Every finding on record at Troy Victorian Rehabilitation & Nursing Care CNTR

Based on observations, record review, and interviews the facility failed to ensure residents maintained acceptable parameters of nutritional status for two (2) of three (3) residents (Residents #1 and #6) reviewed. Specifically, Resident #1 was not assisted with their meals as planned, had significant weight loss, their nutritional needs were not reassessed, weights were not obtained as ordered, and there was no documented evidence a medical provider addressed the resident's weight loss; and Resident #6 had was not assisted as their meals as planned and had significant weight loss. Findings include:The facility policy Meal Delivery/Tray Pass dated, last reviewed 10/2025, documented any resident who required assistance with feeding would be assisted when the tray was removed from the food truck. The facility policy Weight Measurement, Monitoring, and Notification Protocol, last reviewed 06/2025, documented: if a resident had a weight change of 3 pounds from the previous recorded weight, a re-weight would be obtained; and the registered Dietitian, attending physician, and family/ representative would be notified within 24 hours if there was an unintended weight change of 5% in 30 days, 7.5% in 90 days, or 10% in 180 days. The facility policy Comprehensive Nutrition Assessment and Care Planning, last reviewed 09/2025 documented: the facility would conduct timely, accurate, and interdisciplinary nutritional assessments for all resident upon admission, quarterly, annually, and upon a significant change in status; significant change in status reassessment would be initiated within 24 hours of any unintended weight change of 5% in 30 days, 7.5% in 90 days, or 10% in 180 days; and assessment components would include current weight, height, body mass index, ideal body weight range, and 30/ 60/ 180-day weight history trends. Assessment would also include estimated calorie, protein, and fluid needs. 1) Resident #6 had diagnoses including stroke with left sided paralysis and pressure ulcers. The 03/08/2026 Minimum Data Set (a resident assessment tool) documented the resident had moderately impaired cognition, functional impairment to one side of the upper extremity, required substantial/maximal assistance with eating, weighed 154 pounds, had a significant weight loss at 1 month or 6 months, and was on a mechanically altered diet. The comprehensive care plan, initiated 11/03/2025, documented the resident had self-care deficits with activities of daily living. Interventions included to provide extensive 1:1 assistance with eating and provide food in separate bowls during meals. The resident was at nutritional risk due to low intakes at meals and a history of significant weight loss. Interventions included provide liberalized diet, supplements, nourishments, and high biological protein food items. Physician orders documented: - on 02/11/2026 provide 240 milliliters of Ensure Plus (oral nutrition supplement) nectar thick. - on 02/17/2026 dietitian consult. - on 02/17/2026 regular pureed diet with nectar thickened liquids. - on 02/24/2026 nurse to monitor intake with every meal. Coordinate with certified nursing assistant to document appropriately. - on 04/01/2026 monthly weights. The resident's weight record documented: - 01/12/2026: 175.0 pounds - 02/05/2026: 160.0 pounds (15-pound loss/8.5% loss at 1 month and no documented reweight obtained - 02/12/2026: 153.8 pounds (21-pound loss/ 12% loss at 1 month) and no documented reweight obtained. The 02/09/2026 Dietetic Technician #28 progress note documented nursing was unable to weigh due to coronavirus disease isolation precautions. The 02/13/2026 Physician #35 progress note documented the 02/12/2026 weight of 153.8 pounds. The 02/16/2026 Dietetic Technician #28 progress note documented a reweight of 153.8 pounds. The resident had a significant 21.2-pound loss/ 12.1% loss from 01/12/2026 and their body mass index was 24.9, which was within normal limits. The resident had a history of COVID-19, poor intakes, dysphagia (difficulty swallowing), pressure ulcers, and required assistance with feeding. Supplements were increased along with nourishment to promote good intakes, wound healing and maintain weight. Nursing, the registered dietitian, nurse practitioner/physician, and speech language pathologist were aware of weight change. Intakes had improved to 50-75%. The plan was to continue weekly weight collection to monitor stability and weight changes. The 02/21/2026 Registered Dietitian #42 progress note documented current diet of pureed solids and nectar thick liquids and daily supplements remained appropriate. There was no documented evidence the resident's significant weight loss was addressed. The resident's weight record documented: - 03/02/2026: 149.8 pounds (10.2- pounds loss/ 6.3% loss at 1 month and 23.6-pound loss/ 13.6% loss at 3 months) and no documented reweight obtained - 03/24/2026: 145.5 pounds no documented reweight obtained - 03/31/2026: 147.0 pounds The 03/09/2026 Dietetic Technician #28 progress note documented the resident's weight was within normal limits. Supplements and nourishment were provided to promote good intakes, wound healing and weight maintenance. The 03/20/2026 Physician #35 progress note documented resident's weight 149 pounds on 03/02/2026 and 153.8 pounds on 02/12/2026. No change in plan noted. The 04/01/2026 Dietetic Technician #28 progress note documented resident had lost 2.8 pounds from 03/02/2026 to 03/31/2026, had no significant weight change in 4 weeks, and weights could be monitored monthly. The resident's weight record documented: - 04/17/2026: 142.5 pounds (32.5-pound loss/ 18.5% loss at 3 months) and no documented reweight obtained - No weights documented for 05/2026 The 04/17/2026 Physician #35 progress note documented resident's weight as 147 pounds on 03/31/2026, 149 pounds on 03/02/2026 and 153.8 pounds on 02/12/2026. The following observations of Resident #6 were made: -on 05/11/2026 at 12:23 PM lying in bed. Certified Nursing Aide #46 set the resident's lunch tray on the bedside table in front of the resident and left the room. The tray ticket documented regular puree diet with nectar thick liquids, extra meat, no milk, feeding assistance, and aspiration – no straws. The resident ate their meal unassisted, attempting to use their right hand to spoon food into their mouth. -on 05/12/2026 at 12:40 PM Certified Nursing Aide #52 repositioned resident in bed, placed their lunch tray on the bedside stand and left the room. The tray ticket documented feeding assistance. The resident was leaning to the right side using their right hand to feed themself. -on 05/13/2026 at 12:40 PM leaning to the right side attempting to eat lunch unassisted. -on 05/14/2026 at 12:30 PM, the lunch tray was on the bedside table. There were no staff assisting the resident with their meal. During an interview on 05/14/2026 at 12:47 PM Certified Nursing Aide #52 stated they set up the resident's food for their meal but did not assist them with eating. When they reviewed the care instructions for Resident #6, they stated the resident required assistance with eating. During an interview on 05/14/2026 at 1:13 PM, Licensed Practical Nurse #9 stated nursing staff should help residents who need assistance at meals. If a resident did not receive assistance as planned, they might not eat well. Resident #6 required extensive assistance with meals. 2) Resident #1 had diagnoses including dysphagia, cognitive communication deficient, and schizophrenia (a serious mental health disorder). The 03/30/2026 Minimum Data Set (a resident assessment tool) documented the resident had severe cognitive impairment, did not reject care, required substantial / maximum assistance with meals, coughed or choked during meals or when swallowing medications, and received a mechanically altered diet. The 08/13/2025 comprehensive care plan, updated 03/30/2026, documented the resident had an activity of daily living deficit. Interventions included extensive assistance of one (1) with meals. The updated 03/27/2026 comprehensive care plan documented the resident was at nutrition risk related to advanced age, fair intakes, and a history of weight loss. Interventions included provide a liberalized modified diet and supplements. The residents' weight record documented: -10/03/2025: 196.6 pounds -10/06/2025: 176.2 pounds (20.4 pounds/ 10.3% loss in 3 days) and no documented reweight obtained. The 10/07/2026 Registered Dietitian #42 nutrition assessment documented the resident weighed 176 pounds and their estimated daily nutritional needs were 2400 – 2800 calories, 80-104 grams of protein, and 2400 – 2800 milliliters of fluid. They would continue with their current plan. The residents' weight record documented: -10/15/2025: 177 pounds -No documented November 2025 weight -12/05/2025: 165 pounds and no documented reweight was obtained. -12/11/2025: 161 pounds (four (4) pound weight loss) and no documented reweight was obtained. The 12/30/2026 Registered Dietitian #42 nutrition assessment documented the resident weighed 161 pounds and their estimated nutritional needs were 1825-2190 calories, 73-88 grams of protein, and 1825- 2190 milliliters of fluids daily. The resident consumed 50-75% at meals and received Ensure Plus twice daily. They would continue with the current plan. The residents' weight record documented: -01/06/2026: 156 pounds (20 pounds/ 11.3% weight loss at three (3) months) and no documented reweight was obtained. The 01/08/2026 Physician #35 progress note documented the resident was seen for a visit and weighed 156.6 pounds. The progress note did not address weight loss. The residents' weight record documented: -01/15/2025: 158 pounds - No documented February 2026 weight -03/06/2026:159.5 pounds -03/28/2026: 150.7 (8.8-pound weight loss/ 5.5% in 22 days) and no documented reweight obtained. The 02/18/2026 Physician #35 progress note documented they saw the resident for a monthly renewal visit and did not address weight loss. The 03/18/2026 Physician #35 progress note documented the resident's weight was 156.6 pounds on 03/06/2026. They did not address weight loss. The 03/18/2026 Dietetic Technician #28 nutrition assessment documented the resident weighed 159.5 pounds, the resident had a history of weight loss, had no significant weight changes, their intakes were 50-75% at meals, received extra nourishments, and high biological protein foods. The 03/27/2026 Registered Dietitian #42 nutrition assessment documented the resident's estimated daily nutritional needs were 1725 – 2415 calories, 69 – 83 grams pf protein, and 1725 - 2415 milliliters of fluid daily. The resident was on 1:1 assistance for feeding assistance and had a 20.9 pound/ 12.9% significant weight loss at 6 months. Nutrition would continue to monitor weights and provide supplements as ordered. Physician orders documented: -03/27/2026, Pureed solids and honey thick liquid diet and 240 milliliters of honey thickened Ensure Plus (oral nutrition supplements) twice daily. -03/31/2026, Resident to receive 1:1 assistance for all meals. The residents' weight record documented: -04/02/2026: 147.2 pounds (12.3 pounds / 7.7% loss at one (1) month and 49.4 pounds loss/ 25.1% loss at six (6) months) and no documented reweight obtained. -04/09/2026: 150.6 pounds -04/14/2026: 150.2 pounds -04/23/2026: 135.6 (14.6 pounds/ 9.7% loss in 9 days) and no documented reweight obtained -04/28/2026: 156 pounds no documented reweight obtained -04/29/2026: 150 pounds (six (6) pound loss in one (1) day) and no documented reweight obtained -05/06/2026: 151 pounds -05/06/2026: 152 pounds. Resident #1 was observed at the following times: -on 05/11/2026 at 11:20 AM, seated upright in their bed with food debris on their clothing protector. Their breakfast meal was on their over bed tray table. The meal ticket documented aspiration precautions, no straws, total feed, pureed scrambled eggs, oatmeal, yogurt, honey thick orange juice, honey thick water, and honey thick coffee. They consumed 100% of the scrambled eggs, 100% hot cereal, and 0-25% of the yogurt. The resident stated they had a difficult time feeding themselves and had lost weight. At 11:33 AM, Diet Technician #28 entered the resident's room and asked if they could remove the meal tray and took it out of the room. -on 05/12/2026 at 12:26 PM – 1:05 PM, Certified Nurse Aide #29 provided the resident with their meal tray, assisted them to an upright position, pulled the privacy curtain closed, and exited the room. The meal ticket documented aspiration precautions, no straws, and total feed, pureed cottage cheese, pureed fish, applesauce, honey thick apple juice, honey thick water, honey thick Mighty Shake (oral nutrition supplement), honey thick coffee, and chocolate pudding with whipped topping. The resident was not assisted with their meal. At 1:05 PM, Certified Nurse Aide #29 entered the room and removed the resident's meal tray. The resident consumed 100% of their puree items and 0-25% of their drinks. At 1:09 PM, the resident was sipping on their coffee and had two (2) honey thick beverages on their over bed tray table. At 1:38 PM, Licensed Practical Nurse Unit Manger #9 entered the room and spoke to the resident and left the room at 1:40 PM, they did not remove the beverages or assist the resident. -on 05/13/2026 at 12:46 PM, seated upright in bed feeding themselves. Their meal ticket documented aspiration precautions, no straws, and total feed. The resident had pureed beef, pureed corn, pureed taco shell pureed cottage cheese, a honey thick mighty shake, honey thick juice, honey thick water, honey thick coffee, and pudding. At 1:01 PM, the resident had consumed 100% of the puree beef, corn, and pureed taco shell, 0-25% pureed cottage cheese, and their pudding still had the lid on it. They consumed 0-25% of their beverages. No staff assisted the resident with their meal. The May 2026 Medication Record Administration documented the resident was to have 1:1 meal assistance with all meals. -On 05/11/2026, Licensed Practical Nurse #27 signed the order as completed on the 7:00 AM – 3:00 PM shift. -On 05/12/2026, Licensed Practical Nurse Unit Manager #9 signed the order as completed on the 7:00 AM – 3:00 PM shift. -On 05/13/2026, Licensed Practical Nuse #14 documented 1:1 assistance at meals was not provided. During an interview on 05/13/2026 at 1:18 PM, Certified Nurse Aide #26 stated they were assigned to Resident #1, and the resident did not require assistance at meals and could feed themselves. If a resident did not receive assistance per their care instructions, they might not eat as well as they could. During an interview on 05/14/2026 at 12:46 PM, Licensed Practical Nurse #14 stated the certified nurse aides should check the care instructions daily as they could change. If they were unable to provide the care per the care instructions, they should tell the nurse. Resident #1 had an order for 1:1 assistance at meals. If the nurse signed the order as completed it meant the resident was assisted with their meals. They were unaware the resident did not receive assistance at their lunch meal on 05/13/2026 and they should have been told. If a resident did not receive assistance at meals as planned it could impact their weight. During an interview on 05/15/2026 at 10:53 AM, the Director of Therapy stated occupational therapy determined the level of assistance a resident required at meals. Resident #1 required substantial/maximal assistance with meals. The resident could feed themselves but would fatigue during meals and staff would have to assist for completion of meals. Resident #6 required extensive assistance at meals due to fatigue. Resident #6 would start off strong eating and needed assistance to complete meals. During an interview on 05/15/2026 at 11:33 AM, Licensed Practical Nurse Unit Manager #9 stated the nursing staff obtained the weights as ordered, Diet Technician #28 notified the nursing administration team if reweights were needed, and weight changes were discussed with the interdisciplinary team in morning report. Both the nurse managers and Diet Technician #28 notified medical of any significant weight changes. Resident #1, at times refused to weighed, but there was no documented evidence of their refusals, and they had weight loss. Occupational therapy determined the level of assistance a resident required at meals. All staff should review the care instructions daily and follow the instructions. Resident #1 had a medical order for 1:1 with meals. Staff should assist the resident with their meal and stay for the entire meal. If the nurse signed 1:1 at meals order as completed that meant they verified staff was in the room assisting the resident with their meal. If a resident was not assisted with their meals as planned/ ordered it could impact their nutritional status, weight status, and posed a safety risk. They were unaware Resident #1 did not receive assistance as ordered. During an interview on 05/15/2026 at 12:58 PM, Diet Technician #28 stated nursing staff obtained the weight and the facility policy stated if there was a 3 pound weight change from the previous weight, they should notify the nurse managers that a reweight was needed. If the resident refused to be weighed nursing should document any refusals. The registered dietitian should reassess the resident's nutrition needs if there was a significant weight change and complete nutritional assessment. They communicated with the registered dietitian if there were any significant weight changes, as the dietitian worked remotely. Resident #1 had significant weight changes, and they did not see documentation their significant weight change was addressed. During an interview on 05/15/2026 at 1:18 PM, Nurse Practitioner #22 stated the nurse managers and diet technician notified them of significant weight changes. Residents should be assisted with meals as planned. During a telephone interview on 05/15/2026 at 1:44 PM, Registered Dietitian #42 stated the diet technician communicated with nursing staff if there were any outstanding weights and notified nursing if a reweight was needed. They only completed the nutritional assessment for the high risk residents and any significant weight changes triggered by the Minimum Data Set Assessment. Significant weight changes were 3% or more in a week, 5% or more at 30 days, 7.5% at 90 days, and 10% or more at 180 days. They expected the diet technician to complete any significant weight change assessments and reassess the resident's nutritional needs. They worked closely with the diet technician and expected them to reach out if they had concerns. They were not consistently notified of significant weight changes at the facility. They were unaware Resident #1 had significant weight changes and their nutritional needs were not reassessed. They last addressed Resident #6's weight loss in February 2026. They did not notify medical of any significant weight changes. They stated there was no documented evidence the resident's nutritional needs were reassessed after they had significant weight changes. If the resident did not receive assistance as planned at meals it could impact their weight and nutritional status. 10 New York Codes, Rules and Regulations 415.12(i)1

Based on observations, record review, and interviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) for four (4) of nine (9) residents (Residents #2, #47, #97, and #119) reviewed. Specifically, Resident #2's 11:30 AM dose of Renvela (used to lower blood phosphorus levels and taken with meals) was not regularly administered and there was no documented evidence the physician was notified of the missed doses, and no documented evidence the pharmacist reviewed the missed doses during their monthly medication reviews; and Residents #47, #97, and #119 were not provided their carbidopa-levodopa (used to treat Parkinson's disease-a progressive neurological disorder) timely; and Resident #47 had their medications from 5:00 PM and 9:00 PM on 05/12/2026 in the same cup on their bedside table the next morning. Findings include: The facility policy Administering medications/medication errors, last reviewed 06/2025, documented all medications were to be administered in a safe and time manner as prescribed. Staff schedules are arranged to ensure that medications are administered without unnecessary interruptions. Medications are administered in accordance with prescriber orders, including any required timeframes. Medications were administered within 1 hour of their prescribed time unless otherwise specified. The individual administering the medication documents administration after administering the medication.1) Resident #2 had diagnoses including end stage kidney disease. The 02/17/2026 Minimum Data Set documented the resident had intact cognition, had no behaviors, and received dialysis (a process that filters the blood when the kidneys do not work).The 10/24/2024 comprehensive care plan documented the resident was dependent on hemodialysis related to end-stage kidney disease. Interventions include to provide renal diet and follow dietary restrictions as per the provider's order, monitor the shunt for patency, monitor for signs of infection and communicate with the dialysis center any abnormal findings, provide bagged lunch for dialysis, monitor fluid intake and output, vital signs and weight as ordered by the provider, and the resident received hemodialysis three times a week on Monday, Wednesday, and Friday with a pick up time at 10:00 AM.The 04/17/2026 physician order documented Renvela 800 milligrams, give two tablets 3 times daily with food at 11:30 AM, 4:30 PM, and 6:30 AM for end stage kidney disease. The order had a note to vendor Do not send resident has full supply.The May 2026 Medication Administration Record documented Renvela 800 milligram tablet give two (2) tablets by oral route 3 times per day with meals- the 11:30 AM dose on 05/01/2026, 05/04/2026, 05/07/2026, 05/08/2026, 05/11/2026 were marked as the resident being LOA as they were at dialysis and not in the facility (by Licensed Practical Nurse #17 on 05/01/2026, 05/04/2026, and 05/08/2026; and by Licensed Practical Nurse #63 on 05/11/026).There was no documented evidence the provider or the dialysis center was made aware the resident did not receive the 11:30 AM dose of Renvela on dialysis days. There was no documentation the pharmacist was aware of the missed doses and provided a recommendation during their monthly drug regiment review.During an interview on 05/14/2026 at 1:45 PM, Licensed Practical Nurse #17 stated if a resident was not available for their medications and was out of the facility, they marked LOA on the medication administration record. Resident #2's two tablets of 800 milligram Renvela were ordered to be given at 11:30 AM but the resident was at dialysis at that time, so the medication was not given. They did not let the provider know the resident missed the medications because the provider should be aware the resident was at dialysis every other day so they should know the resident was not getting the medication at that time. They had only been marking LOA as that was what everyone else was documenting.During an interview on 05/15/2026 at 9:26 AM, Dialysis Secretary #20 stated the dialysis registered dietitian recommended Resident #2 get 1600 milligrams of Renvela three (3) times a day with meals for their phosphorus levels. The resident did not receive the medication at dialysis, and the dialysis facility expected the resident to receive the medication at the nursing facility.During an interview on 05/15/2026 at 10:10 AM, Licensed Practical Nurse Unit Manager #9 stated they reviewed orders when a resident was due for a Minimum Data Set. They were unaware Resident #2 was not receiving their 11:30 AM dose of Renvela from either the facility or dialysis. They were not notified there was a scheduling conflict for the medication on dialysis days. The dialysis center ordered the medication, and they and the provider should be aware the resident was not receiving this dose of medication.During an interview on 05/15/2026 at 1:25 PM Nurse Practitioner #22 stated they believed they were aware Resident #2 was not receiving their 11:30 AM dose of their Renvela on dialysis days but did not recall when they were notified but stated it was probably recently. The medication was only for when the resident was eating. The medication helped reduce phosphorous levels which dialysis treatment did as well.During an interview on 05/15/2026 2:07 PM Pharmacist Consultant #40 stated they did not review the Medication Administration Records during the pharmacy reviews. They did not review whether medications were being given or not, just what the resident was taking. Resident #2 should not miss doses of Renvela. Kidney function was serious and measurable. Missing several doses of the medication would not be good for the resident.2) Resident #47 had diagnoses including Parkinson's disease (a progressive neurological disease). The 04/21/2026 Minimum Data Set assessment documented the resident had intact cognition and required supervision/ touching assistance for most activities of daily living.The 02/09/2026 physician order documented carbidopa 25 milligrams-levodopa 100 milligram tablet give one tablet 3 times per day at 2:00 PM, 9:00 AM, and 9:00 PM for Parkinson's disease.The 02/12/2025 comprehensive care plan documented a diagnosis of Parkinson's Disease. Interventions included administer medication as ordered.The May 2026 Medication Administration Record documented carbidopa 25 milligrams-levodopa 100 milligram tablet give one tablet 3 times per day at 2:00 PM, 9:00 AM, and 9:00 PM. On 05/12/2026 Licensed Practical Nurse #15 documented they administered the resident one 25 milligram-levodopa 100 milligram tablet at 9:00 PM.During an observation on 05/13/2026 at 10:02 AM, the resident was in bed sleeping. There was a pill cup on their bedside table containing one (1) large white oval pill, two (2) small brownish orange pills, and one (1) small yellow round pill.During an observation and interview on 05/13/2026 at 10:21 AM with Licensed Practical Nurse #14 they stated the pills in the cup included 25 milligram-levodopa 100 milligram tablet from the previous evening. They stated they administered the resident's morning medications in the common area.During an interview on 05/14/2026 at 5:22 PM Licensed Practical Nurse #15 stated medications could be given an hour before and an hour after the scheduled time. Anything outside that required they notify the doctor. They were supposed to stay in the room with the resident to ensure the medications were taken. They provided Resident #47 with their evening medication on 05/12/2026, but the resident became upset, and they left the medication in the room and did not check to ensure the resident took the medication.During an interview on 05/15/2026 at 11:33 AM Licensed Practical Nurse Unit Manager #9 stated carbidopa-levodopa was a time sensitive medication and should be given per the physician order. The nurse should notify the provider if the resident refused medication or was unable to administer the medication as ordered. They were aware Resident #47's evening carbidopa-levodopa was observed in their room the following day and there was no documented evidence the medical provider was made aware the resident missed their evening dose.3) Resident #97 had diagnoses of Parkinson's disease (progressive neurological disease) and dementia. The 05/17/2026 Minimum Data Set documented the resident had moderately impaired cognition and required moderate assistance or was dependent for most activities of daily living.The 10/30/2024 comprehensive care plan documented the resident had a diagnosis of Parkinson's disease. Interventions included encourage activities of daily living performance by allowing the resident to participate in care, initiate safety precautions to protect the resident from injury, and monitor for complications caused by involuntary movement such as injuries from falls or aspiration.The 12/22/2024 physician order documented carbidopa extended release 25 milligrams-levodopa 100 milligram: give one tablet by oral route 5 times per day.During an observation and interview on 05/14/2026 at 10:44 AM Licensed Practical Nurse #17 entered the resident's room with a medication cup to administer medications. Licensed Practical Nurse #17 stated the resident's 9:00 AM dose of carbidopa-levodopa was in the cup.During an interview on 05/14/2026 at 1:45 PM, Licensed Practical Nurse #17 stated carbidopa-levodopa should be given at specific times. If the medication was given late, the provider should be informed so the other doses could be spaced out if needed. They stated they did not inform the provider prior to giving the medication. They stated they informed the provider of any missed, refused, or late medication at the end of their shift in one text message unless it was an emergency.During an interview on 05/15/2026 at 10:10 AM Licensed Practical Nurse Unit Manager #9 stated Resident #97's Carbidopa-Levodopa dose should not be given an hour and 44 minutes past the prescribed time. The nurse should have notified the provider and got directions on how to proceed prior to giving the medication as the dose was very late. 4) Resident #119 had diagnoses including Parkinson's disease. The 04/21/2026 Minimum Data Set assessment documented the resident had intact cognition and required maximum assistance for most activities of daily living.The comprehensive care plan initiated 04/02/2026 documented a diagnosis of Parkinson's Disease. Interventions included administer medication as ordered. The 04/02/2026 Registered Nurse #21 progress note documented the resident went to the neurologist that day and recommendations included increasing the dose of carbidopa-levodopa and to be administered specifically at 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM.The 04/02/2026 physician order documented two (2) carbidopa 25 milligram-levodopa 100 milligram tablets 4 times a day at 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM.The May 2026 Medication Administration record documented two (2) carbidopa 25 milligram-levodopa 100 milligram tablets at 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM.During an observation on 05/14/2026 at 10:34 AM Licensed Practical Nurse #12 administered the resident two (2) carbidopa 25 milligram-levodopa 100 milligram tablets.During an interview on 05/14/2026 at 10:36 AM, Licensed Practical Nurse #12 stated they had an hour before and an hour after the scheduled time to give medication. Anything outside that required they notify the doctor. During a follow up interview at 2:11 PM, Licensed Practical Nurse #12 stated carbidopa-levodopa should be given on time because it was more beneficial to the resident. Resident #119 had a history of falls and had stiffness that improved after receiving their carbidopa-levodopa. That day, the resident's carbidopa-levodopa was administered late because they were busy with other residents. They notified the physician about the late administration of medications that day. They should have called prior to giving it late to get approval but did not because they knew the provider well and they thought it would be okay if they gave it. During an interview on 05/14/2026 at 11:16 AM, Resident #119 stated they were supposed to get their carbidopa-levodopa at certain times and when they were home, they were diligent about taking it on time. Carbidopa-levodopa helped manage their motor skills and if administered late it affected their speech, caused them to stutter, and caused leg tremors which made them unable to move their legs, making them more likely to fall. Earlier that morning, they were having leg tremors that improved since receiving the carbidopa-levodopa. During an interview on 05/14/2026 at 4:38 PM, Registered Nurse Unit Manager #5 stated medications could be given as early as an hour before and as late as an hour after the scheduled time. If beyond those parameters, the supervisor and the provider should be notified prior to administration because the timeline of future administrations could be affected. Parkinsonian medications needed to be given on time, and nurses should prioritize the medication pass to make sure that happened. Resident #119 had some stuttering and a fine hand tremor and was unsure of the impact the carbidopa-levodopa had on those symptoms.During an interview on 05/15/2026 at 1:25 PM Nurse Practitioner #22 stated the instant release carbidopa-levodopa was a time sensitive medication and should be given as close to the ordered time as possible. If it was going to be given late, the nurses should let them know and depending on how late they would decide whether the medication should be held or not They stated they were unsure if they were notified Resident #47 did not take their 9:00 PM dose of carbidopa-levodopa that was left in a medicine cup at their bedside. They did not see why the resident's 5:00 PM and 9:00 PM medications could not be given at the same time, but they should be notified if medications were going to be given early or late. Resident #97's medication being given an hour and 44 minutes past the ordered time should not be a habit but likely would not cause harm. They were unsure if they had been notified it was late prior to the nurse giving the medication. They were unsure if they were notified prior to Resident #119's carbidopa-levodopa being given 2 1/2 hours after the scheduled time.During an interview on 05/15/2026 2:07 PM Pharmacist Consultant #40 stated they could not answer if carbidopa-levodopa was a significant medication or if there could be effects if the medication was missed but a resident should not skip a dose. The medication was sometimes time sensitive. 10 New York Codes, Rules and Regulations 415.18(a)(1)

