resident had received Tylenol between 7:30 and 8:00 pm. The LPN stated that she reported the incident to the RN Supervisor. The LPN stated that she knows the resident well, knew that she usually goes to bed around 8:00 pm and knew that the resident could be combative with care. The LPN stated that she assumed that the resident was combative with the CNAs because she was in pain from the enema and she wasn't sure of how the CNAs had the resident positioned for the procedure. When asked about the timing of the enema, the LPN stated that at the time of the incident, the CNAs were informed at shift change of the residents needing the bowel protocol and that the CNAs were responsible to administer the enema. The LPN stated that she was aware that the CNAs needed to wake the resident up to administer the enema. She stated waking someone up to administer an enema was not a dignified way to deliver treatment. The LPN stated that the resident should have received the enema before she went to bed and was not sure why she hadn't. The LPN stated that the enema could have waited but I could have been disciplined and I didn't want conflict with the next shift. During an interview on 2/16/11 at 3:50 pm CNA #3 stated that CNA #4 asked her at approximately 9:00 pm to assist in giving the resident an enema. CNA#3 stated that resident usually goes to bed between 8:00 pm and 8:30 pm and that CNA #4 woke the resident up and told her they were going to give her an enema. CNA #3 stated that immediately, when she began to administer the enema, the resident "freaked out. CNA#3 then pulled the enema out and rolled the resident over. CNA #3 stated the LPN came into the resident's room, asked the resident if it was okay to give her the enema, the resident nodded yes, and the LPN rolled her over and they administered the enema. CNA #3 stated that she was unaware during the shift that the resident needed an enema. The LPN told the CNAs to give the resident the enema and that she understood the need for the enema and stated "but, you don't keep going when someone is that upset" During an interview on 3/2/11 at 12:00 pm the Registered Nurse Supervisor (RNS) the RNS stated that LPN #1 reported to her at the end of the shift that Resident #1 was given an enema earlier in the shift and that the resident was combative and hit a CNA. The RNS stated that the LPN reported that the resident was not injured so the RNS did not complete an Incident/Accident report and did not observe the resident. The RNS stated I guess I should have done an I & A and assessed the resident. The RNS stated that it was her opinion that enemas should not be given at 9:30 pm but the facility bowel protocol is the problem as it documented that the enema should be given if there is no bowel movement within 12 hours after the suppository was administered. The RNS stated that residents are going to be combative if awakened for an enema and that if the resident was in need of an enema, she would give it before they went to bed or the next day. 10NYCRR415.12