Based on observations, record review, and interviews, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for one (1) of one (1) main kitchen and one (1) of two (2) kitchenettes (2nd Floor kitchenette). Specifically, in the main kitchen food was not labelled, the walk-cooler floor was unclean with food debris, the walk-in freezer floor was unclean with food debris on the floor and reach in cooler wire racks were sticky and had a pink substance on them; and the 2nd floor kitchenette was unclean.Finding included:The facility policy Food Receiving and Storage, last reviewed 03/11/2024, documented, food services or other designated staff would maintain clean food storage areas at all times; all foods stored in the refrigerators and freezers would be covered, labeled and dated with a use by date; and beverages would be dated when opened and discarded after 24 hours.The undated facility policy Sanitation, documented, all kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish; all utensils, counters, shelves, and equipment would be kept clean, maintained in good repair and would be free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning; kitchen and dining room surfaces not in contact with food would be cleaned on a regular schedule and frequently enough to prevent the accumulation of grime; the Food Service Director would be responsible for the scheduling of regular cleaning of the kitchen; and food service staff would be trained to maintain cleanliness.The following observations were made in the main kitchen:-On 05/11/2026 at 10:37 AM, in the walk-in cooler there was one undated opened carton of cranberry juice with a best used by date 03/02/2027. There was one 8-ounce carton of milk, several 4-ounce plastic cartons of thicken juice, and several creamer cups on the floor under the shelves. At 10:39 AM, the walk-in freezer had one metal pan of sliced pizza. Underneath the shelves on the floor were straws and one frozen nutrition supplement.-On 05/11/2026 at 10:41 AM the left reach in cooler wire racks were chipped and had a pink sticky substance.-On 05/11/2026 at 10:52 AM, there was various paper debris and two cartons of thickened juice on the floor under the shelves. -On 05/13/2026 at 11:18 AM, the 2nd Floor Kitchenette freezer had a layer of ice buildup.-On 05/13/2025 at 11:20 AM, the 2nd Floor Kitchenette cabinet had a spilled sticky substance with two cartons of prune juice laying in it. The floor was stained with brown spots and was sticky.During an interview on 05/14/2026 at 10:36 AM, the Food Service Director stated the dietary aides were supposed to clean up any spills in the kitchenettes. During a follow up interview on 05/15/2026 at 09:16 AM, the Food Service Director stated all food items should be labeled and dated when opened. Food and beverage items were good for 3 days unless they were in the original container with a best used by date. If there was a best used by date the item would be discarded on that date. Food should be labeled and dated to ensure food quality and prevent any foodborne illnesses. The Chefs/ Supervisors should ensure all areas of the kitchen were swept and mopped daily. There was no official cleaning schedule, but they had a paper in the office that staff signed when the cleaning was completed. The wire racks in coolers should be cleaned when soiled. They stated they asked for new wire racks in the past but had not received any at this time. 10 New York Codes, Rules and Regulations 415.14(h)

Based on observations, record review, and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to include services provided to maintain the resident's highest practicable physical well-being for one (1) of one (1) resident (Resident #97) reviewed. Specifically, Resident #97 did not have their fall mat (a cushioned floor mat placed next to the bed) in place while in bed as planned. Findings include:The facility policy Comprehensive Care Plans, last reviewed 04/2026, documented each resident was to have an interdisciplinary care plan that was initiated within 24 hours of admission. The care plan would be consistent with the medical plan of care for the resident and identify priority problems and needs addressed for the resident along with strengths, limitations, and goals. Care plans were updated as needed to meet the residents' needs and preferences. Resident #97 had diagnoses including Parkinson's disease (a progressive neurological disease) and dementia with agitation. The 05/17/2026 Minimum Data Set documented the resident had moderately impaired cognition, had two or more falls, and required moderate assistance or was dependent for most activities of daily living. The 10/30/2024 comprehensive care plan documented the resident was at medium to high risk for falls with an actual fall on 09/30/2025, had Parkinson's disease, and was on psychotropic medication. The resident was non-compliant with safety measures and frequently tried to transfer themselves. Interventions included a floor mat on the door side of bed, ensure the head of the bed was lowered at hours of sleep to prevent from leaning and falling out of bed, and do hourly checks while in bed to ensure proper positioning and they were centered in bed. The following observations of the resident were made:-on 05/12/2026 at 8:42 AM in bed with the head of the bed raised, their sheets were twisted and hanging off the bed on the floor and the bare over bed table was raised across their lap. The floor mat was folded up and not in place next to the bed-on 05/14/2026 at 10:02 AM in bed with the head of the bed slightly elevated. They were slumped to the right side with their head to their shoulder at the edge of the bed. The fall mat was not placed next to the bed and was folded up vertically next to the nightstand. During an interview on 05/15/2026 at 10:06 AM Certified Nurse Aide #1 stated if a resident was supposed to have a fall mat in place it should be on their care plan. Resident #97 was care planned to have a fall mat in place while in bed. The resident was usually up for breakfast but if they were still in bed during or after breakfast the fall mat should still be in place. During an interview on 05/15/2026 at 11:09 AM Licensed Practical Nurse #17 stated Resident #97 was care planned to have a fall mat in place when they were in bed. The staff knew to put the fall mat in place while the resident was in bed as the resident would roll out of bed. If the fall mat was moved for the tray table for breakfast it should be put back in place when the tray was removed. During an interview on 05/15/2026 at 11:33 AM Licensed Practical Nurse Unit Manager #9 stated Resident #97 should have a fall mat in place on one side while in bed. If the fall mat was in the way of the tray table for a meal, the fall mat should be put back in place once the tray was removed. 10 New York Codes, Rules and Regulations 415.11(c)(1)

Based on observations, record review, and interviews, the facility failed to ensure residents had the right to a dignified existence in a manner and an environment that promoted the maintenance or enhancement of quality of life for two (2) of two (2) residents (Residents #1 and #132) reviewed. Specifically, Residents #1 and #132 had bright colored signage hung prominently in their room that disclosed personal information regarding the resident's care.Findings include: The facility policy Resident Rights, Dignity, and Respect, last reviewed 03/2026, documented residents had the right to be treated with dignity and respect. Residents had the right to be informed, make their own decisions, and have their personal information kept private.1) Resident #1 had diagnoses including dysphagia (difficulty swallowing). The 03/30/2026 Minimum Data Set assessment documented the resident had severe cognitive impairment, required substantial assistance with meals, coughed or choked during meals or when swallowing medications, and received a mechanically altered diet.The comprehensive care plan initiated 03/31/2026, documented the resident had dysphagia. Interventions included assistance as per occupational therapy recommendations, small bites/sips, slow rate and to be upright for all oral intake.During an observation on 05/11/2026 at 11:20 AM, a bright orange sign dated 05/03/2026 was posted on the bulletin board in the resident's room. The sign stated puree, honey, upright for all meals, assist with feeding as per occupational therapy/care plan, small bites/ sips, and slow rate. The sign was prominent and able to be seen by all staff and visitors.During an interview on 05/14/2026 at 1:08 PM, Certified Nurse Aide #26 stated they were unsure but thought speech therapy put the orange sign up in Resident #1's room. They stated the sign was not violating Health Insurance Portability and Accountability Act because it did not post anything about the resident's diagnosis or medications. 2) Resident #132 had diagnoses including dysphagia (difficulty swallowing) and need for assistance with personal care. The 04/05/2026 Minimum Data Set assessment documented the resident had moderately impaired cognition, required set-up or clean up assistance with eating, oral hygiene, and personal hygiene, had complaints of difficulty or pain with swallowing, coughed or choked during meals or when swallowing medications, and a diagnosis of dysphagia.The comprehensive care plan, initiated 03/31/2026, documented the resident had dysphagia. Interventions included diet per physician order and take small bites and sips at a slow rate.During observations on 05/11/2026 at 1:26 PM and 05/12/2026 at 8:34 AM Resident #132's room had a bright orange sign with black lettering on the wall behind the head of the bed. The sign documented the residents first name and first letter of their last name and mechanical diet, thin liquids, pills crushed in applesauce or pudding.During an observation and interview on 05/13/2026 at 12:06 PM, Resident #132 was sitting on the edge of the bed eating lunch. They stated the sign was taken down because they had their diet advanced to regular. They stated staff told them the sign was hung up, so they did not receive the wrong diet and choke.During an interview on 05/14/2026 at 1:43 PM, Licensed Practical Nurse #36 stated they were familiar with signs being hung in resident rooms and recalled Resident #132 having a sign behind their bed with their diet, consistency, and how they took their medications listed on it. They were unsure who was responsible for the signs or why the signs were hung up because every resident had a copy of their care plan inside their closet door that contained the same information. They stated the sign was not dignified because the resident's personal information was posted for other residents and visitors to see.During an interview on 05/14/2026 at 2:07 PM, Certified Nurse Aide #37 stated they could not recall a sign being posted in Resident #132's room. Personal information should not be posted for everyone to see.During an interview on 05/15/2026 at 10:14 AM, Registered Nurse Unit Manager #5 stated speech therapy initiated signs in resident rooms, so all staff were aware of any changes that were made to the resident's diet or consistency. The information was also updated in the resident care instructions. Therapy or the nurse managers were responsible for hanging the care instructions inside the residents' closet doors when changes were made. Resident #132 had a sign in their room that was removed by speech therapy when their diet was upgraded. Having medical information posted on a sign for other residents and visitors to see was not dignified.During an interview on 05/15/2026 at 10:54 AM, the Director of Therapy stated speech therapy initiated eye-catching signs in resident rooms that had important information for staff to know like diet consistency or if the resident was on aspiration precautions. They were also responsible for updating the information in the resident's care plan and care instructions. Care instructions were kept inside residents' closets for dignity reasons so they could understand how an eye-catching sign with the residents' medical information on it could be a dignity issue. They thought the eye-catching signs could go below the care instructions inside the closets so it would be more of a homelike environment for the residents.10 New York Codes, Rules and Regulations 415.3(c)(1)(i)

Based on observations, interviews, and record review the facility failed to ensure the interdisciplinary team determined a resident's ability to safely administer their own medications, if clinically appropriate, for one (1) of one (1) resident (Resident #47) reviewed. Specifically, Resident #47 had one (1) plastic bottle of over-the-counter calcium carbonate (antiacid medication), an inhaler (for lung disease), and a medication cup with several unidentified pills on their nightstand. There was no documented evidence of assessments and/or physician orders for the resident to safely self-administer medications.Findings included:The facility policy Resident Self-Administration of Medication, last reviewed 09/2025, documented if a resident requested to self-administer medications an assessment would be completed and reviewed by the interdisciplinary team. The interdisciplinary team determines if self-administration was clinically appropriate for the resident and would document it in the medical record and on the resident's care plan. A physician's order was needed prior to the initiation of a self-administration program specifying the specific medications the resident was to be self-administrating. The interdisciplinary team will re-evaluate the self-administration program on a quarterly basis, with any significant changes and as needed to ensure it is clinically appropriate.The facility policy Administering Medications/ Medication Errors, revised 06/2025, documented medications would be administered in accordance with prescriber orders, including required time frame. Residents may self-administer medications only if the attending physician, in conjunction with the interdisciplinary care planning team, had determined they had the decision making capacity to do so safely, and medications could be stored safely in the resident's room.Resident #47 had diagnoses including Parkinson's disease (a progressive neurological disease), chronic obstructive pulmonary disease (lung disease), and paranoid schizophrenia (mental disorder). The 03/17/2026 Minimum Data Set documented the resident had intact cognition and required supervision/ touching assistance with for most activities of daily living.Physician orders documented:-01/20/2025 Breyna 80 microgram- 4.5 microgram/actuation HFA aerosol inhaler (for lung disease) two puffs by inhalation 2 times daily.-02/09/2026 carbidopa 25 milligram-levodopa 100 tablet (for Parkinson's disease) give one tablet 3 times daily.-04/03/2026 senna 8.6 milligram tablet (laxative) give two tablets once daily.The following observations of Resident #47 were made:-on 05/11/2026 at 11:43 AM, lying in their bed. There was one plastic bottle of over-the-counter calcium carbonate (antiacid) and an inhaler on the bedside table.-on 05/13/2026 at 10:02 AM, lying in their bed sleeping. There was a small plastic medication cup on their bedside table containing one large white oval pill, two brownish/ orange smaller round pills, and one yellow small round pill.There was no documented evidence of a medication self-administration assessment, a physician order for self-medication, or a comprehensive care plan related to self-administration or storage of medication in the resident's room.During an interview on 05/13/2026 at 10:21 AM, Licensed Practical Nurse #14 stated the medications in the resident's room must have been from the previous evening as they provided the resident their medications in the common area that morning. The resident did not have an order to self-administer medications and the nurse who provided the residents with their medications should ensure the resident took all their medications. They stated it was a safety issue if medications were left unattended in the resident's room.During an interview on 05/14/2026 at 5:22 PM, Licensed Practical Nurse #15 stated when they provided the residents with medication, they should stay with them to ensure they took their medications. Resident #47 did not have an order to self-administer medications and sometimes they left the inhalers in the residents' rooms if they requested. They attempted to provide Resident #47 with their evening medications last night, but the resident did not want to take the medications at that time, so they left the medications in the room. They forgot to go back and check to see if the resident took their medications. During an interview on 05/15/2026 at 11:33 AM, Licensed Practical Nurse Unit Manager #9 stated if a resident was able to self-administer medications there should be a physician order and their care plan would document their ability to self-administer medications. Resident #47 was forgetful at times and was unable to self-administer their own medications. The nurse providing the residents with their medications should always stay with the residents to ensure they took their medication. Leaving medications in a resident's room posed a safety risk as there were other residents who wandered on the unit. 10 New York Codes, Rules and Regulations 415.23(f)(1)(vi)

Based on observations, record review, and interviews (iQIES intake 2626678) the facility failed to ensure a clean, comfortable, and homelike environment for two (2) of five (5) resident halls (South Wing and [NAME] Wing halls) and the Second Floor common area. Specifically, the South Wing and [NAME] Wing resident halls and the Second Floor common area had unclean floors. Findings include:The facility policy Environmental Services - Floor Maintenance, last reviewed 05/2025, documented there was to be daily routine cleaning in corridors and common areas, as well a spot cleaning as needed. The facility policy Resident Right-Safe/Clean/Comfortable/Homelike Environment, last reviewed 06/2025, documented the facility was to provide a safe, clean, comfortable homelike environment to respect resident rights. Resident care areas including but not limited to passageways, resident rooms, and common areas will be kept free from obstacles, debris, and soil. The following observations were made in the [NAME] Wing resident hall:-on 05/11/2026 at 10:36 AM the hallway floor was dirty with dried, light brown liquid spill spots three doors down from the double doors to end of the hallway. The floor outside resident room [ROOM NUMBER] had debris and paper wrappers.-on 05/13/2026 at 10:00 AM the floor outside locked door and resident room [ROOM NUMBER] had dirt and food crumb debris. Resident room [ROOM NUMBER] had food crumbs and dirt smashed into the floor outside the room. At 10:01 AM, the doorway entrance where the hall floor meets the room floor tiles were stained. There was caked brown, tan, and black crumbs and debris on the floors in rooms 326, 338, 328, and 340. At 10:53 AM the floor in front of the crash cart was dirty with food crumbs and black and brown dirt debris. The following observations were made in the South Wing resident hall:-on 05/13/2026 at 11:31 AM the floor under the fire extinguisher from the doorway of resident room [ROOM NUMBER] to the utility room had crumbs, dirt debris, and brown stains. At 11:33 AM the hallway between resident room [ROOM NUMBER] across to resident room [ROOM NUMBER] had orange and light brown smears. There were stuck on brown and black spots and food crumbs.-on 05/14/2026 at 10:13 AM the floor under the fire extinguisher from doorway 310 to the utility room had visible crumbs, dirt debris, and brown and black spots. At 10:21 AM the wall between resident room [ROOM NUMBER] and the mechanical room was speckled with brown and black spots. During an observation on 05/14/2026 at 1:01 PM the Second Floor common area floorin front of the old nurses' station next to the couch had dried on sticky stains, dried brown smears, and food crumbs and dirt. During an interview on 05/15/2026 at 9:56 AM Certified Nurse Aide #29 stated the floors were cleaned every day. The facility used a heavy scrubber on the floor a couple of times a week, but they had to block off parts of the floor to do it. Housekeeping was responsible for taking care of the dried spills in the common area. During an interview on 05/15/2026 at 11:37 AM Housekeeper #60 stated their responsibilities included making sure the rooms were clean, and the garbage was emptied. The hallways were cleaned every day. Any stuck-on food or grime in the hallways was treated with chemicals and scraped up if needed. During an interview on 05/15/2026 at 1:09 PM, Housekeeping Supervisor #61 stated the housekeepers were responsible for cleaning the rooms, sweeping and mopping the bathrooms, cleaning up any spills or tracks on the floor, and making sure the hallways and common areas were clean. Hallways were done with the auto scrubber every morning before the residents were active for the day and in the evening. Spot mopping was done midday. Any stuck-on spots were supposed to be soaked, then scraped to get the spot up and then spot mop the area. At 1:13 PM the Housekeeping Supervisor observed the South Wing resident hallway spilled dried liquid and dried food spots. They stated some of the spots the auto scrubber did not touch but some of the spots would have easily come up and should have been cleaned. 10 New York Codes, Rules and Regulations 415.5(h)(4)

Based on observations, record review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (2) of five (5) residents (Resident #12 and #101) reviewed and for legionella (a bacteria causing Legionnaires' disease-a respiratory disease) testing. Specifically, Residents #12's and #101's transmission-based precaution orders were not followed; and the facility did not perform legionella testing as required based on positivity rate and a legionella positivity rate greater than 30% was not reported to the Department of Health as required. Findings include:Isolation Precautions:The facility policy Infection Control, Transmission-Based Precautions, dated 11/2025, documented transmission-based precautions were used for residents known or suspected to be infected with highly transmissible or epidemiologically important pathogens for which additional precautions beyond standard precautions were needed to interrupt its transmission.The facility Special Droplet/Contact Precautions signage documented that in addition to standard precautions everyone must clean their hands when entering and leaving the room, wear eye protection (face shield or goggles), a mask (fit tested N-95 or higher when performing aerosol-generating procedures), a gown and gloves.1) Resident #12 had diagnoses including methicillin resistant staphylococcus aureus (a resistant bacteria) infection of an unspecified site and osteomyelitis (a bone infection) of the lower leg bones. The 05/04/2026 Minimum Data Set assessment documented the resident had intact cognition and had a multidrug-resistant organism. A 04/24/2026 wound culture report documented the resident tested positive for methicillin resistant staphylococcus aureus.The 04/30/2026 comprehensive care plan documented an infection of the right knee. Interventions included maintain precautions as ordered.The 05/01/2026 Nurse Practitioner #22 medical order documented the resident was on contact precautions for methicillin resistant staphylococcus aureus wound infection.During an observation on 05/11/2026 at 12:42 PM, Resident #12's room had a Special Droplet/Contact Precautions sign outside the door above their name placket. There was a bin containing personal protective equipment outside the door and there were no hampers near the doorway in the room. Certified Nurse Aide #48 entered the room without putting on any personal protective equipment, picked up the resident's meal tray, exited the room, placed the tray on the cart, then entered another resident's room.The following observations were made of staff entering the resident's room not wearing any personal protective equipment on 05/12/2026:-At 11:56 AM Certified Nurse Aide #6 entered room to deliver a lunch tray, exited the room without performing hand hygiene, then entered another resident's room.-At 12:16 PM Certified Nurse Aide #44 entered the room, picked up the lunch tray, exited the room without performing hand hygiene, put the tray on the cart, then entered another resident's room. -At 12:19 PM Registered Nurse Unit Manager #5 entered the room and was looking at the resident's right hip area. Registered Nurse Unit Manager #5 did not put gloves on and picked up the resident's partially full urinal, entered the bathroom, exited the bathroom with an empty urinal, returned the urinal to the resident then washed their hands. They touched the resident's bedside table and left the room without performing hand hygiene.-At 12:49 PM Physical Therapy Assistant #45, utilized hand sanitizer before entering the resident's room. At 12:50 PM they exited the room without performing hand hygiene, entered the code in the Nursing Supplies room door's keypad, entered that room, exited seconds later then reentered the resident's room.During an interview on 05/12/2026 at 2:06 PM Certified Nurse Aide #6 stated residents on precautions had a sign and a bin containing personal protective equipment outside their room. The signs directed what precautions had to be followed and applied to all staff members. Personal protective equipment should be put on prior to entering the room and removed in the doorway before exiting the room and placed in the trash can. There were not designated hampers. They thought Resident #12 was on enhanced barrier precautions but after looking at their sign stated they were on droplet precautions. All the things that were on the sign should be followed every time someone entered the room, including when delivering and picking up meal trays. They delivered the resident's lunch tray that day and did not follow the sign but should have. During an interview on 05/12/2026 2:24 PM, Physical Therapist Assistant #45 stated residents on precautions had a sign outside the room indicating the type of precaution and what staff needed to wear. The signs applied to all employees. Personal protective equipment should be put on before entering the room, removed and disposed of in a regular garbage can before exiting the room, and hands should be washed before entering and exiting the room. Resident #12 was on contact precautions due to an infection in their knee. A gown and gloves should be worn anytime they go in the room. They did not follow the sign because they did not see the sign. They should have followed the precautions.During an observation on 05/12/2026 at 3:55 PM the droplet/contact sign was no longer outside the resident's room. There was an enhanced barrier precaution posted outside the room. 2) Resident #101 had diagnoses including acute and chronic respiratory failure with hypoxia (low oxygen levels).The 04/22/2026 physician order documented the resident was on contact/droplet precautions.There was no documented evidence the comprehensive care plan included transmission-based precautions. During an observation on 05/11/2026 at 12:48 PM, Resident #101 was in their room. There were enhanced barrier and special droplet/contact precaution signs on their door. There was a bin outside the door, no hampers next to the door, and the door was open.The following observations were made of staff entering the resident's room not wearing any personal protective equipment on 05/12/2026:-At 11:49 AM Certified Nurse Aide #6 entered the room carrying a lunch tray. They exited the room seconds later without performing hand hygiene then delivered a lunch tray to another room.-At 11:53 AM Physical Therapy Assistant #43 entered the room, moved the resident's tray table around, prepared lunch drinks, and touched the resident's reaching tool. At 12:06, while still in the room, they put on a pair of gloves, set up the resident's lunch tray, removed the gloves, exited the room, then used hand sanitizer from a dispenser located in the hall.-At 12:02 PM Certified Nurse Aide #44 entered the room and began making the bed then exited room without first washing hands and dragged a bag of dirty linen down the hall.During an observation on 05/12/2026 at 2:34 PM the droplet/contact sign was removed and only an enhanced barrier precaution was posted.During an interview on 05/12/2026 at 1:50 PM, Certified Nurse Aide #44 stated if a resident was on precautions there should be a sign and a bin outside their room. The precautions applied to everyone and directed what needed to be worn. Everyone must follow the sign, and the precautions were mainly for care delivery and did not apply to dropping off trays. They were not sure why the resident was on precautions. They should have followed the sign's instructions, including washing their hands when entering and exiting the room, but had not noticed the sign until just then. During an interview on 05/12/2026 at 6 2:34 PM, Physical Therapist Assistant #43 stated their understanding, and assumption was the resident had been cleared by the nurse practitioner at least a week ago to not be on both precautions. They asked Registered Nurse Manager #5 about the signs on 05/12/2026 at 2:00 PM and Registered Nurse Manager #5 took the droplet/contact sign down. They did not think they should have followed the droplet/contact precaution sign earlier that day because of that prior conversation they had with the nurse practitioner. During an interview on 05/13/2026 at 1:18 PM, Licensed Practical Nurse #59 stated precautions signs direct what should be worn and they should be followed. They were trained in the hospital, not the facility, about precautions and followed that knowledge and their nursing judgement; not necessarily what the precaution sign said. Their responsibility was to make sure precautions were followed. Resident #101 had an order for droplet/contact precautions, but the order did not say why. They expected staff to follow the signage. Resident #12 had a chronic infected right knee that drained and an active order for contact precautions.During an interview on 05/13/2026 at 1:42 PM, Registered Nurse Unit Manager #5 stated precautions signs were posted at the door and directed staff to what equipment had to be worn for what activity. Precautions should have an order and a care plan. They or the infection control nurse was responsible for putting the signs up and taking them down. If there was an order for precautions that order should be followed. If the order and the signage did not match, the provider should be contacted for clarification. There should always be an order to discontinue precautions prior to taking a sign down. Resident #12 had a chronic problem with an infected right knee and was on enhanced barrier precautions. They did not know if the resident was on contact/droplet precaution earlier that week and no one told them that signage was removed. After referring to the orders they stated there was an order for contact precautions due to methicillin resistant staphylococcus aureus and that should be followed. Resident #101 had enhanced barrier precautions for a pressure ulcer. They were not aware the resident had a droplet/contact precaution sign on their door earlier that week. They did not recall removing any signs but had been redoing the enhanced barrier precaution signs that week and may have taken those signs down without realizing what they were taking down. They expected to be notified if a precautions sign was taken down and no one had notified them of any signs being removed that week. During an interview on 05/15/2026 at 1:25 PM, Nurse Practitioner #22 stated they expected precaution orders were followed and if the precaution order was active the sign should be posted. Resident #101 was admitted on precautions due to pneumonia. The pneumonia had been resolved, and they thought they had talked to the manager earlier that week about discontinuing the precautions. Resident #12 was on contact precautions due to infection in their wound and if there was an active wound, they should still be on precautions.During an interview on 05/15/2026 at 12:56 PM, Registered Nurse Educator/Infection Preventionist #57 stated residents on precautions had a sign outside their door that directed what personal protective equipment was needed to enter the room. Precautions should have a physician order, and signs should not be removed unless the order was discontinued. The nurse manager was responsible for putting up the signs. They expected all staff to follow the ordered precautions or whatever the sign said that was outside the room. If a sign was taken down, they expected to be notified. Resident #101 was admitted on an antibiotic. They were unsure why they were on contact/droplet precautions but if the sign was posted it should be followed. Resident #12 had an order for contact precautions due to methicillin resistant staphylococcus aureus in their wound. Staff should follow the precaution sign to protect themselves and the resident from spreading the infection. They were not aware the signs were removed. Legionella:The undated Water Management Plan documented no less than 10 potable water dispensing locations within the facility would be checked at intervals not to exceed 90 days for the 12-month period beginning June 2018, and annually thereafter. If the percentage of positive Legionella tests were greater than or equal to 30% the water system would be re-sampled no sooner than 7 days and no later than 4 weeks after disinfection to determine the efficacy of the treatment.The 08/08/2024 legionella testing results documented 10 tests were obtained and three (3) had positive results.The 02/25/2026 legionella testing results documented 16 tests were obtained and nine (9) had positive results.There was no documented evidence of legionella test results obtained between 08/08/2024 and 02/25/2026.During an interview on 05/14/2026 at 1:15 PM, the Director of Maintenance stated they conducted legionella tests with an outside vendor and if there was a positive result it was escalated to the administrator. The facility had to test quarterly. The last test was about 2 months ago, and they thought there were 4-5 positives out of about 12 to 15 tests. They were unsure what the positivity percentage was but believed it was higher than acceptable. They did not report the results. When they started in their position approximately 3 months ago an outside water treatment company was working in the facility because of prior positive results. After the vendor's water treatments were completed, they retested, and the number of positive results was higher than prior to the vendor treating the water. They had a treatment scheduled for last week, but the vendor did not show up.During an interview on 05/15/2026 at 12:45 PM, the Administrator stated an outside vendor came in February 2026 to work on their water tank and valves and testing was performed on 02/24/2026. Sixteen sites were tested, and more than half were positive. When the vendor was at the facility in February 2026 more valves had broken, and it was not until April 2026 that the vendor came back to fix them. All the valves were fixed approximately 3 weeks ago. No further testing was done since 02/24/2026. They did not report the positivity rate to the Department of Health because they assumed the results were not accurate due to their valve problem. Reporting it could have created a lot of work if based on faulty results. The vendor was supposed to come back a week ago and put an automatic backflow and flushing system in. They planned to retest the water a week after that work was completed but the vendor did not show up. They were unsure when the next testing would happen. They were on an annual testing schedule but thought they would have to go to quarterly. 10 New York Codes, Rules and Regulations 415.19 (a) (1-3)

Based on observations, record review, and interviews, the facility failed to ensure residents who required dialysis services (filtration of blood when the kidneys do not work) received such services consistent with professional standards of practice for one (1) of one (1) resident (Resident #2) reviewed. Specifically, Resident #2 received hemodialysis treatments at a community-based dialysis center and did not have consistent on-going assessments or oversight before and after dialysis treatments; there was no documented evidence the resident's dialysis access site was routinely assessed; and the resident did not receive a bagged lunch for missed meal during their dialysis treatment.Findings include: The facility policy Care of Resident Receiving Hemodialysis, last reviewed 10/2025, documented the staff were to enter the pre-treatment information per the form fields in the dialysis communication book and enter the resident's departure into the clinical record. When a resident returns from dialysis the staff were to obtain vital signs, observe the access site for bleeding or redness, check for bruit (audible whooshing sound indicating blood flow) and thrill (palpable vibration indicating blood flow), and any alterations in the resident's status. A meal tray was to be ordered if a meal was missed. Record any recommendations and communications from dialysis and the post-treatment data per the form fields. Resident #2 had diagnoses including end stage kidney disease, diabetes, and low blood pressure. The 02/17/2026 Minimum Data Set documented the resident had intact cognition and received dialysis. The 10/24/2024 comprehensive care plan documented the resident was dependent on hemodialysis related to end-stage kidney disease. Interventions included: provide renal diet and follow dietary restrictions as per the provider's order; monitor the shunt for patency; monitor for signs of infection and communicate with the dialysis center any abnormal findings; provide bagged lunch for dialysis; monitor fluid intake and output; and vital signs and weight as ordered by the provider. The resident received hemodialysis three times a week on Monday, Wednesday, and Friday with a pickup time of 10:00 AM.The 12/23/2025 physician order documented collect and document vital signs pre-treatment, complete dialysis communication book, and write progress note. Monitor hemodialysis access site for bruising, bleeding, symptoms of infections, and the presence of thrill and bruit (if applicable) every shift. There was no documented order to check the resident's vitals or to complete an assessment upon the resident's return from dialysis. The May 2026 Treatment Administration Record documented the resident's hemodialysis access site was not documented as monitored on:-the 7:00 AM to 3:00 PM shift: 05/07/2026 by Licensed Practical Nurse #14, and 05/12/2026 by Licensed Practical Nurse #14. - the 3:00 PM to 11:00 PM shift: 05/02/26 by Licensed Practical Nurse #15, 05/05/2026 by Licensed Practical Nurse #14, 05/07/2026 by Licensed Practical Nurse #14, 05/08/2026 by Licensed Practical Nurse #17, and 05/12/2026 by Licensed Practical Nurse #18.- the 11:00 PM to 7:00 AM shift: 05/03/2026 by Licensed Practical Nurse #15, 05/04/2026 by Licensed Practical Nurse #16, 05/16/2026 by unidentified licensed practical nurse and 05/17/2026 by unidentified licensed practical nurse.There were no documented pre-dialysis assessments, and the nurse progress notes only documented the resident was out of the facility for dialysis. There were no documented post-dialysis assessments. The resident did not have their dialysis communication form filled out with necessary information on 05/01/2026, 05/04/2026, and 05/08/2026. The 05/01/2026 dialysis communication form documented dialysis recommended to Please Limit fluid as [resident] is gaining a lot and unable to tolerate the high goal was reviewed by the nurse and communicated to the provider.The resident was observed on 05/13/2026 at 11:26 AM leaving on a stretcher to dialysis and was not sent with a meal. During an interview on 05/14/2026 at 1:03 PM Resident #2 stated the facility did not give them lunch on dialysis days; they gave them a glass of water and sent them on their way. They stated the facility did not do bagged lunches. During an interview on 05/14/2026 at 1:45 PM, Licensed Practical Nurse #17 stated the resident sometimes received a lunch tray that was held until they got back from dialysis. The facility used to make lunches and then keep them at the front desk for the residents to take when they left but they did not think that was happening anymore. They only documented when the resident came and went from dialysis in their notes because there were already a lot of other orders for dialysis in the resident's chart. There used to be a whole specific set of things they had to write in the notes but not anymore. They had to complete the resident's dialysis book before they left for dialysis to include their vitals and if anything happened prior to dialysis. They were also supposed to check the resident's dialysis access site every shift and sign off it was completed; if it was not signed off as completed, it was not done.During an interview on 05/15/2026 at 9:04 AM Food Services Supervisor #19 stated they did not make to-go lunches for dialysis. They used to send bagged lunches, but dialysis stated the residents could no longer bring food with them. Resident #2 has their lunch tray held for them until they get back from dialysis. During an interview on 05/15/2026 at 9:26 AM Dialysis Center Secretary #20 stated they allowed residents to bring food to dialysis. They provided Resident #2 with a protein bar at dialysis as the resident did not bring any food with them. During an interview on 05/15/2026 at 10:10 AM Licensed Practical Nurse Unit Manager #9 stated residents who missed lunch because they were at dialysis were supposed to have a bagged lunch sent with them. They stated Resident #2 would not take a bagged lunch and would say they did not need it. But lunch should always be offered and documented as refused and a snack offered. They were unaware Resident #2 was not provided with a bagged lunch. The resident's dialysis access site should be monitored every shift and signed off. The licensed practical nurses were responsible for filling out the dialysis communication sheets. The nurse who reviewed the dialysis communication sheets when the resident returned from dialysis should put any outcomes, refusals, or information that was included on the communication sheet in their note. It did not appear the recommendation on the 05/01/2026 dialysis communication sheet to limit fluids was communicated to the provider and they were unaware of it. The notes the staff were supposed to document prior to dialysis should include more than just the resident went out to dialysis. There should also be a post-dialysis assessment and note but the resident did not have orders for that. 10 New York Codes, Rules and Regulations 415.12(k)

Based on observations, record review, and interviews, the facility failed to provide the necessary care and services to prevent urinary tract infections, to the extent possible, for one (1) of one (1) resident (Resident #26) reviewed. Specifically, Resident #26 had an indwelling urinary catheter (a tube that removes urine from the bladder), wore a urinary collection leg bag (a small, wearable, and discreet bag) and was not provided with a large capacity urinary collection bag. The urinary collection leg bag was not positioned below the level of the bladder to prevent backward urine flow. Findings include: The facility policy Catheter, Foley Insertion, Removal and Care, last reviewed 07/18/2022, documented the facility would provide catheter care during morning and evening care to residents that had indwelling catheters to prevent infection and reduce irritation. When using a leg bag, they should be checked and emptied every 2 hours. Resident #26 had diagnoses including obstructive uropathy (a condition that blocks the flow of urine), urine retention, and urinary tract infections. The 02/09/2026 Minimum Data Set assessment documented the resident had moderately impaired cognition, required supervision/touching assistance with personal hygiene and showering/bathing, independence with toileting hygiene, and had an indwelling catheter. The comprehensive care plan, revised 04/23/2026, documented the resident had an indwelling urinary catheter related to an enlarged prostate. Interventions included maintaining catheter and urology appointments, providing resident with risk benefit and understanding and agreement for catheter maintenance. There was no documented evidence of the resident's ability to empty or change their urinary collection bag. Physician orders documented: -on 03/10/2026, change 16 French (catheter size) urinary catheter on 03/12/2026 and every 4 weeks thereafter. -on 04/23/2026, may change urinary catheter if plugged, leaking or out. -on 04/25/2026, Augmentin (antibiotic) oral tablet 500-125 milligram give one tablet by mouth 2 times a day for 7 days for urinary tract infection. -on 04/29/2026, monitor indwelling catheter to leg bag/bedside drainage bag and ensure privacy bag was in place. -on 05/01/2026, change leg bag and obtain a urine specimen and send it to the lab for processing. The 05/10/2026 Registered Nurse #21 progress note documented a urine specimen was obtained and was awaiting pick up by the lab. During an observation and interview on 05/12/2026 at 8:29 AM, the resident was sitting in a chair with their urinary collection leg bag attached to their lower right thigh extending from just above the knee to just below the knee. A large, overnight collection bag was in an unopened package on the resident's dresser. No collections bags were observed in the bathroom. The resident stated they wore the leg bag all the time because they did not know how to switch it to the overnight collection bag. During an observation and interview on 05/13/2026 at 8:02 AM, the resident was sitting on their bed, and their leg bag was on their right thigh with the distal portion above the knee area, and not below the level of the bladder. The bag contained a scant amount of dark yellow urine. The resident stated they kept the same leg bag on their right upper thigh when they sat in the chair and while lying in bed. They slept with the leg bag and sometimes woke up at night to find the bag very full, requiring them to empty it. During an observation on 05/13/2026 from 11:23 AM – 11:52 AM, the resident was sitting in a chair in their room. Their leg bag was on their right thigh with the distal portion level with the resident's upper knee, not below the level of bladder. During an observation on 05/14/2026 at 08:51 AM, the resident was sitting on the edge of their bed. Their leg bag was on their right thigh, and the distal portion of the bag was at their knee, and not below the level of the bladder. During an observation and interview on 05/14/2026 at 11:53 AM, the resident was sitting on the edge of their bed. The leg bag was on their right lower leg below the knee extending to their calf. The resident stated staff recently told them the drainage bag should be kept on their lower leg so it could drain. Staff never explained that to them before. During an interview on 05/14/2026 at 1:52 PM, Licensed Practical Nurse #36 stated nursing was responsible for monitoring catheter output, placement, and were to report any related issues. The certified nurse aides should switch the collection bags from a leg bag to an overnight collection bag at night and switch back over to a leg bag in the morning. They were unsure if Resident #26 was allowed to change their collection bags themselves. They were not aware the resident was using a leg bag all the time and was not notified by the aides the resident used the leg bag even when in bed. The resident should not wear a leg bag on their thigh if they were sitting down or even lying down because it could have disrupted the urine flow, causing backup and a urinary tract infection. During an interview on 05/14/2026 at 2:14 PM, Certified Nurse Aide #13 stated the certified nurse aides were supposed to change the leg bag to the overnight collection bag at bedtime and back over in the morning. Resident #26 had used a large overnight collection bag but switched over a few weeks ago to wearing a leg bag all the time so they could get used to it before they went home. They had not changed it over for them in a long time because they were letting the resident manage the collection bag so they could do it when they went home. They were aware the resident was sleeping with the leg bag and kept it on their thigh, but they just realized it was not being kept below the level of the bladder when they were sitting or lying down so it could have caused the urine to back up and not flow freely. During an interview on 05/15/2026 at 10:02 AM, Registered Nurse Unit Manager #5 stated in the mornings the certified nurse aides should assist the resident with changing over from an overnight collection bag to a leg bag if the resident agreed to it and it should have been monitored to ensure it was kept below the level of the bladder. They were not aware Resident #26 was sleeping with a leg bag and not using an overnight collection bag. The resident had a history of bladder infections, and the bag needed to be kept lower than the bladder. 10 New York Codes, Rules and Regulations 415.12(d)(1)

Based on observations, record review, and interviews the facility failed to ensure that each resident received adequate supervision to prevent accidents for four (4) of six (6) residents (Residents #1, #6, #115, and #119) reviewed. Specifically, Residents #1 and #6, were at risk for aspiration (inhaling food or liquids into the lungs) and were not supervised or monitored when eating; Residents #115 and #119 had mattresses that were not adequately fitted to the bed frame and their beds tilted laterally causing a downward slope; and Resident #119 had a loose enabler bar on their bed. Findings include: The facility policy Aspiration Precautions, last reviewed 04/2026 documented no resident on aspiration precautions would use a straw for the delivery of nutrition or fluids, unless otherwise specified by the Speech Language Pathologist; no resident on a thickened liquid diet shall use straws; and residents on aspiration precautions would receive frequent monitoring by nursing staff. The facility Maintenance Policy, updated 05/2026, documented routine preventative maintenance schedules included weekly bed/siderail/mattress inspections. The undated facility policy Restraints, Safety Devices, Enabler Bars/Side Rails Policy, documented it was the responsibility of the maintenance department to ensure the enabler bar/side rail was securely placed and it was the responsibility of all departments to report any safety concerns regarding equipment to maintenance. Aspiration Precautions 1) Resident #6 had diagnoses including stroke with left sided paralysis. The 02/26/2026 Minimum Data Set (a resident assessment tool) documented the resident had mild to moderately impaired cognition; functional impairment to one side of the upper extremities, and to both lower extremities; required substantial/maximal assistance with eating and was on a mechanically altered diet. The 10/31/2025 hospital discharge instructions documented the resident was to receive a dysphagia 5 diet with mildly thick liquids (used for swallowing difficulties). The 11/03/2025 comprehensive care plan documented the resident had a self-care deficit and dysphagia. Interventions included extensive assistance of one with eating, provide food in separate bowls during meals, control rate and amount of oral intake, and place in an upright position for all oral intake. The 02/03/2026 Speech Language Pathologist #53 progress note documented the resident continued to tolerate ordered diet well without overt signs or symptoms of aspiration or other reported difficulty. Baseline dysphagia continues without candidacy for further advancement. No further evaluation or treatment indicated. Physician orders documented:- on 02/17/2026 regular pureed diet with nectar thickened liquids.- on 02/24/2026 nurse to monitor intake with every meal. Coordinate with certified nursing assistant to document appropriately. The 02/26/2026 comprehensive care plan documented the resident had a respiratory disorder of wheezing. The resident had a frequent, congested cough and wheezing. The resident was observed at the following times: -on 05/11/2026 at 12:23 PM lying in bed. Certified Nurse Aides #46 and #47 boosted the resident up in bed into a sitting position. Certified Nurse Aide #46 set the lunch tray on the bedside table in front of the resident and left the room. The resident's meal ticket documented regular puree diet with nectar thick liquids, extra meat, no milk, feeding assistance, and aspiration-no straws. The resident ate unsupervised and was unassisted during the meal. The resident attempted to use their right hand to spoon food into their mouth. -on 05/12/2026 at 12:40 PM Certified Nursing Assistant #52 repositioned the resident into a sitting position, placed the lunch tray on the bedside table in front of the resident and left the room. The meal tray ticket documented the resident required total assistance. The resident was leaning to the right side using their right hand to feed themself. -on 05/13/2026 at 12:40 PM in their room leaning to the right side attempting to eat lunch unassisted and unsupervised. -on 05/14/2026 at 12:30 PM in their room with their lunch tray in front of them. The resident was not assisted or supervised. During an interview on 05/14/2026 at 1:13 PM Licensed Practical Nurse Unit Manager #9 stated the certified nurse aides, or the nurses were responsible for assisting residents who needed help with eating. If residents did not receive the assistance they needed, they could choke, or they may not eat. They stated the resident's care plan documented the resident required extensive assistance of one with eating. During an interview on 05/15/2026 at 11:33 AM, Licensed Practical Nurse Unit Manager #9 stated aspiration precautions meant the resident was at risk for choking, they needed to monitored closely at meals. Monitoring could include staff circulating the unit and checking in periodically with the residents. During an interview on 05/15/2026 at 10:53 AM, the Director of Therapy stated the facility's aspiration policy documented the residents should be seated upright, staff should conduct frequent monitoring, and if the residents were on a thickened liquid diet they should not be provided with straws. Occupational Therapy determined the level of assistance a resident required at meals. Resident #6 required extensive assistance with meals due to fatigue, they started off strong and needed assistance to complete meals. Staff should have set up the resident's meal and checked to ensure the resident was completing meals. They stated speech language pathology communicated to nursing and dietary regarding aspiration precautions and instructions would have been added to the meal ticket. 2) Resident #1 had diagnoses including dysphagia (difficulty swallowing) and Schizophrenia (a serious mental health disorder). The 03/30/2026 Minimum Data Set documented the resident had severe cognitive impairment, did not reject care, required substantial / maximum assistance with meals, coughed or choked during meals or when swallowing medications, and received a mechanically altered diet. Resident #1's Comprehensive Care Plan documented: -08/13/2025 and updated 03/30/2026, the resident had an activity of daily living deficit. The resident required extensive assistance of one at meals. -03/27/2026 the resident was at nutrition risk related to advanced age, fair intakes, and a history of weight loss. Interventions included provide a liberalized modified diet and supplements. -03/31/2026 the resident had dysphagia. The goal was to safely manage the restrictive diet without signs/ symptoms of aspiration. Interventions included to provide the diet as ordered, remain upright for all intakes, assist with meals per occupational therapy recommendations and small bites/ sips at a slow rate. Physician orders documented:-03/27/2026, pureed solids and honey thick liquid diet and 240 milliliters of honey thickened Ensure Plus (oral nutrition supplements) twice daily.-03/31/2026, resident on 1:1 assistance with staff for all meals. The 03/30/2026 Occupational Therapist #24 Occupational Therapy Plan of Treatment documented moderate assistance with feeding. The 03/31/2026-04/29/2026 Speech Language Pathologist #23 Evaluation and Plan of Treatment documented puree solids, honey thick liquids, and close supervision for oral intakes. Strategies included upright for all meals, small bites/ sips, slow rate, and assist per occupational therapy recommendations. The current care instructions documented the resident required extensive assistance of one with meals, was on a pureed solids and honey thickened liquid diet and was 1:1 assistance with meals. The following observations of Resident #1 were made: -on 05/11/2026 at 11:20 AM, seated upright in their bed with food debris on their clothing protector. Their breakfast meal was on their over bed tray table. The meal ticket documented aspiration precautions, no straws, total feed, pureed scrambled eggs, oatmeal, yogurt, honey thick orange juice, honey thick water, and honey thick coffee. The resident stated they were on thickened liquids because they were easier to swallow, and they had a hard time feeding themselves. At 11:33 AM, Diet Technician #28 entered the resident's room and asked if they could remove the meal tray and removed the tray from the room. There was a bright orange sign in the room that read Puree honey, upright for all meals, assist with feeding per occupational therapy/ care plan. -on 05/12/2026 from 12:26 PM-1:05 PM, Certified Nurse Aide #29 provided the resident with their meal tray, assisted them to an upright position, pulled the privacy curtain closed, and exited the room. The meal ticket documented aspiration precautions, no straws, and total feed puree cottage cheese, puree fish, applesauce, honey thick apple juice, honey thick water, honey thick Mighty Shake (oral nutrition supplement), honey thick coffee, and chocolate pudding with whipped topping. The resident was in their bed and staff did not monitor or assist the resident. At 1:05 PM, Certified Nurse Aide #29 entered the room and removed the resident's meal tray. At 1:09 PM, the resident was sipping on their coffee and had two honey thick beverages on their over bed tray table. At 1:38 PM, Licensed Practical Nurse Unit Manger #9 entered the room and spoke to the resident and left the room at 1:40 PM, they did not remove the beverages or assist the resident. -on 05/13/2026 at 12:46 PM, the resident was seated upright in bed feeding themselves without staff assistance or supervision. Their meal ticket documented aspiration precautions, no straws, and total feed. The resident had pureed beef, pureed corn, pureed taco shell, pureed cottage cheese, a honey thick mighty shake, honey thick juice, honey thick water, honey thick coffee, and pudding. The May 2026 Medication Record Administration documented the resident was on 1:1 meal assistance with staff at all meals.-On 05/11/2026, Licensed Practical Nurse #27 signed the order as completed on the 7:00 AM – 3:00 PM shift.-On 05/12/2026, Licensed Practical Nurse Unit Manager #9 signed the order as completed on the 7:00 AM – 3:00 PM shift.-On 05/13/2026, Licensed Practical Nurse #14 documented 1:1 assistance at meal was not provided. During an interview on 05/13/2026 at 1:18 PM, Certified Nurse Aide #26 stated they were assigned to Resident #1. Each resident had care instructions that were supposed to be checked daily, and the certified aides were to follow the care instructions. Aspiration precautions meant the resident had a risk for choking and staff were supposed to check on them throughout the meal. Extensive assistance with meals meant the certified nurse aide was supposed to assist the resident with their meal. They stated Resident #1 did not need assistance with meals but just needed to be set-up and was able to feed themselves. During an observation on 05/14/2026 at 5:22 PM, the resident was in bed seated upright drinking their Ensure Plus with a straw. Licensed Practical Nurse #15 stated the resident was on a puree honey thick diet. They thickened their Ensure Plus supplement and provided them with a straw and then continued with their medication pass. They stated there was no order for the resident not to have straws or they were on aspiration precautions. They stated they were unaware the resident should not have straws. The resident was supposed to receive 1:1 assistance with meals per their orders. On 5/14/2026 at 5:54 PM, Licensed Practical Nurse Unit Manager #9 was alerted by the surveyor the resident was drinking their Ensure Plus supplement with a straw. They reviewed the resident's orders and stated there was not an order for no straws. They called the Director of Therapy via telephone, who told them there was no documentation in the speech pathologist notes regarding straws. During an interview on 05/15/2026 at 10:53 AM, the Director of Therapy on 05/15/2026, stated the facility's aspiration policy documented the residents should be seated upright, staff should conduct frequent monitoring, and if the residents were on a thickened liquid diet they should not be provided with straws. Resident #1 should not have a straw as it posed a safety risk, as they received honey thick liquids. The speech pathologist recommendations were to provide close supervision for oral intakes and strategies included upright for all meals, small bites/ sips, slow rate, and assist per occupational therapy recommendations. During an interview on 05/15/2026 at 11:33 AM, Licensed Practical Nurse Unit Manager #9 stated aspiration precautions meant the resident was at risk for choking and needed to be monitored closely at meals. Monitoring could include staff circulating the unit and checking in periodically with the residents. The speech language pathologist determined who could have straws. If there was a medical order for 1:1 assistance at meals staff should be in the room assisting the resident. If the nurse signed that the order was completed it meant someone was in the room when the resident was eating. They were unaware staff were not assisting the resident with their meal or when they received their nutritional supplements between meals. Resident mattresses/beds/side rails 1)Resident #115 had diagnoses including polyneuropathy (nerve damage), chronic obstructive pulmonary disease (lung disease), and congestive heart failure. The 03/17/2026 Minimum Data Set documented the resident was cognitively intact, had moderate depression, had no behaviors, and required maximum assistance for rolling side to side in bed. The 10/24/2024 comprehensive care plan documented the resident had a self-care deficit in bed mobility. Interventions included extensive assistance of two for bed mobility and dependence with a mechanical lift of three for transfers. The 03/28/2025 comprehensive care plan documented the resident had chronic obstructive pulmonary disease and was at risk for inadequate oxygenated blood circulation and respiratory distress. Interventions include to maintain the head of the bed 30 degrees elevation or higher to tolerance to prevent shortness of breath while lying flat. The resident was observed at the following times: -on 05/11/2026 at 11:07 AM lying in bed. There was a mobility bar on the left side of the bed, and the bed tilted right at the head of the bed approximately 20 degrees resulting in a downward slope. The mattress was hanging over the left side of the bed frame at the foot of the bed approximately six inches. The bed was also slightly hanging over the frame on the right-side foot of the bed. The resident stated their right shoulder hurt from leaning on it due to the slope of the bed and they also could not assist with bed mobility as much as the staff wanted because they were not able to roll up a hill at their size. -on 05/12/2026 at 12:07 PM lying on the right side of bed with the bed sloped approximately 20 degrees to the right side. The mattress was slightly hanging over on the right side and approximately six inches on the left side of the bed. The resident stated they were tired of being crooked in the bed.-on 05/13/2026 at 10:38 AM lying on the right side of bed with the bed sloped approximately 20 degrees to the right side. The mattress was slightly hanging over on the right side and approximately six inches on the left side of the bed. They stated their right arm was painful and numb this morning when they woke up and thought it was due to the weight on their right shoulder due to the slope of the bed.-on 05/14/2026 at 1:09 PM lying on the right side of bed with the bed sloped approximately 20 degrees to the right side. The mattress was slightly hanging over on the right side and approximately six inches on the left side of the bed. There were no documented Maintenance Requests for Resident #115's bed from 01/16/2026 to 05/15/2026.During an interview on 05/14/2026 at 2:26 PM Certified Nurse Aide #55 stated some of the resident mattresses in the facility did not fit the frames. When they moved resident rooms, they moved the mattresses but did not always take the frames. They stated if you make Resident #115's mattress fit the bottom of the bed, it pops out on the top. They reported the mattress not fitting to both the nurses and maintenance. They did not believe the frame tilted at the head of the bed was reported. The resident complained of pain on their right side from the way they slept in the bed and leaning onto the right side. During an interview on 05/14/2026 at 2:11 PM, Licensed Practical Nurse #14 stated they would let maintenance know if a resident's mattress was not fitting their bed or if the bed frame was tilted. They were unaware Resident #115's mattress was hanging over the side of their bed or the frame was tilted. At 2:14 PM Licensed Practical Nurse #14 observed the resident in their bed with the mattress hanging over the left side and inquired if the top of the bed was stuck in the tilt. The resident stated the mattress did not do it so much when the bed was flat, but the mattress slid when they were repositioned in bed. During an interview on 05/15/2026 at 10:10 AM Licensed Practical Nurse Unit Manager #9 stated mattresses were applied by housekeeping and maintenance. Maintenance and housekeeping should be notified if a resident's mattress was hanging over the bed frame as that meant the resident needed a new mattress. They stated they should also be notified as the unit manager. If the top of the bed frame was sloped maintenance should be notified as soon as possible as the resident should not be in a bed that was broken. They were not informed Resident #115 had any issues with their mattress or bed. 4) Resident #119 had diagnoses including Parkinson's Disease (a progressive neurological disease). The 04/21/2026 Minimum Data Set assessment documented the resident had intact cognition and required maximum assistance for bed mobility. The comprehensive care plan initiated 10/28/2024 and revised 06/23/2025, documented the resident was at risk for falls. Interventions included provide hourly visual checks to ensure they were centered properly in bed and to reposition if not. The comprehensive care plan initiated 11/25/2024 documented the resident used a left quarter rail as an enabler for bed mobility. Interventions included the resident understood and signed enabler bar consent form. The following observations of Resident #119's bed were made on 05/11/2026 at 11:05 AM, 05/12/2026 at 1:55 PM, and 05/14/2026 at 1:30 PM: the right side of the mattress was extending approximately 6 inches beyond the bed frame resulting in that section of the mattress being suspended and not supported; the bed as a unit was leaning to the left (towards the door) approximately 20 degrees resulting in a downward slope; and the enabler bar on the left side of the bed was very loose in all directions. During an observation on 05/13/2026 at 10:01 AM, the resident was in bed lying diagonally on their left side facing the door. Their upper body was positioned on the right upper quadrant of the mattress and their legs dangled off the left lower quadrant resulting in the right lower mattress lifting creating a space of approximately 3 inches between the frame and mattress. There was no documented evidence of maintenance performed on the resident's bed in 2026. During an interview on 05/11/2026 at 11:05 AM, Resident #119 stated the bed rail was loose for a couple of weeks. It loosened up a couple times in the past and had to be tightened. They used the rail to pull themselves from lying to the side of the bed and to help them roll to their side. During an interview on 05/14/2026 at 1:30 PM, Certified Nurse Aide #13 stated housekeeping brought up beds and mattresses. Mattresses should be the same size as the bed frame and not extend beyond the frame. Side rails were applied by maintenance and were used to help residents move around and should be secure and tight and if not, should be reported right away. Resident #119 was a big person and had a wide mattress and a bed rail that made it easier for them to sit up and move around in bed. Upon looking at the bed, they stated the mattress was not squarely on the frame; the mattress should be squarely on the frame; and the bed rail was loose and seemed to be bent. During an interview on 05/14/2026 at 2:11 PM, Licensed Practical Nurse #12 stated maintenance obtained and set up the beds. Beds should be level, and the mattress should fit the bed frames. Any issues with an ill-fitting mattress should be reported to the supervisor or maintenance. Side rails were used for positioning and should not be loose or wobbly and if they were, it should be reported. Resident #119 had a bariatric bed and a bed rail used for mobility. They stated the bed was leaning in the direction of the door and the mattress did not fit the frame because the frame had not been extended. They were unsure why the bed was like that, and no one had reported any of those issues to them. During an interview on 05/14/2026 at 4:38 PM, Registered Nurse Unit Manager #5 stated the facility had bariatric beds and bariatric mattresses. Housekeeping or maintenance set those beds up. Visualizing mattresses would show whether a mattress fit the frame properly. Beds should not lean and if it did, they would question if the control was faulty or the bed was bent. Side rail/enabler bars were used for mobility and should be snug to not cause an entrapment risk. They expected any of those issues to be reported to them and to the maintenance department. Resident #119 had a bariatric bed and an enabler bar. Upon looking at the bed, they stated the mattress was hanging past the bed frame and the bed appeared to be leaning. No one had reported any of these issues to them. During an interview on 05/15/2026 at 10:52 AM, the Assistant Director of Maintenance stated they or housekeeping set up beds when requested from nursing. Preventative maintenance checks involved only the electrical component of the beds; bariatric bed frames had extenders on either side that needed to be extended to accommodate a bariatric mattress; mattresses should fit the bed frame and not extend over the bed frame; and beds should not tilt to one side because that could cause a tipping issue. They installed and removed side rails based on directives from nursing or therapy and side rails should be snug, not loose. Once on, they did not do anything with the rails unless notified there was a problem. They were called regarding Resident #119's bed on 05/14/2026. They noticed the bed was tilted in the direction of the door and a piece was missing from the side rail. They thought maybe the bed was bent from the resident positioning themselves on that side of the bed. They moved the mattress around and thought they resolved the issue. They had to take the side rail to the maintenance shop to fix it before reinstalling it on the bed. They had not received any recent work orders involving Resident #115's mattress or sloping of their bed. 10 New York Codes, Rules and Regulations 415.12(h)(1)

Based on observations, record review, and interviews (iQIES intake 2727573), the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new ulcers from developing for one (1) of one (1) resident (Resident #17) reviewed. Specifically, Resident #16 had an existing Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer on the sacrum (large bone at the base of the spine) and treatments were not administered as ordered and the wound was not monitored consistently. Findings include: The facility policy Pressure Ulcer Prevention and Managing Skin Integrity, last reviewed 12/2025, documented care and interventions regarding pressure ulcers included implementation of appropriate evidence-based care, and close monitoring of the responses to treatment.Resident #16 had diagnoses including a Stage 4 pressure ulcer to the sacrum, impaired circulation and urinary incontinence (loss of bladder control). The 02/09/2026 Minimum Data Set (a resident assessment tool) documented the resident had moderately impaired cognition; was dependent on staff for all personal hygiene and mobility; had unhealed pressure ulcers present on admission; was at risk for developing new pressure ulcers; had pressure reducing devices for bed; and received application of nonsurgical dressings and ointments/medications.The 03/02/2025 comprehensive care plan documented the resident was at risk for skin breakdown related to impaired mobility, refusals to reposition in bed, refusals to get out of bed, urinary incontinence, and diabetes. The resident had a Stage 4 sacral pressure ulcer. Interventions dated included provide urinary incontinence care; perform wound care rounds weekly; monitor for changes in pressure ulcer daily and documenting findings weekly; provide a pressure reducing mattress; maintain turning and positioning schedule as recommended; prevent skin friction during transfers and positioning; use skin protectant ointment when performing perineal care; promote optimal hydration and nutrition; apply local treatments as ordered by the physician; and wound care consult as needed.The 04/13/2026 Physician #30 order documented fill sacrum wound cavity with gauze moistened with Dakin's solution 25% (a strong antiseptic used to treat and prevent infections), soak for 20 to 30 minutes. Gently cleanse with normal saline after soak, use collagen dressing and cover with blue antibacterial foam dressing followed by a dry dressing every Monday, Wednesday, and Friday during 7:00 AM - 3:00 PM shift.The 04/14/2026 consulting Wound Physician #33 documented the sacrum wound was improved with no overt infection. Recommendations included cleansing the wound with normal saline, applying skin protectant ointment around the edges of the wound; soaking with Dakin's solution 20 to 30 minutes prior to dressing changes, gentle cleansing with normal saline after the soak, applying collagen dressing to wound bed, then covering with an antibacterial foam dressing. Change dressing 3 times a week and as needed.There was no documented evidence of facility-documented wound assessments in the electronic health record from 03/27/2026 through 05/12/2026.The April 2026 and May 2026 Treatment Administration Record documented fill sacrum wound cavity with gauze moistened with Dakin's solution 25%, soak for 20 to 30 minutes. Gently cleanse with normal saline after soak, use collagen dressing and cover with blue antibacterial foam dressing followed by dry dressing with a start date of 04/13/2026. There was no documented evidence the treatment was administered on 04/13/2026, 04/15/2026, 04/17/2026, 04/22/2026, 04/24/2026, 04/27/2026, and 05/15/2026. During an observation on 05/13/2026 at 1:00 PM Licensed Practical Nurse #31 performed wound care to Resident #17's sacral wound with the assistance of Assistant Nurse Manager #32. The sacrum wound dressing was intact without visible drainage. The dressing was removed by Assistant Nurse Manager #32. The wound was 3.0 centimeters x 1.0 centimeter x 1.0 centimeter with granulation (new healthy tissue), no signs or symptoms of infection, and surrounded by pink intact skin. Licensed Practical Nurse #31 sprayed the wound with wound cleanser, wiped the wound with a sterile gauze, packed the wound with collagen dressing, and covered the wound with an antibacterial foam dressing followed by a dry sterile dressing. There was no evidence the wound was filled with Dakin's solution gauze for 20-30 minutes as ordered.During an interview on 05/14/2026 at 1:46 PM Licensed Practical Nurse #31 stated they did not perform the Dakin's solution soak for 20 to 30 minutes prior to completing the dressing change as ordered. During an interview on 05/15/2026 at 11:30 AM Wound Care Registered Nurse #21 stated they assess all pressure ulcers weekly with the facility physician, the physical therapy director, a registered dietitian, and a unit nurse manager. They state the resident had an outside consultant for pressure ulcer care. They stated they still assessed Resident #17's pressure ulcer weekly but had not completed any documentation of the assessments since starting in the position in late March of 2026. They stated the last time they saw the resident's wound was Thursday, 05/07/2026, but they did not document the assessment in the medical record. They stated the medication nurse was responsible for completing pressure ulcer dressing changes, and they documented in the Treatment Administration Record. They stated if dressing were not performed as ordered this could have led to infection, delayed healing, and pain.10 New York Codes, Rules and Regulations 415.12 (c)(1)

Based on observations, record review, and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (1) of one (1) resident (Resident #19) reviewed. Specifically, Resident #19 had leg wounds, and their dressings were not changed as ordered or as scheduled.Findings include: Resident #19 had diagnoses including cellulitis (a skin infection) of both legs. The 03/16/2026 Minimum Data Set assessment documented the resident had intact cognition, required moderate assistance with most activities of daily living, and received application of nonsurgical dressings (with or without topical medications) other than to feet.The 12/09/2025 comprehensive care plan documented the resident had cellulitis of both legs and a risk for skin breakdown related to impaired mobility, weakness and lymphedema (swelling). Interventions included application of local treatments as ordered, off-load extremities and elevating both legs.The 05/08/2026 physician order documented cellulitis to left and right lower leg wounds: Cleanse with Dakin's solution (a cleanser used to prevent infection). Apply methylene blue (an antimicrobial wound dressing) to the wound bed only. Wet methylene blue prior to applying. Apply abdominal pads (thick, absorbent dressing) then wrap the extremity with Coban (a type of compression wrap) starting at the toes to the knees 3 times a week on Monday, Wednesday and Friday, and as needed.The 05/11/2026 Registered Nurse #34 progress note documented 3+ edema (a measurement that indicates a moderate to severe amount of swelling) to their legs.The May 2026 Treatment Administration Record documented the leg dressings were not changed on 05/13/2026.The 05/15/2026 Physician #35 History and Physical note documented the resident had 2+ pitting edema (a measurement that indicates a moderate amount of swelling) of their extremities.The following observations of the resident's legs and leg dressings were made:-On 05/11/2026 at 11:27 AM the resident had kerlix (a type of gauze wrap) wrapped around both lower legs just above their feet. The resident was barefoot, their legs were not wrapped with Coban, and both feet and lower legs were very swollen.-On 05/12/2026 at 3:58 PM the resident was lying in bed with kerlix dressings on their lower legs just above their feet. The right leg dressing had a date of 05/11/2026 written on a piece of tape holding the dressing in place. Their legs were not wrapped with Coban and both legs and feet were swollen. -On 05/14/2026 at 9:51 AM the resident was sitting in their wheelchair with kerlix dressings on their lower legs just above their feet. The right leg dressing had a date of 05/11/2026 written on a piece of tape holding the dressing in place, and the left leg dressing had a large amount of yellow drainage covering about 30% of the dressing. The resident was barefoot, their legs were not wrapped with Coban, and their legs and feet were swollen.During an interview on 05/11/2026 at 11:27 AM, the resident stated they had wounds on their legs because of poor fluid flow up and down their legs. They stated compression stockings were discussed last week but talk was as far as it went. During an interview on 05/15/2026 9:21 AM, Registered Nurse Unit Manager #5 stated whichever nurse was assigned to the medication cart completed those residents' treatments. Most treatment orders could also be done as needed in case the dressing fell off or became soiled. Nurses should be checking the integrity of the dressing and change accordingly. If a nurse was unable to complete a treatment it should be relayed during shift report so the next shift could do it. If the treatment was still unable to be done, the provider should be notified for further directives and that should be documented. Resident #19 was admitted with leg cellulitis and an extreme case of edema which was an issue with their legs healing. They received a diuretic (water pill) and Coban wraps. It has not been reported to them the resident had not been getting the Coban wraps.During an interview on 05/15/2026 at 10:07 AM, Registered Nurse #34 stated treatment orders were on the treatment administration record and should be followed as ordered; if a treatment was not done, the nurse should write a note as to why and notify the provide. Dressing integrity should be checked even if the dressing was not due to be changed. They stated they changed Resident #19's dressing on 05/11/2026 at 3:00 PM. There was not any Coban on the unit and they planned to go upstairs and get some but never got around to it. On 05/13/2026, they were assigned to the resident but did not do their dressing because they only worked until 1:00 PM and it was supposed to be passed on to the evening shift for them to do the dressing. During an observation and interview on 05/15/2026 at 12:14 PM the resident's left leg dressing had a large amount of yellow drainage extending from the lateral to posterior aspect and the right dressing had a date of 05/11/2026 written on a piece of tape holding the dressing in place. Wound Care Registered Nurse #21 removed the dressings and stated the date on the right dressing was dated 05/11/2026. They should not have a dressing on that was dated 05/11/2026 and the amount of drainage on the left dressing should have prompted it to be changed. The legs were not wrapped with Coban but should have been. The Coban treated the edema, promoted healing, and decreased pain. During an interview on 05/15/2026 at 1:40 PM Nurse Practitioner #22 stated they expected treatments be completed as ordered and they should be notified if they were not. Resident #19 had chronic lymphedema (fluid buildup) and vascular disease (a disease that affects blood flow). Coban was ordered to help with compression which could help with healing. The resident should be getting those wraps, and they expected to be notified if they were not. 10 New York Codes Rules and Regulations 415.12

Based on observations, record review, and interviews (iQIES Intakes 2626678, 2727573, and 2970379) the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (1) of six (6) residents (Resident #9) reviewed. Specifically Resident #9 did not receive showers as planned.Findings include:The facility policy AM/PM/ Activity of Daily Living Care, last reviewed 07/2025, documented residents would receive hygienic care at routine intervals. Hygienic care was in addition to any regular scheduled bathing. Shaving, nail hygiene, and oral care were considered parts of AM / PM/ activity of daily living care. Any refusal of care would be immediately reported to the nurse.Resident #1 had diagnoses including muscle weakness and need for assistance with personal care. The 04/13/2026 Minimum Data Set assessment documented the resident had intact cognition, did not reject care, required setup or clean-up assistance with bathing and was independent with personal hygiene.The comprehensive care plan, initiated 10/21/2024 and revised 02/24/2026, documented the resident had a self-care deficit. Interventions included the resident was independent with bathing after set-up and independent with personal hygiene.The undated care instructions documented the resident was independent with bathing after set-up.The 2nd floor shower schedule documented Resident #9 was scheduled to receive a shower on Friday evenings (3:00 PM-11:00 PM).Certified Nurse Aide Documentation Records documented the following;-March 2026 the resident received a shower on 03/19/2026.-April 2026 no showers were provided.-May 2026 no showers were provided.Resident #9 was observed at the following times:-on 05/11/2026 at 11:53 AM, in the dining room. They were eating and licking their fingers, their fingernails were long and unclean with a dark substance underneath. At 1:11 PM, the resident was walking down the hallway, their hair was long, greasy, had white specs in it, and their nails were long and unclean with a dark substance underneath them. The resident stated they would like their nails cut, they had not had a shower in a month, and wanted their hair washed.-on 05/12/2026 at 9:10 AM, seated in the common area. Their hair was long, greasy, and had white specs in it. Their nails were long and had a dark substance underneath them. At 12:42 PM, the resident was walking down the hallway. Their hair was long, greasy, and had white specs in it. Their nails were long and had a dark substance underneath them.-on 05/13/2026 at 9:58 AM, the resident was walking in the hallway. Their hair was long, greasy, and had white specs in it. They stated their nails were cut.During a telephone interview on 05/14/2026 at 12:06 PM Certified Nurse Aide #54 stated showers were completed Monday through Fridays on the day or evening shifts. There was a shower schedule posted behind the nurse's station and each aide completed the provided showers as scheduled based on their assignment. If a resident refused to be showered the aide should tell the nurse and provide a bed bath, if the resident was agreeable. They documented the shower was provided in the certified nurse aide documentation. If it was not documented, that meant it was not done. The nurse aides could document any refusals, and the nurse was supposed to document the refusals as well. Resident #9 was on their assignment last Friday evening, the resident refused to be showered, and they told Licensed Practical Nurse #15. They were unsure if they documented the refusal. During an interview on 05/14/2026 at 5:22 PM, Licensed Practical Nurse #15 stated showers were provided by the certified nurse aides according to the schedule at the nurse's station. If a resident refused their shower the certified nurse aide should notify the nurse of the refusal and both the nurse and certified nurse aide should document the refusal. They did not recall being told that Resident #9 refused their shower on Friday evening. They stated if they were made aware they would have documented it.During an interview on 05/15/2026 at 11:33 AM, Licensed Practical Nurse Unit Manager #9 stated the certified nurse aides showered the residents per the shower schedule based on their assignments. Both the nurse and the certified nurse should document any refusals. Resident #9 at times refused showers, but if they were reapproached, they would typically be agreeable to a shower. Residents should be showered at least weekly, nail care should be done on shower days, and as needed. Resident #9 was not a diabetic and the nursing staff could cut and clean their nails. They were unaware the resident had not had a documented shower since March 2026, but their hair looked greasy, and they had staff cut the resident's nails this week as they were long and unclean. 10 New York Codes Rules Regulations 415.12(a)(3)

Based on observations, record review, and interviews, the facility failed to ensure services provided met professional standards of clinical practice for two (2) of six (6) residents (Residents #2 and #5) reviewed. Specifically, Resident #2 had multiple medications not documented as administered; and Resident #5 had multiple medications not documented as administered and units of insulin administered per sliding scale coverage were not consistently documented. Findings include:The facility policy Administering Medications/Medication Errors, last reviewed 06/2025, documented all medications were to be administered in a safe and timely manner as prescribed. Staff schedules are arranged to ensure that medications are administered without unnecessary interruptions. Medications are administered in accordance with prescriber orders, including any required timeframes. Medications were administered within 1 hour of their prescribed time unless otherwise specified. The individual administering the medication documents administration after administering the medication. 1) Resident #2 had diagnoses including end stage kidney disease, diabetes, and low blood pressure. The 02/17/2026 Minimum Data Set documented the resident had intact cognition and received hemodialysis (process that filters blood when the kidney does not function adequately). Physician orders documented the following medications:- Depakote (seizure medication) 125 milligram tablet, delayed release: give one tablet two (2) times per day- Eliquis (blood thinner) 2.5 milligram tablet: give one (1) tablet two (2) times per day- midodrine (low blood pressure) 10 milligram tablet: give one tablet three (3) times per day; hold for systolic (upper number) blood pressure more than 120- levetiracetam (seizure medication) 250 milligram tablet: give one (1) tablet by oral route two (2) times per day- metoprolol tartrate (high blood pressure) 25 milligram tablet: give one (1) tablet two (2) times per day- Juven (protein supplement) 7 gram-7 gram-1.5-gram oral powder packet: give one (1) packet two (2) times per day- sevelamer carbonate (Renvela) (phosphate binder) 800 milligram tablet: give two (2) tablets (1600 mg) three (3) times per day with meals.- insulin lispro (fast acting insulin) inject 4 units subcutaneously before meals 4 days per week. The May 2026 Medication Administration Record documented:- on 05/02/2026 and 05/07/2026 at 4:00 PM insulin lispro subcutaneous inject 4 units before meals were not documented as given. - on 05/02/2026 and 05/07/2026 at 4:30 PM sevelamer carbonate was not documented as given. - on 05/02/2026 and 05/07/2026 at 5:00 PM midodrine and Juven were not documented as given.- on 05/02/2026, 05/07/2026, and 05/09/2026 at 9:00 PM Depakote, midodrine, levetiracetam, and metoprolol tartrate were not documented as given by an unidentified nurse. There were no documented nursing progress notes addressing the medications not being administered. 2) Resident #5 had diagnoses including diabetes, polyneuropathy (nerve damage) and heart disease. The 02/25/2026 Minimum Data Set documented the resident had intact cognition and received insulin injections. The May 2026 Medication Administration Record documented:- the 05/01/2026 at 5:30 AM, 05/06/2026 at 4:30 PM, and 05/06/2026 at 9:00 PM doses of Novolog U-100 insulin aspart 100 unit/milliliters subcutaneous solution: inject by subcutaneous route per prescriber's instructions. Insulin dosing requires individualization and did not have the number of units administered per the sliding scale insulin order.- the 05/03/2026 and 05/08/2026 at 5:00 PM dose of carvedilol (for high blood pressure) 12.5 milligram tablet: give one tablet by mouth twice daily; and acetaminophen 500 milligram tablet give 2 tablets (1000 milligrams) by oral route three (3) times per day were not documented as administered.- the 05/05/2026 at 5:30 AM dose of Novolog U-100 Insulin aspart 100 unit/milliliters subcutaneous solution: inject by subcutaneous route per prescriber's instructions. Insulin dosing requires individualization was not documented as administered and the blood sugar was not documented as checked.- the 05/10/2026 at 9:00 PM dose of Novolog U-100 Insulin aspart 100 unit/milliliters subcutaneous solution: inject by subcutaneous route per prescriber's instructions. The blood sugar documented was 341. Per the order the resident was to receive 8 units of insulin. Licensed Practical Nurse #14 documented the resident received 10 units of insulin.- the 05/08/2026 at 4:30 PM and 9:00 PM dose of Novolog U-100 Insulin aspart 100 unit/milliliters subcutaneous solution: inject by subcutaneous route per prescriber's instructions. Insulin dosing requires individualization was not documented as administered and the blood sugar was not documented as checked- the 05/08/2026 at 9:00 PM dose of quetiapine (an antipsychotic) 25 milligram tablet: give one tablet once daily at bedtime; melatonin (hormone for sleep) 5 milligram tablet: give one (1) tablet by oral route once daily; insulin glargine (U-100) inject 16 units by subcutaneous route 2 times per day; gabapentin (an anticonvulsant used for nerve pain) 100 milligram: one (1) capsule by mouth at bedtime; Eliquis (a blood thinner) 5 milligram tablet: and ranolazine (a medication for chest pain) 12 hour extended release 500 milligram tablet: daily were not documented as administered.- the 05/13/2026 at 9:00 PM dose of Novolog U-100 Insulin 100 unit/milliliters subcutaneous solution: inject by subcutaneous route per prescriber's instructions. Insulin dosing requires individualization was not documented as administered and the blood sugar was not documented as checked. During an interview on 05/14/2026 at 2:21 PM Licensed Practical Nurse #14 stated they knew how many units of insulin to give when a resident was on sliding scale insulin by the scale in the order. Resident #5's blood sugar on 05/10/2026 at 9:00 PM was 341 so they gave 8 units of insulin per the sliding scale. They must have made an error when documenting in the comment section as they gave 8 units, not 10. The number of units given was supposed to be documented in the dose box, not the comment box. During an interview on 05/14/2026 at 5:51 PM Licensed Practical Nurse #38 stated they followed the physician order on how many units of insulin to give based on the resident's blood sugar for a sliding scale insulin. The number of units given should be documented on the Medication Administration Record. They put ok in the comments on Resident #5's 4:30 PM and 9:00 PM sliding scale insulin doses as the Medication Administration Record would not let them document. They did not let anyone know the record would not let them document the units. During an interview on 05/15/2026 at 10:10 AM, Licensed Practical Nurse Unit Manager #9 stated they go through the orders when a resident was due for a Minimum Data Set assessment and reviewed the medications. The amount of insulin given should be entered for a sliding scale insulin order in the dose box that comes up on the Medication Administration Record. They documented how much insulin was given and the physician reviewing the documentation knew the doses the resident received. They were aware there were times the nurses did not document in the Medication Administration Record; consistency was a problem. If a nurse could not complete their documentation during their shift, they should report it or stay and complete it. There should never be an entire shift of medications not signed for. During an interview on 05/15/2026 at 1:25 PM, Nurse Practitioner # stated they expected the nursing staff to sign off on the medications they administered in the Medication Administration Record. They expected the nurses to document the number of units given for a sliding scale insulin order as there needed to be a record of the amount of insulin given. During an interview on 05/15/2026 2:07 PM Pharmacist Consultant #40 stated they did not review the Medication Administration Records during the pharmacy reviews. They did not review whether medications were being given or not, just what the resident was taking. They were only in the facility once a month for a short visit and they did not have any clinical interactions with the residents. 10 New York Codes, Rules, and Regulations 415.11(c)(3)(i)

Based on record review and interviews, the facility failed to operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. Specifically, the facility did not provide the Medicare/Medicaid Application (CMS-671), Civil Rights Questionnaire (DOH-1506), Facility Assessment, Equipment Inventory Form, Legionella policies and procedures, menus for the duration of the survey, admission packet, and documentation of the Infection Preventionist's specialized training in infection prevention and control in a timely manner as required.Findings include:The Centers for Medicare and Medicaid Services survey form Entrance Conference Worksheet, provided to the Administrator upon survey entrance documented the following items were required during the recertification survey:-menus including therapeutic menus for the duration of the survey within 1 hour of entrance.-documentation of the Infection Preventionist's specialized training in infection prevention and control within 1 hour of entrance. -admission packet within 4 hours of entrance -Facility Assessment within 4 hours of entrance.-completed Medicare/Medicaid Application (CMS-671) within 24 hours of entrance.The New York State Addendum form Entrance Conference Worksheet, provided to the Administrator upon survey entrance documented the following items were required during the recertification survey:- Equipment Inventory Form within 24 hours of entrance.- Legionella policies and procedures within 24 hours of entrance.- completed Civil Rights Questionnaire (DOH-1506) within 24 hours of entrance.The New York State Department of Health surveillance team entered the facility on 05/11/2026 at 10:00 AM. The Team Coordinator met with the facility's Administrator and Director of Nursing at 10:42 AM to review the documents required for the survey as outlined on the entrance conference worksheets. The Administrator was provided with a hard copy of the entrance conference worksheets. The worksheets included the time frame for providing the Medicare/Medicaid Application (CMS-671), Civil Rights Questionnaire (DOH-1506), Facility Assessment, Equipment Inventory Form, Legionella policies and procedures, menus for the duration of the survey, admission packet, and documentation of the Infection Preventionist's specialized training in infection prevention and controlOn 05/12/2026 at 9:35 AM, the Administrator sent the admission packet that was required within 4 hours of entrance.On 05/12/2026 at 12:44 PM, The Team Coordinator met with the Administrator and notified them they had sent an email at 12:41 PM with blank copies of the Medicare/Medicaid Application (CMS-671), Civil Rights Questionnaire (DOH-1506), and Equipment Inventory Form that were required within 24 hours of entrance.On 05/12/2026 at 2:25 PM, the Team Coordinator sent an email to the Administrator requesting all food menus that would be served for the duration of the survey that was required within 1 hour of entrance.On 05/12/2026 at 2:37 PM, the Administrator sent the food menus that would be served for the duration of the survey.On 05/13/2026 at 9:45 AM, the Team Coordinator met with the Administrator to review all missing documents that were required from the Entrance Conference Worksheets. The Administrator stated they were doing their best to get things completed and sent.On 05/13/2026 at 1:05 PM, the Administrator sent the Civil Rights Questionnaire (DOH-1506), Equipment Inventory Form, and Legionella policies and procedures that were required within 24 hours of entrance.On 05/14/2026 at 10:15 AM, the Administrator sent documentation of the Infection Preventionist's specialized training in infection prevention and control that was required within 1 hour of entrance.On 05/18/2026 at 12:44 PM, the Team Coordinator sent an email to the Administrator requesting the Medicare/Medicaid Application (CMS-671) that was required within 24 hours of entrance.On 05/18/2026 at 1:03 PM, the Administrator sent the Medicare/Medicaid Application (CMS-671).The Facility Assessment that was required within 4 hours of entrance was never received.10 New York Codes, Rules, and Regulations 483.70 (i)

Based on record reviews and interviews during survey, the facility failed to ensure residents at risk of elopement remained under supervision for two (2) (Resident's #5 and #9) of four (4) residents reviewed for elopement risk. Specifically, (a.) Resident #5 left the faciity on [DATE] without the facility's knowledge and was not located until hours later; and (b.) Resident #9 was able to exit the facility on 11/16/2025 and was located shortly after on facility grounds. This resulted in Immediate Jeopardy and Substandard Quality of Care to Resident #5's health and safety, and no actual harm with potential for more than minimal harm that was not Immediate Jeopardy for Resident #9.This is evidenced by:The policy and procedure titled, Elopement, dated 07/14/2021, stated if an employee discovered a resident was missing, they should make a thorough search of the building and premises, and notify the Administrator and Director of Nursing Services, the resident's legal representative, attending physician, and law enforcement agencies. The Emergency Preparedness Section V (five): Emergency Response titled Missing Resident, dated 10/2021, stated a Code Pink would be announced with the resident's unit and a search would start of the facility and surrounding grounds. If the resident was not found within 10 minutes, the facility administrator/incident commander was to call the police to report the resident missing, document the time the resident was noticed to be missing, search progress and contacts. The policy and procedure titled, Against Medical Advice (AMA) Policy, dated 11/2025, stated the definition of against medical advice discharge, is a cognitively intact resident who willingly leaves the facility against the advice of the professional licensed staff and without the order of the treating physician. The policy stated information would be provided about the risks of leaving against professional advice. They documented the resident or decision maker would be asked to sign an Against Medical Advice document which would be counter signed by Nursing/Social Work. Careful, concise, and comprehensive documentation will be placed to the medical record regarding any and all education, counseling, options, resident/responsible party reactions and any and all actions taken by the Facility, including contact to physician and Adult Protective Services. Resident #5Resident #5 was admitted to the facility with the diagnoses of alcohol abuse (medical condition that impairs the ability to stop or control alcohol use despite harmful consequences) with withdrawal delirium (a sudden, serious change in mental state causing confusion, disorientation, memory problems, and fluctuating alertness), dysphagia (difficulty swallowing), and opioid dependence (a physical reaction to chronic opioid use where withdrawal is precipitated upon abrupt discontinuation). The Minimum Data Set (an assessment tool) dated 10/18/2025 documented the resident was understood, could understand others, and had a Brief Interview for Mental Status score of 14/15, indicative of intact cognition. The Interdisciplinary Assessment completed on 10/13/2025 documented the resident was an elopement risk. Resident #5's Comprehensive Care Plan titled, Behavior Problem: Wandering and Elopement risk dated 10/15/2025; Goals, Resident to be maintained safely under supervision of facility staff, as evidenced by remaining away from unsafe areas and within the facility, unless under escort by family or staff, Interventions include: documenting and notifying providers of intensity, duration, or frequency of behavior and to redirect resident. Resident #5's Comprehensive Care Plan titled, Substance Use Disorder History dated 10/15/2025 documented the resident had a current history of substance use disorder which included drug-seeking whether by prescription or by unauthorized means. Interventions included administer medications as ordered for cessation and/or nutritional support, consult follow ups as ordered, monitor for signs/symptoms of acute intoxication or potential substance use, monitor liver function labs, report abnormal to PCP (primary care provider), promote environment of judgement-free and supportive communication, and Social Work/Psychology/Psychiatric consults as indicated. Resident #5's progress note dated 10/13/2025 written by Assistant Director of Nursing #1 documented the resident arrived at the facility and was alert and oriented, but an electronic monitoring device was applied for wandering tendency. Resident #5's progress note dated 10/16/2025 at 12:34 AM by Licensed Practical Nurse #10 documented the resident stated they wanted to leave against medical advice due to not receiving pain medication but was convinced to stay. Resident #5's progress note dated 10/17/2025 at 6:33 AM written by Licensed Practical Nurse #5 documented the resident was noted to be walking up and down the hallway demanding medication. Resident #5's progress note dated 10/17/2025 at 8:08 AM written by Licensed Practical Nurse #6 documented the resident attempted to leave through the front door several times, yelling and being aggressive but was calmed. There was no documented evidence the medical provider was notified about Resident #5's statements to leave against medical advice or that the resident attempted to leave the facility.Resident #5 late entry progress note dated 10/18/2025 at 11:43 AM written by Licensed Practical Nurse #5 documented Resident #5 was yelling about their pain medication, pacing up and down the hallway and yelling the nurses had given them tramadol at 2000 and I'm going to need another dose I have pain in my legs. It further documented Resident #5 was talking fast in a loud voice, sweating and swearing. Licensed Practical Nurse #5 documented they told Resident #5 that they would speak to the physician about an extra dose of tramadol in which they did and then offered Resident #5 a topical analgesic and Resident #5 refused and continued to pace up and down the hallways. They documented the resident took a shower and then walked to the front lobby, sat in a chair by the door, and fell asleep. It further documented facility staff allowed the resident to sleep in the chair because prior the resident had continued onset pain while awake and was calm at the time. When approached for medication pass, the resident was not in the chair and not in their room. They notified Director of Nursing #1, the medical provider, and Health Care Proxy #1 and told them Resident #5 had left the facility against medical advice. After receiving information from Health Care Proxy #1 they confirmed Resident #5 was in a local hospital emergency department. They made social services aware of the discharge, who would inform Adult Protective Services. There was no documented evidence of any education, counseling, options, resident/responsible party reactions or any discussions surrounding the risks of Resident #5 signing out against medical advice.The Medication Administration Record for October 2025 documented Resident #5 was administered Clonidine HCl 0.2 milligrams tablet by oral route on 10/18/2025 at 3:00 AM. During a telephone interview on 01/07/2026 at 12:15 PM, Certified Nurse Aide #3 stated Resident #5 was on their assignment during the evening shift on 10/17/2025. They stated during that shift the resident stated they wanted to leave because they found the facility too restrictive (couldn't smoke for example). They stated they did inform Licensed Practical Nurse #5. They stated the resident did not try to leave during that shift. During a telephone interview on 01/07/2026 at 12:26 PM, Certified Nurse Aide #4 stated Resident #5 was on their assignment during the overnight shift 10/17/2025 - 10/18/2025. They stated the resident stated they wanted to leave, and they informed their supervisor (Licensed Practical Nurse #5). They stated the resident liked to sleep in the front lobby and had slept in the lobby on their shift. The resident made no attempts to physically leave, and Certified Nurse Aide #4 stated Resident #5 was in their room when they left. They believed the resident had an electronic monitoring device on. During a telephone interview on 01/07/2026 at 1:14 PM, Health Care Proxy #1 stated Resident #5 left in the middle of the night, but they were not called until 9:00 AM on 10/18/2025. They stated Licensed Practical Nurse #5 asked them if they knew where Resident #5 was because they could not be located. Health Care Proxy #1 stated they had access to the records portal at the local hospital and had an alert from that morning that Resident #5 was in the emergency department since around 8:00 AM. They stated they then called the facility back and informed the facility where the resident was. They stated they went to see Resident #5 in the emergency department and Resident #5 had all their belongings with them. The resident had minor injuries from a reported fall on the walk to the hospital. Health Care Proxy #1 stated the facility told them Resident #5 had the right to leave and there was no risk, but they could not remember which staff member told them that. They stated they were also told the resident had cut their electronic monitoring device off and left it on the front desk before exiting. During an interview on 01/07/2026 at 1:40 PM, Licensed Practical Nurse #2 stated when they attempted to administer morning medications to the resident on 10/18/2025 at around 7:30 AM, the resident was not in their room. They asked other staff if they knew where Resident #5 was, and no one knew where Resident #5 was located. Licensed Practical Nurse #2 stated they went to their supervisor (Licensed Practical Nurse #5) and informed them. They stated they performed a head count of the unit and the only resident unaccounted for was Resident #5. Licensed Practical Nurse #2 stated they did not recall if Resident #5 had an electronic monitoring device on or not. During a phone interview on 01/07/2026 at 1:45 PM, Licensed Practical Nurse #5 confirmed they were the overnight supervisor on 10/17/2025-10/18/2025. They stated the resident left against medical advice. They stated they were informed by Licensed Practical Nurse #2 that the resident was unable to be located and had removed their electronic monitoring device. They stated they spoke to the resident's Health Care Proxy, who informed them that Resident #5 was in the emergency department of a local hospital. They stated they called Director of Nursing #1, who watched the security cameras of the lobby from their home and stated the resident was an against medical advice discharge and instructed them on how to discharge the resident from the electronic medical system, using the time of 4:48 AM on 10/18/2025 as the time of discharge. They stated they called the local hospital and verified the resident was in their emergency department and gave a quick report to the emergency department nurse about Resident #5. They stated they had last seen the resident in the lobby at around 6:00 AM on 10/18/2025, but the resident did not have their belongings with them. They stated they did not have a discussion with the resident about leaving against medical advice or asked them to sign any forms. During a telephone interview on 01/07/2026 at 11:29 AM, hospital Registrar #1 stated Resident #5 was admitted to the emergency room at 7:54 AM on 10/18/2025. During an interview on 01/07/2026 at 3:00 PM, Director of Nursing #1 stated Resident #5 was alert and oriented and the facility had no responsibility if the resident wanted to leave. Director of Nursing #1 stated they watched the camera footage on 10/18/2025 and stated Resident #5 had all their belongings in the lobby at 6:42 AM and they watched Resident #5 leave through the front door after an unnamed staff member returned from a break. They further stated the resident was alert and oriented and they could not stop the resident from leaving. They stated this incident was not an elopement because the resident was alert and oriented. They stated an electronic monitoring device was placed on the resident when the resident was admitted based on their past admission in July 2025. The electronic monitoring device was removed the next day based on their Brief Interview for Mental Status. They stated Resident #5 did not have an electronic monitoring device on that night. Director of Nursing #1 stated they did not need to supervise the resident because the resident was alert and oriented and allowed to leave at any time. Resident #9Resident #9 was admitted to the facility with diagnoses of Alzheimer's unspecified (progressive brain disorder that slowly destroys memory and thinking skills), cognitive communication deficit (condition that affects how individuals think and communicate), and muscle weakness generalized (muscles aren't as strong as they should be). The Minimum Data Set, dated [DATE], documented the resident had severely impaired cognition, could be understood and could sometimes understand others.Resident #9's Care Plan titled, Wandering/Elopement effective dated 11/03/2025, documented Resident was at risk for wandering into unsafe areas, or for elopement out of the building, without supervision. Goals documented resident will be maintained safely under supervision of facility staff, as evidenced by remaining away from unsafe areas and within the facility, unless under escort by family or staff, over the next 30 days. Interventions documented, identify pattern of behavior (specify): Activities, Medical, Nursing, Social Services Active Effective: 11/03/2025 Document in the progress notes intensity, duration or frequency of behavior. Activities, Medical, Nursing, Social Services Active Effective: 11/03/2025 Orient to daily routines. Activities, Dietary, Nursing, Occupational Therapy, Physical Therapy, Social Services Active Effective: 11/03/2025 Refer for Psychiatric Consult as per Medical Doctor order. Medical, Nursing, Social Services Active Effective: 11/03/2025 Ensure proper placement of ankle alert and check for any malfunction.Resident #9 Treatment Administration Records dated 11/2025, documented electronic monitoring device checks every shift in place starting 11/03/2025.Facility investigation documented on 11/16/2025 at approximately 11:12 AM, Housekeeper #1 heard an alarm from One (1) North exit door, they immediately alerted Licensed Practical Nurse #2 and nursing supervisor. An immediate resident accountability was initiated. Resident seen by dietary staff from kitchen window and returned to the facility unharmed. Investigation statement dated 11/16/2025, Registered Nurse #3, last saw the resident at approximately 11:00 AM on their unit sitting in their wheelchair. Investigation statement dated 11/16/2025 by Dietary aide #2, stated at approximately 11:45 AM they noticed a resident outside by the One (1) North exit door, two (2) of their coworkers went to the resident and brought them inside.During an interview on 01/12/2026 at 1:30 PM, Dietary Aide #1 stated they saw Resident #9 through the kitchen window outside the North rehabilitation door alone in their wheelchair. They stated they immediately notified their supervisor. During an interview on 01/12/2026 at 1:40 PM, Director of Nursing #1, stated electronic monitoring device orders were never placed in Resident #9's Medication or Treatment Administration Record when ordered. Monitoring of residents electronic monitoring device started after their Quality Assurance audit proceeding the elopement incident on 11/17/2025. It was corrected and monitoring was added to the resident Treatment Administration Record. The admission or nurse manager was responsible for putting the electronic monitoring device orders in the chart. Director of Nursing #1 stated the door that Resident #9 left facility from is an emergency exit and alarmed as such, it is not an electronic monitoring device alarmed door. They stated interventions put in place through the facility have decreased elopement attempts.The facility was informed of Immediate Jeopardy status on 1/09/2026 at 6:10 PM. The facility took the following steps to lift the Immediate Jeopardy as of 1/11/2026: - As of 1/10/2026, it was confirmed by review of camera footage and interviews with six staff of various titles that the front door to the facility was manned.- As of 1/11/2026, record review of revised elopement policy dated 01/2026 document an addition of when a resident is found missing from the facility staff is to follow the missing person policy.- As of 1/11/2026, Record review of revised missing person policy dated 01/2026 documented the addition of residents that have not signed or declined to sign Against Medical Advice paperwork with additional steps of notifying Administrator #1 or Director of Nursing #1 immediately, notifying the police, as well as New York State Department of Health- As of 1/11/2026, according to provided roster and education sign off sheets, 93 percent of employees have been educated on elopement and missing person policies.- As of 1/11/2026, interviews with 11 different staff members of various titles confirmed they had all been educated on the revised elopement and missing person policies. 10 New York Codes, Rules, and Regulations 415.12(h)(1)(2)

Based on record reviews and interviews, the facility failed to ensure that alleged violations involving elopement were reported immediately, but not less than two hours later to the State Survey Agency for one (Resident #5) of two residents reviewed for elopement. Specifically, the facility was unable to locate Resident #5 until Health Care Proxy #1 informed the facility that Resident #5 had left the facility and was in a local hospital emergency department. The incident was not reported to the New York State Department of Health.Cross reference F689This is evidenced by:The Policy and Procedure titled Elopement, dated 7/14/2021, stated if an employee discovered a resident was missing, they should make a thorough search of the building and premises, and notify the administer and director of nursing services, the resident's legal representative, attending physician, and law enforcement agencies. Resident #5 Resident #5 was admitted to the facility with the diagnoses of alcohol abuse (when a person can't stop drinking even when it puts their health and safety at risk) with withdrawal delirium (a sudden, serious change in mental state causing confusion, disorientation, memory problems, and fluctuating alertness), dysphagia (difficulty swallowing), and opioid dependence (a mental health condition where a pattern of opioid use affects health and daily life). The Minimum Data Set (an assessment tool) dated 10/18/2025 documented the resident was understood, could understand others, and had a Brief Interview for Mental Status score of 14/15, indicative of intact cognition. Resident #5 was assessed for wandering in the Minimum Data Set and documented that no wandering behavior had occurred. The Interdisciplinary Assessment completed on 10/13/2025 documented the resident was an elopement risk. Resident #5 late entry Progress note dated 10/18/2025 at 11:43 AM written by Licensed Practical Nurse #5 stated they were notified by Licensed Practical Nurse #2 that Resident #5 was not in their room or in the lobby. They notified Director of Nursing #1, the medical provider, and Health Care Proxy #1 and told them Resident #5 had left the facility against medical advice. After receiving information from Health Care Proxy #1 they confirmed Resident #5 was in a local hospital emergency department. They made social services aware of the discharge, who would inform Adult Protective Services. During a telephone interview on 1/7/2026 at 1:14 PM, Health Care Proxy #1 stated Resident #5 left in the middle of the night, but they were called until 9:00 AM on 10/18/2025. They stated Licensed Practical Nurse #5 asked them if they knew where Resident #5 was because they could not be located. Health Care Proxy #1 stated they had record portal to the local hospital and had an alert from that morning that Resident #5 was in the emergency department since around 8:00 AM. They stated they then called the facility back and informed the facility where the resident was. They stated they went to see Resident #5 in the emergency department and Resident #5 had all their belongings with him. During an interview on 1/07/2026 at 3:00 PM Director of Nursing #1 stated the resident was alert and oriented and the facility had no responsibility if the resident wanted to leave. Director of Nursing #1 stated they watched the camera footage on 10/18/2025 and stated Resident #5 had all their belongings in the lobby at 6:42 AM and they watched Resident #5 leave through the front door after an unnamed staff member returned from a break. They stated again that the resident was alert and oriented and they could not stop the resident from leaving. They stated this incident was not an elopement because the resident was alert and oriented, so it did not need to be reported.10 New York Codes, Rules and Regulations 415.4(b)(2)

Based on record reviews and interviews, the facility failed to ensure that comprehensive care plan interventions were implemented, for 2 (two) (Resident #5 and Resident #9) of 18 residents reviewed for care plans. Specifically, Resident #5 and Resident #9 were not adequately supervised as per their care plans resulting in elopement. Cross reference F689 This is evidenced by:Care Plan Policy and Procedure dated 06/20/2025 documented:INTENT: It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. It is utilized to plan for and manage resident care as evidenced by documentation from admission through discharge for each resident. PROCEDURE: 1. The following health care professionals contribute to the Interdisciplinary Care Plan by collaboration and direct documentation: Registered Nurse, Licensed Practical Nurse, Certified Nurse Assistant, Physical Therapist, Occupational Therapist, Speech Therapist, Respiratory Therapist, Activity Director, Social Services Coordinator, Dietitian, Physician and other appropriate members of the Care Plan Team. Other specialty areas available for consultation when needed include, but are not limited to diabetic, pain, wound, psychological, hospice and pharmacy professionals.2. The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at S483.10(c)(2) and S483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Resident #5 was admitted to the facility with the diagnoses of alcohol abuse (when a person can't stop drinking even when it puts their health and safety at risk) with withdrawal delirium (a sudden, serious change in mental state causing confusion, disorientation, memory problems, and fluctuating alertness), dysphagia (difficulty swallowing), and opioid dependence (a mental health condition where a pattern of opioid use affects health and daily life). The Minimum Data Set (an assessment tool) dated 10/18/2025 documented the resident was understood, could understand others, and had a Brief Interview for Mental Status score of 14/15, indicative of intact cognition. Resident #5 Comprehensive Care Plan titled Behavior Problem: Wandering and Elopement risk dated 10/15/2025; Goals, Resident to be maintained safely under supervision of facility staff, as evidenced by remaining away from unsafe areas and within the facility, unless under escort by family or staff, Interventions added the intervention of documenting and notifying providers of intensity, duration, or frequency of behavior and to redirect resident.Resident #5 Progress Note dated 10/16/2025 at 12:34 AM noted the resident stated they wanted to leave against medical advice due to not receiving pain medication but was convinced to stay.Resident #5 Progress Note dated 10/17/2025 at 6:33 AM written by Licensed Practical Nurse #5 stated the resident was noted to be walking up and down the hallway demanding medication.Resident #5 Progress Note dated 10/17/2025 at 8:08 AM written by Licensed Practical Nurse #6 stated the resident attempted to leave through the front door several times, yelling and being aggressive but was calmed.Resident #5 late entry Progress note dated 10/18/2025 at 11:43 AM written by Licensed Practical Nurse #5 stated Resident #5 was yelling about their pain medication. They stated the resident walked to the lobby, sat in a chair by the door, and fell asleep. They were notified by Licensed Practical Nurse #2 that Resident #5 was not in their room or in the lobby. They notified Director of Nursing #1, the medical provider, and Health Care Proxy #1 and told them Resident #5 had left the facility against medical advice.During a telephone interview on 01/7/2026 at 12:15 PM, Certified Nurse Aide #3 stated Resident #5 was on their assignment on the evening shift on 10/17/2025. They stated during that shift the resident stated they wanted to leave because they found the facility too restrictive (couldn't smoke for example). They stated they did inform Licensed Practical Nurse #5. They stated the resident did not try to leave during the shift. During a telephone interview on 01/7/2026 at 12:26 PM, Certified Nurse Aide #4 stated Resident #5 was on their assignment on the overnight shift 10/17/2025-10/18/2025. They stated the resident stated they wanted to leave and they informed their supervisor (Licensed Practical Nurse #5). They stated the resident liked to sleep in the front lobby and had slept in the lobby on their shift. The resident made no attempts to physically leave and Certified Nurse Aide #4 stated Resident #5 was in their room when they left.During a telephone interview on 01/7/2026 at 1:14 PM, Health Care Proxy #1 stated Resident #5 left in the middle of the night but they were called until 9:00 AM on 10/18/2025. They stated Licensed Practical Nurse #5 asked them if they knew where Resident #5 was because they could not be located. Health Care Proxy #1 stated the facility told them Resident #5 had the right to leave and there was no risk but they couldn't remember which staff member told them that.During an interview on 01/7/2026 at 1:40 PM, Licensed Practical Nurse #2 stated when they attempted to administer morning medications to the resident on 10/18/2025, the resident was not in their room. They asked other staff if they knew where Resident #5 was and no one knew where they were. Licensed Practical Nurse #2 stated they went to their supervisor (Licensed Practical Nurse #5) and informed them. They stated they performed a head count of the unit and the only unaccounted for resident was Resident #5. During a phone interview on 01/7/2026 at 1:45 PM, Licensed Practical Nurse #5 confirmed they were the overnight supervisor on 10/17/2025-10/18/2025. They stated the resident left against medical advice. They stated they were informed by Licensed Practical Nurse #2 that the resident wasn't able to be located. They stated they spoke to the resident's Health Care Proxy who informed them that Resident #5 was in the emergency department of a local hospital. They stated they called Director of Nursing #1 who watched the security cameras in the lobby at their home and stated the resident was an against medical advice discharge and instructed them on how to discharge the resident from the electronic medical system. They stated they had last seen the resident in the lobby at around 6:00 AM on 10/18/2025. They stated they did not have a discussion with the resident about leaving against medical advice or asking them to sign any forms.During an interview on 01/07/2026 at 3:00 PM Director of Nursing #1 stated the resident was alert and oriented and the facility had no responsibility if the resident wanted to leave. Director of Nursing #1 stated they watched the camera footage on 10/18/2025 and stated they watched Resident #5 leave through the front door after an unnamed staff member returned from a break. They stated again that the resident was alert and oriented and they could not stop the resident from leaving. They stated this incident was not an elopement because the resident was alert and oriented. Director of Nursing #1 stated they did not need to supervise the resident because the resident was alert and oriented and allowed to leave at any time. Resident #9Resident #9 was admitted to the facility with diagnoses of Alzheimer's unspecified (progressive brain disorder that slowly destroys memory and thinking skills), cognitive communication deficit (condition that affects how individuals think and communicate), and muscle weakness generalized (muscles aren't as strong as they should be). The Minimum Data Set (an assessment tool) dated 11/26/2025, documented the resident could be understood and could understand others with severely impaired cognition.New York State Department of Health received an Incident reported by facility on 11/16/2025 at 2:20 PM, which documented Resident #9 had eloped from their facility.Facility Investigation for Resident #9 elopement dated 11/16/2025, document thorough investigation and that Resident # 9 was able to leave facility.Resident #9 Care Plan titled Wandering/Elopement effective dated 11/03/2025, documented Resident was at risk for wandering into unsafe areas, or for elopement out of the building, without supervision. Goals documented resident will be maintained safely under supervision of facility staff, as evidenced by remaining away from unsafe areas and within the facility, unless under escort by family or staff, over the next 30 days. Interventions documented, identify pattern of behavior (specify): Activities, Medical, Nursing, Social Services Active Effective: 11/03/2025 Document in the progress notes intensity, duration or frequency of behavior. Activities, Medical, Nursing, Social Services Active Effective: 11/03/2025 Orient to daily routines. Activities, Dietary, Nursing, Occupational Therapy, Physical Therapy, Social Services Active Effective: 11/03/2025 Refer for Psychiatric Consult as per Medical Doctor order. Medical, Nursing, Social Services Active Effective: 11/03/2025 Ensure proper placement of ankle alert and check for any malfunction.During an interview on 01/12/2026 at 1:30 PM, Dietary Aide #1, stated on 11/16/2026 they saw Resident #9 through the kitchen window outside north rehabilitation door alone in their wheelchair. They stated they immediately notified their supervisor. During an interview on 01/12/2026 at 1:40 PM, Director of Nursing #1, stated that the door Resident #9 left facility from is an emergency exit and alarmed as such, it was not a Wandergaurd alarmed door.During an interview on 01/13/2026 at 1:35 PM, Director of Nursing #1, stated it is a shared responsibility of all staff to know and implement care plans for each resident. They stated the process is with all admissions, quarterly assessments, or significant changes care plans are updated by a nurse manager or someone above in administration. They stated once the care plan was updated it was the responsibility of the person who updated the care plan to be sure the certified nursing assistant care card was updated at the same time.10 New York Codes, Rules, and Regulations 415.12(h)(1)(2)

Based on record review and interviews during a recertification and abbreviated survey (Case #s NY00344251 and NY00355131), the facility did not ensure residents were free from abuse and neglect for three (3) (Resident #s 48, 78, and 416) of nine (9) residents reviewed. Specifically, (a.) Resident #416, who was a two (2)-person maximum assist with mechanical lift for transfers, was transferred by two (2) Certified Nurse Aides via stand pivot on 6/04/2024. Resident #416 was reportedly lowered to the floor during the transfer from chair to bed and later that evening diagnosed with a left femur (leg bone) fracture. (b.) Resident #48, who was known to have aggressive behaviors, struck Resident #78 on their eye while grabbing a personal item from Resident #78 on 9/22/2024. This resulted in actual harm for Resident #416 that was not Immediate Jeopardy. This is evidenced by: 43805 The facility's Policy and Procedure titled, Abuse Prevention and Reporting, last revised 4/2024, documented that all residents would be treated with respect and dignity, with self-determination and freedom from abuse, mistreatment, neglect and misappropriation of property. The purpose was to protect all residents and provide a safe environment. Abuse was defined as inappropriate physical, verbal or mental contact which harms or was likely to harm a resident. Examples included hitting, pinching, kicking, shoving, sexually molesting, belittling, teasing, ignoring, and embarrassing by either actions or words. Neglect was defined as failure to provide timely, consistent, safe, adequate, and appropriate services such as nutrition, medication, therapy, clean clothing and surroundings, and activities of daily living. 48615 Resident #416 Resident #416 was admitted to the facility with diagnoses of hemiplegia (paralysis of one side of the body) following a cerebral infarction (disrupted blood flow to the brain), Parkinson's Disease (a movement disorder of the nervous system that worsens over time), and muscle weakness (when muscles aren't as strong as they should be). The Minimum Data Set, dated dated dated [DATE], documented the resident had severe cognitive impairment, could be understood and was able to understand others. The Comprehensive Care Plan titled, Activities of Daily Living, last revised 4/16/2024, documented shower transfer dependent - assist of two (2) person mechanical lift. The Facility's Investigative Report dated 6/05/2024, documented Certified Nurse Aide # 2 and #3 attempted to transfer Resident #416 from the bed to a chair using a stand pivot technique along with the use of a walker. Resident's legs gave way and was lowered to the floor. Resident was sent to the hospital and diagnosed with left distal femur fracture (broken hip). Administrator #1 documented that it was unclear where and when the resident sustained hip fracture. It further documented Certified Nurse Aides were suspended until the investigation was completed due to possible failure to follow the resident's care plan. Certified Nurse Aide #2 statement documented family insisted resident get out of bed for a shower. They looked in resident's closet for the care card (Certified Nurse Aide's instructions for the resident's care) and did not see it available. They stated Certified Nurse Aide #3 assured them they were familiar with Resident #416, and they proceeded with two (2) person stand pivot transfer. Resident #416 immediately began to yell that their legs were hurting. Resident #416 lost their balance and was lowered to the floor. Certified Nurse Aide #3 statement documented they came to assist Certified Nurse Aide #2 to get Resident #416 out of bed and into their wheelchair. They stated the resident would usually stand and get into the chair, and that staff would need to be patient with the resident during the transfer. They further wrote that they stood resident up from the bed, the resident had taken a few steps away from their bed, the resident's legs were really weak, and then the resident was lowered to the floor. Certified Nurse Aide #3 wrote that they were told the resident was a mechanical lift for transfers but could be a two (2) person assist stand pivot. They stated they did not check the care card in the resident's closet. Progress note dated 6/04/2024 at 7:17 PM written by Registered Nurse #4, documented that upon entering the resident's room, the resident was lying on the floor alongside the bed. Resident appeared out of their norm, vital signs: blood pressure 84/68, skin was pale, neurological assessment was within normal limits. The resident was assisted off the floor via mechanical lift. Family insisted on sending resident to hospital for further evaluation, 911 was called and resident transferred to hospital. Hospital progress note dated 6/07/2024, documented resident was brought to the hospital on 6/03/3024 with a reported history of hypoxia (low levels of oxygen in your body tissues) and hypotension (low blood pressure). They were admitted with diagnosis of severe sepsis with shock (infection in your body causing extremely low blood pressure and organ failure), and distal left femur fracture (broken long bone of the leg) due to a mechanical fall (an external force that caused the patient to fall and/or that there is no underlying pathology of concern and/or the patients did not pass out first). Orthopedic Surgery note dated 6/08/2024 documented x-ray left femur (hip) moderately displaced comminuted distal femoral fracture (the bone in the thigh was broken into multiple pieces and the pieces were out of alignment). Resident #416's Care Kardex (resident care instructions for the Certified Nurse Aides) dated 5/30/2024, documented chair to bed transfer, dependent (with two (2) staff members to assist), mechanical lift. During an interview on 5/06/2025 at 12:57 PM, Assistant Director of Nursing #1 stated that on 6/03/3024, Certified Nurse Aide #s 2 and 3 attempted to transfer Resident #416 from the bed to a chair with a two (2)-person stand pivot and, in the process, the resident was lowered to the floor. Later, the resident complained of intense pain and was sent to the hospital. Assistant Director of Nursing #1 stated Certified Nurse Aide #2 was terminated for failure to follow the resident's care plan. During an interview on 5/06/2025 at 1:30 PM, Director of Rehabilitation #1 stated Resident #416 was well known to the therapy department as requiring full assistance with two (2) staff members for mechanical lift transfers. Rehabilitation Director #1 stated Certified Nurse Aide #2 was terminated for failure to follow the resident's care plan. Resident #48 Resident #48 was admitted to the facility with diagnoses of diabetes type 2 (when the body cannot use insulin or produce enough insulin), dementia (loss of the ability to think, remember, and reason to levels that affect daily life and activities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Minimum Data Set (an assessment tool) dated 11/05/2024, documented the resident had moderate cognitive impairment, could be understood and understand others. The Comprehensive Care Plan focus area titled, Resident had Potential to be an Aggressor Related to Mental Illness, dated 9/23/2024, documented interventions including administer medications as ordered, analyze key times, places, circumstances, triggers and what de-escalates behavior, assess and anticipate resident needs; and monitor resident closely when they were around other residents. Record review of psychiatric consultation note dated 9/07/2024, documented Resident #48 was easily annoyed, and resident admitted to picking/choosing medications to take. Resident had limited cooperation, poor insight, low concentration and attention. Consider increase Risperdal one (1) milligram twice daily. Resident #78 Resident #78 was admitted to the facility with diagnoses of aphasia (difficulty speaking), cerebral infarction (disrupted blood flow to the brain), and apraxia (when a person is unable to perform tasks or movements when asked). The Minimum Data Set, dated dated dated [DATE], documented the resident had moderate cognitive impairment, could be understood and understand others. The facility Investigative Summary dated 9/22/2024 at 7:30 PM, documented Resident #78 reported to Registered Nurse #2 that while sitting in the hallway near the nurse's station, Resident #48 struck them in the eye. They were complaining of eye swelling. Upon assessment, Resident #78 had mild edema (swelling) to right eye but no abrasions, discolorations or lacerations (cuts). Resident #78 was tearful but later calmed down after speaking with family. Resident #48 denied ever striking Resident #78. It further documented there were no witnesses to the incident despite it occurring in the hallway. It documented Licensed Practical Nurse #3 reported Resident #48 had been agitated and experiencing hallucinations over the past few weeks with psychiatry following. Resident #48's psychotropic medications were adjusted. The facility reported incident report, submitted to the Department of Health on 9/22/2024, indicated Resident [#48], struck Resident [#78] with a closed fist on the right eye. During an interview on 4/30/2025 at 1:55 PM, Licensed Practical Nurse #2 stated on 9/22/2024, Resident #78 sat at the nurse's station and Resident #48 was standing there as well and there was confusion about a personal item. Resident #48 wanted the item and took it from Resident #78. Residents #48 and #78 were separated and assessed. During an interview on 4/30/2025 at 2:58 PM, Registered Nurse #2 stated Resident #48 had a long psychiatric history, and they were very impulsive, but they did not recall them hitting anyone else. During an interview on 4/30/2025 at 3:10 PM, Licensed Practical Nurse #6 stated Resident #48 wandered about the unit most of the day including in and out of other resident rooms. Resident #48 was difficult to redirect and would start to use profanity when redirected. Resident #48 had attempted to hit staff. During an interview on 05/08/2025 at 11:49 AM, Director of Nursing #1 stated they were not employed at this facility at the time of the incident. They were aware of resident #48's behaviors and that they were followed by psychiatry. Staff on second floor are also aware resident #48's behavior and try to keep resident in high visible areas where they can be monitored close. During an interview on 05/08/2025 at 12:23 PM, Administrator #1 stated they were only at this facility a few months and not the administrator at time of the incident. They deferred all clinical discussions to Director of Nursing #1. Administrator #1 stated all allegations of abuse and or neglect are reported to the Department 10 New York Code of Rules and Regulations 415.4 (b)(1)(i)

Based on observations, interviews, and record reviews conducted during an Abbreviated survey (Case # NY00345181), the facility failed to provide an environment free of accident hazards and adequate supervision to prevent elopement for 1 (Resident #1) of 3 residents reviewed for elopement. Specifically, on 6/11/2024, Resident #1 was observed leaving the facility through the front entrance. The facility did not put any measures in place to prevent further elopements. Subsequently, on 6/14/2024, Resident #1 was observed in the parking lot by facility staff and was brought back into the facility. On 6/14/2024 an electronic monitoring device was placed on the resident; however, the facility did not implement a system to monitor the resident for elopement or for the placement of the electronic monitoring device. This resulted in no actual harm with the likelihood for more than minimal harm that was Immediate Jeopardy and Substandard Quality of Care for Resident #1. This is evidenced by: The Policy and Procedure titled, Elopement, effective 4/01/2024, documented it was the responsibility of all personnel to report any resident attempting to leave the premises to the Unit Manager and/or Charge Nurse immediately. The Policy and Procedure titled, Wander Guard, effective 4/01/2024, documented any resident with a new elopement attempt needed to have a Wander-Guard applied and care plan updated immediately. Should an elopement attempt/episode occur, the contributing factors, as well as the interventions tried, were to be documented on the nurses' notes. Resident #1 was admitted to the facility with diagnoses of cognitive communication deficit (condition that may include memory problems, learning disorders, attention problems, or problems with processes that help people connect their past experiences with their present action), anxiety disorder, and bipolar disorder (a mental illness that causes unusual shifts in a person's mood). The Minimum Data Set (an assessment tool) dated 5/12/2024, documented the resident could be understood, could understand others, and had intact cognition for decisions of daily living. An Elopement Risk Evaluation completed on 5/06/2024 documented the resident had no elopement risk. Review of the Progress Notes revealed the following: - On 6/11/2024, Resident #1 went out front door today with 2 packed bags. Remained in sight of staff at all times. Easily redirected inside, was calm and agreed to stay inside. - On 6/14/2024, Resident #1 found in upper parking lot at approximately 7:19 AM. - On 6/14/2024, Resident #1 stated they can hear someone over the loudspeaker announcing they are going to jail and would ask various staff if the police were on their way. Reassurance was given but not received. Electronic monitoring device was placed on the left ankle for safety. Elopement attempt on 6/11/2024: During an interview on 6/17/2024 at 3:15 PM, Social Worker #3 stated they were at the copy machine on 6/11/2024 between 7:30 AM and 8:00 AM and watched the resident walk outside. They followed the resident and brought them up to their room. Social Worker #3 did not report it to anyone on the unit at that time. Social Worker #3 stated that, within one hour, they brought the incident up at morning meeting and Licensed Practical Nurse #2 was present. Social Worker #3 stated they should have reported it to the Director of Nursing and the Administrator. During an interview on 6/17/2024 at 1:55 PM, Registered Nurse #1 stated they were not made aware of the elopement attempt on 6/11/2024, and that an electronic monitoring device should have been placed, with 15-minute checks implemented. During an interview on 6/17/2024 at 3:45 PM, Licensed Practical Nurse #2 stated they were not at the morning meeting on 6/11/2024 because they were doing rounds with the doctor, and they were not told about the elopement attempt. They further stated if they had been told, they would have started an Incident report and placed an electronic monitoring device on the resident immediately. An Attendance Sign-in Sheet for a morning meeting dated 6/11/2024 at 9:00 AM and titled, Report, documented Social Worker #3, Rehabilitation Director #4, and the Assistant Director of Nursing were present. There was no documentation of Licensed Practical Nurse #2, Administrator, or Director of Nursing #1 being present for the meeting. Elopement on 6/14/2024: Record review of the surveillance video dated 6/14/2024 showed Resident #1 walking away from the building at video timestamp of 06:20:16 (AM). At 06:20:32 (AM) the resident stopped walking when it appears the staff recognized them from across the parking lot. At 06:20:50 (AM), the staff took Resident #1 by the hand and escorted them toward the front entrance. An interview with Administrator #1 confirmed the timestamp was incorrect and should have read 07:20 due to clock not changed for daylight savings. An Incident Report dated 6/14/2024 documented a staff member (Occupational Therapist #2) who was coming into work saw Resident #1 enter the parking lot near the front entrance. The resident was brought into the building and an electronic monitoring device was applied to left ankle. The Comprehensive Care Plan titled, at risk for elopement related to impaired safety awareness, was initiated on 6/14/2024. The interventions included: distract resident by offering pleasant diversions, provide structured activities, toileting, walking and reorientation strategies, and a wander alert. There was no Care Plan in place to address wandering and elopement risk prior to 6/14/2024. There was no Physician's Order for an electronic monitoring device. The Medication and Treatment Administration Records for June 2024 did not include documentation of an electronic monitoring device. Interviews: During an interview on 6/17/2024 at 11:30 AM, Occupational Therapist #2 stated they came into work on 6/14/2024 and saw Resident #1 in the parking lot, approximately 30-40 feet away from the front door. They brought them back in and told the nurse on the unit that the resident had been found outside. During an interview on 6/17/2024 at 10:35 AM, Resident #1 stated they could go outside with staff but not alone. At the time of interview, an electronic monitoring device was not observed on the resident's left ankle. During an observation and interview on 6/17/2024 at 11:50 AM Licensed Practical Nurse #1 stated they were told by the unit manager that the resident had an electronic monitoring device but had not checked for placement yet. Licensed Practical Nurse #1 then proceeded to where Resident #1 was located. When asked by Licensed Practical Nurse #1 if Resident #1 had an electronic monitoring device on, Resident #1 stated they took it off. When asked who took it off, the resident smiled and stated, I cut it off, it was too tight. Resident #1 stated they were not sure when they took it off. During an interview on 6/17/2024 at 12:20 PM, Assistant Director of Nursing #1 stated they were told Resident #1 was found in the parking lot by therapy and placed an electronic monitoring device on the resident. Assistant Director of Nursing #1 stated the unit manager should have entered an order that would result in the check function and placement being on the Treatment Administration Record, then staff would have known the resident had removed the electronic monitoring device. During an interview on 6/18/2024 at 11:50 AM, Rehabilitation Director #4 stated they were at the morning meetings every day except the previous Thursday (6/13/2024). They did not recall discussing an elopement attempt prior to 6/14/2024. During an interview on 6/18/2024 at 11:00 AM, Director of Nursing #1 stated they were on leave when the incident occurred and it was their first day back and they watched the surveillance video. In an observation at this time, Director of Nursing #1 and surveyor walked outside together and were able to determine-from the markings on the pavement seen in the video-that the resident was approximately 40 feet away from the front door when the staff member appeared from the lower parking lot (approximately 200 feet away from the entrance), saw the resident, approached, and escorted the resident toward the front entrance. During an interview on 6/18/2024 at 10:35 AM, the facility Medical Director #1 stated they were made aware of the two elopements by Resident #1 but were not sure when. They stated the first elopement on 6/11/2024 was due to increased behaviors, delusions and hallucinations, and Medical Director #1 requested a psych consult. Medical Director #1 stated they did not order an electronic monitoring device because they thought Resident #1 had one already in place. During an interview on 6/18/2024 at 11:41 AM, Administrator #1 stated they did not recall if they were at morning meeting on 6/11/2024 and was not sure when they were made aware of the elopement attempt. Administrator #1 stated they determined it was not an elopement because the staff coming in saw the resident and brought them in safely. 10 New York Codes, Rules, and Regulations 415.12(h)(1)(2)

Based on observation, interview and record review during a recertification survey and abbreviated survey (Case #NY 798) the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility did not establish and maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection. Specifically, the facility experienced an upper respiratory illness (URI) outbreak from August 22, 2016 thru September 30, 2016 that involved 38 residents out of 115 residents reviewed for URI and a second outbreak which began 10/7/16. During these outbreaks the facility failed to: investigate the URI outbreak; maintain complete and accurate line lists; or institute any measure to contain the outbreak. Additionally, the facility was notified by the New York State Department of Health (NYSDOH) Regional Epidemiology Office (REO) that Resident #112 had tested positive for [MEDICATION NAME] Influenza, and the facility failed to follow their recommendations to test residents with new onset URI symptoms for [MEDICAL CONDITION] and bacterial influenza. Furthermore, the facility did not complete the Nosocomial Outbreak Reporting Application (NORA) as required and requested by the NYSDOH Regional Epidemiology Office. This resulted in no actual harm, but with potential for more than minimal harm that is Immediate Jeopardy. This was evidenced by: Refer to F 441- Infection Control-Scope/Severity K Finding #1: A notification was received by the NYSDOH Long Term Care Program (NYSDOH,LTCP) from the NYSDOH Regional Epidemiology Office in regards to the facility outbreak of URI symptoms and the facility not following the recommendations to test residents with new onset URI symptoms for [MEDICAL CONDITION] and bacterial influenza, and not reporting the outbreak as required and requested by the Regional Epidemiology Office. During an interview on 10/17/16 at 12:42 PM a representative of the Regional Epidemiology Office (REO) revealed the following communications between REO and the facility: 9/6/16 and 9/7/16 REO left a voice mail message for the Director of Nursing (DON) to alert the facility of a positive [MEDICATION NAME] Influenza with one of the facility resident's #112 that had been tested in the hospital. There had been no return call to REO. 9/9/16 REO called the facility and spoke with the DON and was told there were five residents with respiratory symptoms. REO instructed the DON to add those residents to the line list and complete a NORA report and send to REO (Nora report was not done or sent to REO until 10/18/16). REO also recommended the facility swab test residents with new onset URI symptoms for Bacterial and [MEDICAL CONDITION] Influenza (the facility did not swab test any resident). 9/12/16, and 9/16/16 REO called the facility to follow-up on outbreak and left voice mail message, with no return call to REO. 9/19/16 REO called the facility and spoke with the DON and again requested the NORA report that REO never received. 9/23/16, 9/26/16 and 9/28/16 REO left a voice mail message for the DON to again request the NORA report that REO never received. 9/29/16 REO left a voice mail message for the DON that if she did not receive the NORA report, there would be a report sent to the NYSDOH, LTCP. 10/4/16 REO sent a report to the NYSDOH, LTCP. During an interview on 10/17/16 at 1:25 pm, the Director of Nursing (DON) stated she had been working in the facility for approximately one year and had become the Acting DON in September. REO had asked for the NORA report repeatedly, but she did not know how to do the NORA report. The line list was the only documentation regarding the respiratory illness. She did not review the line lists daily, and did not keep track of or document the outbreak. There was no closing of the units, and there were no swab tests for influenza done as recommended by REO, and she did not remember being told to do them. The Infection Control Nurse (ICN) had left prior to the URI outbreak and the DON was the only one left to manage the infection control role. During an interview on 10/18/16 at 7:20 am, the DON stated that she was the Infection Control Nurse from July through October. She had no training on being an ICN and she was not aware of guidelines to follow when a facility had a positive influenza test. When she was told about the positive influenza test she told Doctor (MD) #2 and he gave no new orders. Finding #2: During an interview on 10/18/16 at 8:40 am, the Registered Nurse Manager (RNM) #2 stated there were currently 6 residents being treated for [REDACTED]. The RNM #2 reviewed the electronic resident records and stated those residents currently being treated for [REDACTED].#5 was on the 2nd day of treatment, Resident #32 on the 4th day of treatment, Resident #45 was on the 14th day of treatment, Resident #67 was on the 6th day of treatment, Resident #68 was on the 11th day of treatment, Resident #85 was on the 3rd day of treatment. The RNM stated that all residents with URI symptoms were discussed in morning report, which is attended by department heads, nurse managers and the DON. There were no instructions to start a line list or start precautions. Residents #32, 67, 68, and #85 had also been treated for [REDACTED]. During an interview on 10/18/16 at 8:30 am, Registered Nurse Manager (RNM) #1 stated during the first URI outbreak there were a lot of residents coughing, a lot of chest xrays and antibiotics. He had received no instruction or direction in regards to the URI outbreak and preventing the spread of the URI. RNM #1 was not made aware that there was a resident who tested positive for the flu. During an interview on 10/18/16 at 9:20 am, the DON stated she did not know how many residents were being treated for [REDACTED]. The DON stated she did not follow-up and review the number of residents or the URI symptoms, and had not started a line list to monitor for a potential outbreak. During an interview on 10/18/16 at 9:20 am, the Administrator stated he did not know there was that many residents with a URI and that there were no tracking or line lists being done. He did not know the URI illness in September was an outbreak, or that REO was attempting to contact the DON. During an interview on 10/18/16 at 11:00 am the Medical Director (MD #1) stated he was aware of the outbreak of URI. Resident #112 (resident who tested positive for [MEDICATION NAME] influenza) was a bacterial disease, not an influenza. In my opinion it was a wrong decision to swab for Influenza. I use my judgement, I had no suspicion that this was an influenza outbreak. I saw no reason to restrict movement of the residents. During an interview on 10/21/16 at 10:50 am, MD #2 stated he was told about the swabs, lab said we don't do swabs, it's not the season. He was not aware of such a high number of URI, he would have stopped travel of the residents through the house and cohorted residents where they could. I should have noticed that. Corrective measures employed by the facility prior to the completion of survey removing the Immediate Jeopardy included the following: The appointment of a facility Infection Control Coordinator on 10/18/16, the development of line lists for resident's exhibiting flu-like symptoms, the submission of required Department of Health reports, review and revision of Infection Control policies and procedures, the re-education of 90% of the nursing staff on infection control standards, signs/symptoms of infection and handwashing, the development of an infection control audit and the addition of an infection control report to the facilities monthly Quality Assurance Performance Initiative (QAPI) meeting. 10 NYCRR 415.26

Based on observation, interview and record review during a recertification survey and abbreviated survey (Case #NY 798), the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Specifically, the facility experienced an upper respiratory illness (URI) outbreak from August 22, 2016 thru September 30, 2016 that involved 38 (Resident #'s 6, 17, 19, 23, 28, 29, 32, 34, 35, 43, 46, 47, 52, 64, 65, 66, 67, 68, 69, 72, 73, 75, 79, 83, 85, 88, 89, 96, 97, 100, 105, 107, 108, 109, 110, 112, 114 and #115) out of 115 residents reviewed for URI and a second outbreak which began on 10/7/16. Subsequently, the facility failed to investigate the outbreak, maintain complete and accurate line lists, or institute measures to contain the outbreaks. Additionally, the facility failed to follow the recommendations of the New York State Department of Health (NYSDOH) Regional Epidemiology Office (REO) to test residents with new onset of URI symptoms, and the facility did not complete the Nosocomial Outbreak Reporting Application (NORA) as required by the NYSDOH Regional Epidemiology Office. This resulted in no actual harm, but with potential for more than minimal harm that is Immediate Jeopardy. This was evidenced by: Finding #1: During an upper respiratory illness (URI) outbreak the facility failed to investigate the outbreak, maintain complete and accurate line lists, and institute measures to contain the outbreaks. The facility also failed to follow the recommendations of the NYSDOH Regional Epidemiology Office and did not complete the NORA as required by the NYSDOH Regional Epidemiology Office. On 10/4/16 (NYSDOH, LTCP) received notification from the NYSDOH Regional Epidemiology Office that the facility had an outbreak of URI symptoms. Additionally, the facility did not follow the Regional Epidemiology Office recommendations to test residents with new onset of URI symptoms for viral and bacterial influenza, and the facility did not report the outbreak as required. During an interview on 10/17/16 at 12:42 PM a representative of the Regional Epidemiology Office (REO) revealed the following communications between REO and the facility: On 9/6/16 and 9/7/16, REO left a voice mail for the Director of Nursing (DON) that Resident #112 tested positive for [MEDICATION NAME] Influenza. REO did not receive a return call from the facility. On 9/9/16, the DON informed REO that there were five residents at the facility with URI symptoms. The DON was instructed to add the five residents to the line list and submit a NORA report. REO staff also recommended the facility swab test residents with new onset URI symptoms for Bacterial and Viral Influenza. On 9/12/16 and 9/16/16, the facility did not return calls to the REO. On 9/19/16, REO requested the NORA report a second time from the DON. On 9/23/16, 9/26/16 and 9/28/16, REO left a voice mail for the DON requesting the NORA report. On 9/29/16, REO left a voice mail message for the DON stating that if REO did not receive the NORA report, a report would be sent to the NYSDOH. On 10/4/16, REO reported to NYSDOH that the facility had not submitted a NORA report. The facility Line List Form for upper respiratory symptoms with dates from 8/29/16 through 9/10/16 documented 17 residents with URI symptoms: 8/29/16: Resident #43 on 2nd floor 9/2/16: Resident #'s 26, 66 and #101 on 1st floor 9/4/16: Resident #'s 78 and 79 affecting both floors 9/5/16: Resident#'s 52, 88 and #110 affecting both floors 9/6/16: Resident #68 on 2nd floor 9/7/16: Resident #113 on 1st floor 9/8/16: Resident #108, 109 on first floor 9/9/16: Residents #'s 65, 72 and 83 affecting both floors 9/10/16: Resident #21 on 2nd floor A review of the August and September 2016, 24 Hour Report sheets revealed 38 residents had one or more symptoms of a URI from 8/22/16 through 9/30/16. Symptoms and/or [DIAGNOSES REDACTED]. During an interview on 10/17/16 at 1:25 PM, the Director of Nursing (DON) stated she had been working in the facility for approximately one year and had become the Acting DON in September. REO had asked for the NORA report repeatedly, but she did not know how to do the NORA report. The line list was the only documentation regarding the respiratory illness. She did not review the line lists daily, and did not keep track of or document the outbreak. There was no closing of the units, and there were no swab tests for influenza done as recommended by REO, and she did not remember being told to do them. The Infection Control Nurse (ICN) had left prior to the URI outbreak and the DON was the only one left to manage the infection control role. During an interview on 10/17/16 at 2:00 PM, LPN #1 stated several residents were on antibiotics, but no quarantine measures were implemented during the respiratory outbreak. During an interview on 10/18/16 at 6:45 am, LPN #2 stated there was no special isolation procedures to the resident rooms or unit during the URI outbreak. LPN #2 was not made aware there was an outbreak. LPN #2 stated that she was ill with URI in September and was out of work for 5 days and she was not asked her about her symptoms. During an interview on 10/18/16 at 6:53 am, CNA#1 stated she was not told about a URI outbreak on the units during the outbreak. During an interview on 10/18/16 at 7:00 am, the Food Service Director stated he was not aware of an URI outbreak or Influenza. There were no quarantines, and all residents continued to be allowed to come to the community dining room. During an interview on 10/18/16 at 7:20 am, the DON stated that she was the Infection Control Nurse from July through October. She had no training on being an ICN and she was not aware of guidelines to follow when a facility had a positive influenza test. When she was told about the positive influenza test she told Doctor (MD) #2 and he gave no new orders. During an interview on 10/18/16 at 9:00 am, LPN #4 stated that there were no residents isolated to their rooms or the units during the URI outbreak. During an interview on 10/18/16 at 10:10 am, the Nursing Staffing Coordinator stated she was not aware of a respiratory outbreak on the resident units. She was not told to limit staff floating to other units. There was no special instruction by management to track staff call outs and/or symptoms of staff infections. Finding #2: The facility experienced a second URI outbreak which began on 10/7/16. Subsequently, the facility failed to investigate the outbreak, maintain complete and accurate line lists, or implement measures to contain the outbreaks. During an interview on 10/18/16 at 8:40 am the Registered Nurse Manager (RNM) #2 stated there were currently 6 residents being treated for [REDACTED]. RNM #2 reviewed the electronic resident records and stated those residents being treated for [REDACTED].#5 was on the 2nd day of treatment, Resident #32 on the 4th day of treatment, Resident #45 was on the 14th day of treatment, Resident #67 was on the 6th day of treatment, Resident #68 was on the 11th day of treatment, Resident #85 was on the 3rd day of treatment. The RNM stated that all residents with URI symptoms were discussed in morning report, which was attended by department heads, nurse managers and the DON. There were no instructions to start a line list or start precautions. Residents #32, 67, 68, and #85 had also been treated for [REDACTED]. During an interview on 10/18/16 at 8:30 am, RNM #1 stated that there was one resident (Resident #19) being treated for [REDACTED]. During an interview on 10/18/16 at 9:00 am, LPN #4 stated that a line list had not been done for the 6 residents being treated for [REDACTED]. During an interview on 10/18/16 at 9:20 am, the DON stated she did not know how many residents were being treated for [REDACTED]. The DON stated she did not follow-up and review the number of residents or the URI symptoms, and had not started a line list to monitor for a potential outbreak. During an interview on 10/18/16 at 9:20 am, the Administrator stated he did not know there were that many residents with a URI and that no tracking or line lists were maintained. He did not know the URI illness in September was an outbreak, or that REO had attempted to contact the DON. During an interview on 10/18/16 at 11:00 am the Medical Director (MD #1) stated he was aware of the outbreak of URI. Resident #112 (who tested positive for [MEDICATION NAME] influenza) had a bacterial disease, not an influenza. In my opinion it was a wrong decision to swab for Influenza. I use my judgement, I had no suspicion that this was an influenza outbreak. I saw no reason to restrict movement of the residents. During an interview on 10/18/16 3:50 PM, the evening Registered Nursing Supervisor (RNS) stated that he had worked at the facility for almost 3 years and was not familiar with a line list until this incident. During an interview on 10/21/16 at 10:50 am, MD #2 stated he was told about the swabs, lab said we don't do swabs, it's not the season. He was not aware of such a high number of URIs, and he would have stopped travel of the residents through the facility and cohorted residents where they could. He also stated I should have noticed that. During an interview on 10/21/16 at 9:22 am, the DON called and verified with the pharmacy that the swabs would have been available in September. The pharmacy informed the DON that no order for swabs to test A&B Influenza, was received from the facility in September or October. If the orders had been sent to pharmacy in September they would have been delivered to the facility. Resident #64: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. A review of the facility Line List Form for URI dated 8/29/16 through 9/10/16 (first URI outbreak), revealed Resident #64 was not included on that list. Resident #64 was treated with antibiotic for URI starting on 8/26/16 and ending on 9/2/16. The nursing progress note dated 8/26/16 at 6:41 PM, documented, new order for [MEDICATION NAME] 100 milligrams (mg), by mouth (po), twice per day (bid) for 7 days, diagnosis (dx) URI. New order acidophilus ([MEDICATION NAME]) one capsule, po bid for 7 days. New order [MEDICATION NAME] DM (used to relieve coughs caused by the common cold, bronchitis, and other breathing illnesses) 20 milliliters (ml) po, every 6 hours (q6h) as needed (prn) for 7 days, dx cough. New order [MEDICATION NAME] (relieves allergy symptoms, including nasal congestion and sinus pressure) 10 mg, po, every day (qd) for 7 days, will continue to monitor. The MD orders dated 8/26/16 documented, [MEDICATION NAME] 100 mg, po, bid for one week. Acidophilus capsule, give one capsule po, bid for one week. [MEDICATION NAME] DM 10 mg/100 mg, give 20 ml q6h for one week. [MEDICATION NAME] 10 mg po, qd, for one week. The nursing progress note dated 8/30/16 at 12:54 am, documented the resident day 4/7 (in the fourth day of treatment of [REDACTED]. The resident's temperature (temp) was 97.1 F (Fahrenheit, normal range 97.7 degrees Fahrenheit 99.5 F.) No cough or congestion was noted, and the resident offered no complaints. The nursing progress note dated 9/2/16 at 12:33 pm, documented, day 7/7 on [MEDICATION NAME] for URI, tolerated well. The progress note dated 10/7/16 at 3:30 PM, written by MD #2 documented, red eyes, [MEDICATION NAME] (antibiotic) locally. Cough green sputum, no fever, oxygen saturation (an estimate of the amount of oxygen in the blood) 94% (normal range 95 to 100%) on room air, [MEDICATION NAME] (antibiotic) cause allergies [REDACTED].>The MD orders dated 10/7/16, documented, [MEDICATION NAME] 0.3% eye gtts, instill 2 gtts by opthalmic route 3 times per day (tid) for one week. [MEDICATION NAME] 500 mg, po qd for one week. Acidophilus, one tablet bid for one week. The nursing progress note dated 10/10/16 at 12:29 PM, documented, day 3/7 on [MEDICATION NAME] for URI, tolerated well. Temp 98.3. Said she is bringing up less green phlegm. [MEDICATION NAME] opthalmic continues, eyes less red. The nursing progress note dated 10/14/16 at 7:28 PM, documented, day 7/7 [MEDICATION NAME] for URI. No cough or congestion noted. Final dose of [MEDICATION NAME] eye drops (gtts) given. Both eyes with no redness or drainage. Resident #73: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE]. assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 99 indicating resident was unable to participate in the interview and exhibits modified independence in decision making. A review of the facility Line List Form for URI dated 8/29/16 through 9/10/16 (first URI outbreak), revealed Resident #73 was not included on that list. Resident #73 was treated with antibiotic for URI starting on 8/30/16 and ending on 9/6/16. The nursing progress note dated 8/30/16 at 11:02 pm, documented, temp 97.9, blood pressure 124/69, pulse 134 (normal adult range 60-100), respirations 20 (normal range 12-20), oxygen saturation 79% on room air, oxygen applied via nasal cannula at 3 liters, lung sounds diminished, MD made aware. New order, [MEDICATION NAME] 1 gram (gm) IM (intramuscular injection) daily for 7 days. Acidophilus one caplet bid, for 7 days. [MEDICATION NAME] (diuretic) 20 mg now. Duo-nebulizer (converts medication for asthma or another condition into an aerosol mist) treatment 4 times per day (qid) for 7 days, and the resident was to have a chest x-ray. A list titled chest x-ray ordered from 8/30/6 to 10/17/16 signed by the DON and provided to the DOH documented, dates x-rays were taken, with resident names, and results. The x-ray for Resident #73 was not documented on that list. The MD orders dated 8/30/16, documented, [MEDICATION NAME] 10 mg/ml injection, 2 ml by injection route now for 1 dose. [MEDICATION NAME] 1 gm, qd, for 7 days. Acidophilus 1 capsule, bid for 7 days. The nursing progress note dated 9/2/16 at 12:43 am, documented, day 3/7 [MEDICATION NAME] for URI, congested non productive cough noted. Resident out of bed for most of shift. Oxygen remains on continuously at 2 liters per minute via nasal cannula. Oxygen saturation 96%. Skin warm and dry, temp 96.6, no shortness of breath. Refused evening meal but did drink all fluids. A review of a progress note dated 9/2/16 at 12:35 pm, written by MD #2 documented, status [REDACTED]. Follow-up x-ray negative, also better now. A review of a nursing progress note dated 9/4/16 at 11:45 pm, documented, [MEDICATION NAME] continues for URI, temp 96.1, no short of breath. Occasional congested non productive cough noted. Oxygen remains on continuously at 2 liters per minute via nasal cannula with oxygen saturation 96%. A nursing progress note dated 9/6/16 at 3:50 pm, documented, day 7/7 on [MEDICATION NAME] for URI, tolerated well. Temp 97.2, no complaints offered. Resident #105: Resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 99 indicating resident was unable to participate in the interview, and exhibits moderately impaired decision making. A review of the facility Line List Form for URI dated 8/29/16 through 9/10/16 (first URI outbreak), revealed Resident #105 was not included on that list. Resident #105 was treated with [MEDICATION NAME] for URI starting on 9/4/16 and subsequently hosptalized on [DATE]. The nursing progress note dated 9/4/16 at 11:39 pm, documented resident noted to have clear/yellow nasal discharge. Temp 97.9, skin warm and dry, no cough noted. [MEDICATION NAME] to start in am (morning) per supervisor. The MD orders dated 9/4/16, documented, [MEDICATION NAME] 10 mg po, qd. Cough control DM, 10 mg-100 mg/5 ml, give 10 ml po q4h, prn. The nursing progress note dated 9/5/16 at 10:34 am, documented MD #2 ordered [MEDICATION NAME] 10 mg, po daily and cough syrup 10 ml, q4h, porn. The MD #2 progress note dated 9/6/16 at 11:51 am documented, cough, allergies [REDACTED]. The MD orders dated 9/6/16 at 5:14 PM documented, influenza A and B [MEDICATION NAME] detection (swab test for influenza). During an interview on 10/21/16 at 1:00 pm a laboratory representative stated the influenza test ordered on [DATE], was not received by the laboratory. The nursing progress note dated 9/9/16 at 1:05 pm documented, temp 97.5, blood pressure 133/90, pulse 90, 108, oxygen saturation 88% on room air. Resident being sent to the hospital due to congestion, cough, poor appetite and weakness. The nursing progress note dated 9/9/16 at 7:47 pm documented, resident admitted to the hospital, [DIAGNOSES REDACTED]. During an interview on 10/20/16 at 8:30 am the DON stated that in September 2016 there was no 2nd floor nurse manager that she had covered the role of nurse manager. There was nothing in MD #2's note in regards to follow-up of the influenza test. She did not know why the swab test for influenza was not done. During an interview on 10/21/16 at 9:22 am the DON called and verified with the pharmacy that the swabs were available. The order for swabs to test A&B Influenza should have been sent to the pharmacy on 9/7/16. During an interview on 10/21/16 at 10:50 am MD #2 stated that he ordered the influenza swab for resident #105 because there were so many residents with runny nose and other symptoms. The facility Policy & Procedure (P&P) dated April 26, 2011 documented, Infection Control, Practices used to prevent transmission of infectious disease. Documented under the heading most common infections in nursing homes Influenza. An acute respiratory disease signaled by the onset of fever, cough, chills and headache. It is the major threat to nursing home residents who are among the high risk groups. It is very contagious and outbreaks in facilities are common and often severe. Preventative measures include, annual influenza vaccines, cohorting residents with influenza, precautions during an outbreak. Transmission-based precautions are designed for patients documented or suspected to be infected with highly transmittable infections for which additional precautions beyond standard precautions are needed. The Dear Nursing Home Administrator letter dated October, 1998 for Outbreak Reporting in Health Care Facilities documented, the NYSDOH is charged with the responsibility of protecting public health and ensuring the safety of health care facilities. The collection of outbreak data enables the NYSDOH to inform health care facilities of potential risks and preventive actions. Reporting facilities can obtain consultation, laboratory support and on-site assistance in outbreak investigations as needed. Any outbreak or significant increase in nosocomial infections above the norm or baseline in nursing home residents or employees should be reported. Health care facilities are expected to conduct surveillance that is adequate to identify background rates and detect significant increase above those rates. Outbreaks or select nosocomial infections must be reported within 24 hour of recognition. It is preferred that clusters or significant increases be reported as soon as they are recognized so that control measures, laboratory testing or need for assistance can be discussed. Corrective measures employed by the facility prior to the completion of survey removing the Immediate Jeopardy included the following; The appointment of a facility Infection Control Coordinator on 10/18/16, the development of line lists for resident's exhibiting flu-like symptoms, the submission of required Department of Health reports, review and revision of Infection Control policies and procedures, the re-education of 90% of the nursing staff on infection control standards, signs/symptoms of infection and handwashing, the development of an infection control audit and the addition of an infection control report to the facilities monthly Quality Assurance Performance Initiative (QAPI) meeting. 10NYCRR415.19(a)(1-3)

Based on medical record review and staff interviews during a recertification survey, the facility failed to provide a Quality Assessment and Assurance (QAA) Program that readily and effectively identified issues with the potential to cause serious harm to the health and safety of residents. Specifically, the facility QAA program failed to identify that there was not an effective system in place to monitor and supervise residents receiving oxygen. Additionally, the QAA program failed to identify that there was not an effective system in place to maintain ongoing assessment of the safety and functionality of side rails. This was evidenced by: Refer to F 309 - Quality of Care - Scope/Severity K Refer to F 323 - Quality of Care - Scope/Severity K The Immediate Jeopardy at F 309, identified on 7/31/15, was removed on 8/3/15, when the facility took the following measures: 90% of licensed nursing staff were inserviced on Oxygen Tank Monitoring, and inservices were to continue until 100% had received the training. Additionally, a facility-wide audit was conducted and all identified problems were corrected. An Ad Hoc Quality Assurance Meeting was held to review corrective actions that had been taken. A Policy &Procedure (P&P) for Oxygen Monitoring was implemented. The Immediate Jeopardy at F 323, identified on 7/29/15, was removed on 7/31/15 when the facility took the following measures: 100% of the Maintenance Department was educated on the P&P and utilizing a lesson plan regarding the safe installation, monitoring and repair of side rails. They were also educated that they were responsible for daily monitoring of the safety and functionality of the rails. Also, 90% of full and part time staff were inserviced on the Preventative Maintenance program P&P specific to side rails. Additionally, a facility-wide audit was conducted and all identified problems were corrected. An Ad Hoc (formed, arranged, or done for a particular purpose only) Quality Assurance Meeting was held to identify the root cause of the situation. During an interview on 7/29/15 at 1:52 pm, the Administrator stated that she was the chairperson for the Quality Assurance Committee (QAC). She stated that the facility environment had been a focus of the QAC, and that equipment was part of the observation rounds that had been implemented. The Administrator also stated that no problems or concerns related to side rails had been brought to her attention, and that if there were identified concerns, staff should have notified the Quality Assurance team so it could be reviewed. She also stated that the Director of Therapy (DOT) performed a whole house audit on side rails in 5/2015, and reported that there were no concerns identified pertaining to side rails. During an interview on 7/29/15 at 1:55 pm, the DOT stated that she performed a monthly check of side rails, but does not check the function, or whether they wobbled or were loose on these checks. It was a visual check to verify that the side rails were in place. 10 NYCRR 415.27(a-c)

Based on medical record review and staff interviews during a recertification survey, it was determined that the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, the facility failed to have an effective system in place to monitor and supervise residents receiving oxygen. Additionally, the facility failed to have an effective system in place to maintain ongoing assessment of the safety and functionality of side rails. Also, the facility did not ensure that a Licensed Practical Nurse, assigned as a Unit Manager, did not create, initiate, or alter nursing care goals or establish nursing care plans for five (Resident #'s 66, 71, 77, 78, and #89 ) of five residents on Unit 2 reviewed for care planning. This was evidenced by: Refer to F 309 - Quality of Care - Scope/Severity K Refer to F 323 - Quality of Care - Scope/Severity K Refer to F 520 - Quality Assessment and Assurance - Scope/Severity K Finding: The facility Administration did not ensure that a Licensed Practical Nurse Manager (LPNM), did not create, initiate, or alter nursing care goals or establish nursing care plans. New York State Education Law §6902, New York law does not include nursing [DIAGNOSES REDACTED]. Thus, Licensed Practical Nurses in New York State do not have assessment privileges; they may not interpret patient clinical data or act independently on such data; they may not triage, they may not create, initiate, or alter nursing care goals or establish nursing care plans. Source:http://www.op.nysed.gov/prof/nurse/nursebroch.htm) Resident #66: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) of 5/26/15, assessed the resident as usually understands, usually understood and with moderately impaired decision making ability. During an interview on 8/3/15 at 9:01 am, the Licensed Practical Nurse Manager (LPNM) stated she had initiated this resident's Abuse Neglect and Psychosocial Comprehensive Care Plans (CCP). Resident #71: The resident was admitted [DATE], with [DIAGNOSES REDACTED]. The Comprehensive Care Plan (CCP) for Falls documented that it was electronically signed on 3/20/15 by the LPNM. The careplan Risk for falls/injury secondary to a HX (history) of falls was identified as the problem. The goals documented that the resident would be free from fall/injuries daily x 90 days. The Interventions documented: to keep the room well lit; PT/OT (Physical Therapy/Occupational Therapy) screens PRN (as needed); keep bed in lowest position; and provide assistance in ADLs. Resident #77: The resident was admitted [DATE] with [DIAGNOSES REDACTED]. The Comprehensive Care Plan (CCP) for Pain electronically signed on 6/15/15, by the LPNM, documented Pain/at risk for alteration in comfort as the identified problem. The goal documented that the resident would be free from signs and symptoms of pain i.e. verbal c/o (complain of) pain, facial grimacing, moaning, decrease in ability to participate in ADL's (Activities of Daily Living) x 3 months. The Interventions on the CCP documented: Observe for signs and symptoms of pain daily, i.e. verbal complaints, moaning, restlessness, facial grimace, and sighing; inform MD for any change in pain status i.e. relief is short termed or having breakthrough pain; and provide pain medications as ordered by MD; and assess for drug effectiveness and adverse effects. Resident #78: The resident was re-admitted [DATE] with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], assessed the resident to be sometimes understood, sometimes understands and with severely impaired cognitive skills for daily decision making. The Comprehensive Care Plans for Pain and Dental care were electronically signed on 3/7/13 by the Licensed Practical Nurse Manager (LPNM). The Pain/at risk for alteration in comfort was identified as the problem on the CCP. The goal was documented for the resident to be free from signs and symptoms of pain i.e. verbal c/o (complain of) pain, facial grimacing, moaning, decrease in ability to perform/participation in ADL's (Activities of Daily Living) x 3 months. The Interventions documented to: observe for signs and symptoms of pain daily, i.e. verbal complaints, moaning. restlessness, facial grimace, sighing; inform MD for any change in pain status i.e. relief is short termed or having breakthrough pain; and to provide pain medications as ordered by MD; assess for drug effectiveness and adverse effects. The Dental Care CCP documented the resident was at high risk of impairment of oral or dental condition. The goals were documented: resident will be free of oral/dental pain and discomfort; resident will be free of oral/dental infection; and resident will be able to chew food without discomfort. The Interventions documented: assess chewing ability; assess risk factors; and assist with or provide oral hygiene daily to prevent infection and cavities. During an interview on 7/31/15 at 10:04 am, the LPNM stated that she wrote, created, and initiated the care plans on the residents on the second floor. She stated that she did not know whether or not a Registered Nurse reviewed and signed the care plans. During an interview on 7/31/15 at 10:07 am, the Director of Nursing (DON) stated that the Unit 2 LPNM initiated the care plans for the residents on that unit. The DON stated that all care plans were supposed to be reviewed by RN's at the morning meetings. She also stated that there was no documentation, including signatures, that an RN had reviewed the care plans written, created and initiated by the LPNM. During an interview on 8/4/15 at 9:05 am, the LPNM stated that she initiated the care plans on Residents #'s 71, 77 and and #78. She also stated that since she started in 2013 as the Unit Manager, she has initiated or created the majority of the care plans for the residents on the second floor. She stated that the care plans were then supposed to be reviewed by a Registered Nurse (RN), either the DON, ADON or a Supervisor, and that the RN did not usually sign or initial the care plans as being reviewed and that would have to take their word it was done. The Immediate Jeopardy at F 323, identified on 7/29/15, was removed on 7/31/15 when the facility took the following measures: 100% of the Maintenance Department was educated on the P&P and utilizing a lesson plan regarding the safe installation, monitoring and repair of side rails. The facility was educated regarding their responsibility for daily monitoring of the safety and functionality of the rails. Also, the facility in-serviced 90% of full and part time staff on the Preventative Maintenance program Policy and Procedure (P&P) specific to side rails. Additionally, a facility-wide audit was conducted and all identified problems were corrected. An Ad Hoc (formed, arranged, or done for a particular purpose only) Quality Assurance Meeting was held to identify the root cause of the situation. The Immediate Jeopardy at F 309, identified on 7/31/15, was removed on 8/3/15, when the facility took the following measures: 90% of licensed nursing staff were inserviced on Oxygen Tank Monitoring, and inservices were scheduled to continue until 100% had received the training. Additionally, a facility-wide audit was conducted and all identified problems were corrected. An Ad Hoc Quality Assurance Meeting was held to review corrective actions that had been taken. A P&P for Oxygen Monitoring was implemented 10 NYCRR 415.26

Based on observation, record review and interviews during the recertification survey, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for 9 (Resident #'s 9, 10, 40, 42, 59, 67, 71, 91, and #92) of 13 residents observed with side rails in use. Specifically, the facility failed to have an effective system in place to maintain an ongoing assessment of the safety and functionality of side rails. The side rails bowed out from the beds, permitting a gap greater than 4.5 inches between the mattress and the side rails. This gap allowed for the potential of head or body entrapment. Additionally, the facility did not have a bed side rail preventative maintenance program or policy and procedure. This resulted in no actual harm, but there was a potential for serious harm for all residents in the facility and this resulted in Immediate Jeopardy to Resident Health and Safety and Substandard Quality of Care. This was evidenced by: The Guidance for Industry and FDA (Federal Drug Administration) Staff (the industry standard) for The Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, with an issue date of March 10, 2006 and presented by the Center for Devices and Radiological Health documented under the title Zone 3- Between the Rail and the Mattress: This space is the space between the inside surface of the rail and the mattress compressed by the weight of a patient's head. The space should be small enough to prevent head entrapment when taking into account the mattress compressibility, any lateral shift of the mattress or rail, and degree of play from loosened rails. FDA is recommending a dimensional limit of less than 120 millimeters (4 3/4 inches) for the area between the inside surface of the rail and the compressed mattress. Resident #10: The resident was admitted on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed that the resident was able to understand others, was usually able to be understood by others and had a Brief Interview of Mental Status of 12/15 or moderately impaired cognition. The MDS also documented that she was independent in bed mobility and transfer status. A Physical Therapy evaluation dated 10/8/14, documented under the heading Factors Affecting Need for Side Rail that the resident requested and used the side rail as a bed mobility enabler while she was in bed. A Physician order [REDACTED]. Each renewal order after that included the order for the side rail as an enabler. During an observation on 7/29/15 at 8:25 am, the resident was in her bed with the enabler bar in the up position. The enabler bar was very wobbly and bowed out from the side of the bed at least a fist width from the mattress to the enabler bar. The resident stated the bar had been that way since she had come to this unit around September 2014. She was asked if she had told anyone about the enabler bar being wobbly and stated they know and gave a name. She said nothing was done. At 1:42 pm she was reinterviewed and stated she came from the second floor with this bed with the side rail. She stated she may use the rail to pull herself up in bed once in a while. She said she could pull herself up without it and demonstrated that she could. During this reinterview of the resident, a maintenance worker came into the room to fix the side rail. He stated the bed was already in the room and did not have side rails when the resident came to this unit as they take them off when a resident leaves. During an observation and interview on 7/29/15 at 11:30 am, the Director of Maintenance (DOM) tested the left side rail on the resident's bed, revealing the the side rail bowed out from the side of the bed and was unstable (wobbly). The DOM stated that the bar was way too loose, and measured the gap from the side rail to the mattress to be 5.5 inches. The DOM also stated that it looked like the rail was also bent. During an interview on 7/29/15 at 12:30 pm, the Registered Nurse Manager (RNM) stated that Therapy determines who needs side rails. He also stated that the Therapist determined who needed side rails for mobility and they put it into the computer, and the physician approves it. He was not aware that this resident had loose, wobbly side rails. During an interview on 7/29/15 at 12:43 pm, the Physical Therapist stated that Therapy determines whether a resident needs side rails. She stated that any new admission is always assessed if the Therapist is here. She also stated that if the Therapist is not in the facility then the assessment occurs the next day. The Physical Therapist stated that for long term care residents, the therapy department receives referrals from nursing. She further stated that if a resident comes in after the Therapist had left for the day, she thought that the resident would not get rails until the next morning when the Therapist was there. She further stated that she did not know if there was a process in place to take the rails off a bed when a resident left. She additionally stated that if there were rails on a bed for a new admission and they assessed the resident did not need the rails they would ask to have them taken off. She stated they call all bars on a bed side rails. During an interview on 7/29/15 at 1:11 pm, Certified Nurse Aide (CNA) #1 stated she was not aware that the resident's side rail was very loose. She stated the resident does not need very much help from staff and that she did most of her own care. She stated the resident could not put the side rail up and down herself. She also stated that she thought the resident had been in this bed about 6 months. CNA #1 further stated the only way aides would know a rail was loose was if they put it up or down. She additionally stated that if a side rail was loose, she would tell maintenance. During an interview on 7/29/15 at 1:39 pm, Licensed Practical Nurse (LPN) #3 stated that neither staff nor the resident had ever let her know the resident's side rail was loose. During an interview on 7/29/15 at 1:49 pm, a housekeeper stated that when a resident left the facility, housekeeping completed a thorough cleaning of the bed and room. She stated the side rails stay on the bed until a new resident comes in. She also stated that if a new person didn't need side rails, they came off. She further stated that it is nursing/maintenance who deals with side rails. She stated she had seen beds with side rails still on them after a resident had left. During interview on 7/29/15 at 1:55 pm, the Director of Rehabilitation was asked when this resident was evaluated for siderail use. The Director of Rehabilitation stated that the resident was evaluated for side rails on 10/8/14. There were no evaluations after that. Resident #9: The resident was admitted on [DATE] with the [DIAGNOSES REDACTED]. There was no Minimum Data Set available for the resident. The undated Care Card (used by staff to know what care each resident required) documented that this resident required one person physical assistance for bed mobility and transfers. During an observation, and interview on 7/29/15 at 11:30 am, the Director of Maintenance (DOM) tested the right side rail on the resident's bed, revealing the the side rail bowed out from the side of the bed and was unstable (wobbly). The DOM stated that the bar was way too loose, and measured the gap from the side rail to the mattress to be 5.5 inches. The DOM also shook the right side rail and stated that it too was loose and needed to be tightened. Resident #40: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed that the resident understands, was understood and had a Brief Interview for Mental Status (BIMS) score of 15/15 or no cognitive impairment. The MDS also documented that the resident needed limited assist of one staff for bed mobility and extensive assist of two staff for transfers. The Comprehensive Care Plan for Mobility, Ambulation and Transfers dated 1/9/15, documented that the resident required the extensive assistance of one person for bed mobility. During an observation and interview on 7/29/15 at 11:30 am, the Director of Maintenance (DOM) tested the left side rail on the resident's bed, revealing the side rail bowed out from the side of the bed and was unstable (wobbly). The DOM lifted the mattress and stated that the side rail had been improperly applied to the bed. The DOM also stated that each side rail required two bolts to attach the rail to the bed and only one bolt was in place for the left rail. He further stated that this caused the side rail to be unstable. Additional Interviews: During an interview on 7/29/15 at 11:30 am, the Director of Maintenance (DOM) stated that the maintenance department was responsible for checking the functionality of the side rails on residents' beds and that they tried to check the side rails every month, but that was not always completed. He also stated that there was no maintenance documentation of the side rails. The DOM further stated that he was not aware of a policy and procedure (P&P) for maintaining the side rails and that he did not have the manuals for the side rails, but would try to find them on the Internet. He further stated that of the four types of side rails in use, he was able to locate and download from the Internet manuals for three of the types. During an interview on 7/29/15 at 1:42 pm, the Director of Nursing (DON) stated that the the Therapy Department evaluated residents for side rail use, the Maintenance Department was responsible for applying side rails to beds, and that nursing monitored the residents' use of the side rails. She also stated that it was the Therapy Department's responsibility to monitor the side rails for proper fit and tightness to the beds. She further stated that it was the nursing department's responsibility to notify the Maintenance Department of loose side rails using a Maintenance Slip. During an interview on 7/29/15 at 1:52 pm, Licensed Practical Nurse #2 stated that she had noticed side rails being loose on resident beds, but thought that maintenance would check them. She stated that she had not thought to report loose side rails to a supervisor. During interview on 7/29/15 at 1:55 pm, the Director of Rehabilitation stated the Physical Therapy and Occupational Therapy make recommendations for side rails. The Director of Rehabilitation stated they put a request in to Maintenance to put the bars on the bed for a resident. She also stated that she would put the order in for the physician to approve or deny the recommendation. She further stated that side rails should be taken off a bed before a new resident comes into that bed. She additionally stated that mistakes happen and that side rails are left on a bed for a new admission. She stated that if that happens they assess to see if they are needed and if not needed they put in a request or call maintenance to have the side rails removed. She also stated they do not do quarterly reviews (to include need of side rails) of all residents. She further stated that she does a monthly visual placement check of side rails but does not check the function of the rails or if the rails wobble or are loose on this check. During an interview on 7/29/15 at 1:52 pm, the Administrator stated that nursing staff were responsible for monitoring resident-use equipment every day, and that it was also the Maintenance Department's responsibility to monitor side rails for safety and functionality. The Administrator also stated that no problems or concerns related to side rails had been brought to her attention, and that if there were identified concerns, staff should have notified the Quality Assurance team so it could be reviewed. The Immediate Jeopardy identified on 7/29/15 was removed on 7/31/15, when the facility took the following measures: 100% of the Maintenance Department was educated on the P&P and utilizing a lesson plan regarding the safe installation, monitoring and repair of side rails. They were also educated that they were responsible for daily monitoring of the safety and functionality of the rails. Also, 90% of full and part time staff were inserviced on the Preventative Maintenance program P&P specific to side rails. Additionally, a facility-wide audit was conducted and all identified problems were corrected. An Ad Hoc (formed, arranged, for a particular purpose only) Quality Assurance Meeting was held to identify the root cause of the situation. 10 NYCRR 415.12(h)(1)

Based on observation, record review and interview during a recertification survey, the facility failed to 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, for eight (8) (Resident #'s 3, 16, 22, 32, 34, 44, 45, and #89) of thirteen (13) residents reviewed for oxygen use. Specifically, Resident #'s 32, 44 and #45 were observed to have empty oxygen tanks. Resident #16 received continuous oxygen without a physician's orders [REDACTED].#22, with known histories of self-adjusting their oxygen flow rates, did not have care planning interventions. Additionally, there was inconsistent documentation of physician ordered oxygen saturation levels for Resident #44. This resulted in no actual harm, but there was a potential for serious harm for all residents in the facility and this resulted in Immediate Jeopardy to Resident Health and Safety and Substandard Quality of Care. Additional Findings: The facility did not ensure consistent documentation and assessment of residents' pain before and after administration of as needed (prn) pain medication, or for non-pharmacological interventions prior to administration of pain medications for three (3) (Resident #'s 3, 30 and #34) of fifteen residents' reviewed for pain. This was evidenced by: Resident #32: The facility did not effectively monitor this resident to ensure that the resident's oxygen tank did not run empty. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) of 6/2/15, assessed that the resident understands, was understood and had severely impaired decision making ability. It also documented the resident received oxygen therapy. The resident had a physician order [REDACTED]. The Comprehensive Care Plan (CCP) for Alteration in Respiratory Function-[MEDICAL CONDITION] dated 12/10/13, documented that staff were to administer oxygen as ordered by the physician. On 7/29/15 at 12:12 pm, the resident's room was observed to have oxygen tubing on the floor. It extended from the concentrator out the door into the hallway. This surveyor questioned staff nearby about where the resident was, and someone pointed out that she was down the hallway across from the nurses station. Staff then noticed the resident was not wearing her oxygen and put it on her. On 7/29/15 at 5:10 pm, the resident was observed at a table in the dining room and her oxygen tank was empty. She was not observed to be in respiratory distress. At 5:25 pm, a nurse was observed taking the resident out of the dining room. Observation of the oxygen tank revealed that it was empty. The nurse stated she had last seen the resident in her room at approximately 4:00 pm and that the resident was on the oxygen concentrator. The Registered Nurse (RN) stated the resident came to the dining room at about 4:30 pm and that she had connected the resident to the oxygen tank. She stated that the tank was not in the red (red indicates oxygen tank is empty) yet. She also stated she came to the dining room to check this resident's oxygen tank because the resident uses 3 liters per minute which uses up the oxygen fast. During an interview on 7/30/15 at 7:48 am, the resident said she uses the oxygen all the time. She stated that sometimes she feels like she cannot breathe. During an interview on 7/31/15 at 9:04 am, Licensed Practical Nurse (LPN) #1 stated he sometimes takes care of the resident, but was not the resident's usual nurse. He stated the resident uses an oxygen tank on her wheelchair. LPN #1 stated that he checks oxygen tanks on the resident's that are in wheelchairs frequently. LPN #1 stated that he was not aware of a facility policy regarding a time frame for the frequency of checking oxygen tanks. During an interview on 7/31/15 at 10:25 am, a Certified Nurse Aide (CNA) #1 stated that when a resident is going to an activity, they do not take the concentrators because there is no place to plug in the concentrator in the dining room. CNA #1 stated that they were supposed to look at the oxygen tank when they put a resident in a wheelchair and that when the oxygen tank dial is low they have to let the nurse know. CNA #1 stated she considered anything below 1/2 tank to be low, however, was never instructed of a facilty directive regarding when an oxygen tank needed to be changed. During an interview on 8/3/15 at 9:52 am, CNA #2 stated that sometimes the resident takes her own oxygen off. She stated that she checks the residents oxygen tank when she gets the residents into the wheelchair. CNA #1 said if the oxygen tank is low (1/2 to 1/4 tank full) she would let the nurse know. She stated that she has found resident's oxygen tanks empty and has informed the nurse. On 7/31/15, a review of the facility's policy regarding any type of oxygen therapy revealed policies titled: [MEDICAL CONDITION] Management; Non-Re-Breather Mask; Simple Oxygen Mas; [MEDICAL CONDITION]/[MEDICAL CONDITION]; and Nasal Canula. There was no documented evidence of a policy and procedures regarding oxygen use via tank. At approximately 10:00 am, the Director of Nursing (DON) stated that the policies provided were the only ones the facility had. Resident #44: The facility did not ensure that this resident's oxygen tank was effectively monitored so that the oxygen tank did not run empty. Also, documentation of the physician ordered oxygen saturation levels on the Treatment Assistance Records (TAR) was inconsistent. The resident was admitted on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as being understood, sometimes understands and assessed with [REDACTED]. The Physician orders [REDACTED]. The Comprehensive Care Plan (CCP) dated 3/25/13, documented under the care plan for Respiratory - oxygen use to: provide oxygen as ordered by the Physician; pulse oximetry as ordered by the Physician; and report to the Physician when the pulse oximetry is below normal limits. On 7/30/15 at 10:30 am, the resident was in an activity in the main dining room. At 11:52 am, the resident was observed in the dining room with her oxygen tank approximately half full. At 2:35 pm the resident was observed sitting across from another resident in the dining room and both residents' were observed with oxygen tanks on their wheelchairs. Resident #32's oxygen tank was observed to be empty and when the other resident stated that he did not have oxygen the Licensed Practical Nurse (LPN) #2 went to that resident, checked her oxygen tank, and told the resident she had oxygen. At this time, LPN #2 also checked Resident #32's oxygen tank. LPN #2 took Resident #32's oxygen tank and got another oxygen tank. During an interview on 7/30/15 at 3:26 pm, LPN #2 stated she checked this resident's oxygen tank because she was doing her routine check of the oxygen tanks. She stated that she had changed the oxygen tank because it was empty. She also stated that oxygen tanks are checked every 2 hours. LPN #2 reviewed the Medication Administration Record [REDACTED]. LPN #2 stated she had checked this resident's oxygen tank at 2:30 pm for her 2:00 pm and did not know why the tank was empty. The TAR for July included a directive to titrate the oxygen to maintain oxygen saturation rates greater than 90% every shift (7:00 am-3:00 pm; 3:00 pm-11:00 pm; and 11:00 pm-7:00 am). The TAR dose box entry documentation included inconsistent entries i.e oxygen saturation rates, # of Liters of Oxygen, dashes and blanks. During an interview on 8/4/15 at 8:04 am, LPN #2 stated the oxygen order on the TAR meant that they have to keep the oxygen saturation above 90%. She stated that the oxygen saturation rate is entered in the TAR dose box. She stated that some people entered the number of liters and some people entered the saturation rate. LPN #2 also stated that she did not know the entries were different. She stated she thought that nurses were interpreting the physician order [REDACTED]. She also stated that the resident is always on 2 liters of oxygen therefore she did not know what the number 1 entries on the TAR indicate or what the dashes or blanks meant or the reason for blanks on the TAR dose boxes. LPN #2 also stated that she did not know what the dose entry on the TAR meant. During interview on 8/4/15 at 8:16 am, the Licensed Practical Nurse Manager (LPNM) was shown the above mentioned TAR. She stated the nurses should document the oxygen saturation rate and the liters of oxygen on the TAR. The LPNM left the interview to look up the procedure, returned and stated the dose entries should be documented in liters and the saturation documented under the comments. She stated that the nurses should have documented the doses in liters and the saturation levels under comments per procedure. During an interview on 7/31/15 at 10:04 am, the Director of Nursing (DON) stated that this resident, plays with her oxygen flow rate. She reviewed the resident's CCP and stated that there was no information on the care plan regarding the resident self-adjusting her oxygen, The DON stated that this should have been addressed in the care plan. She stated that the LPNM wrote the care plans on this resident's unit, but she had not written one for that problem. Resident #45: The facility did not ensure that this resident's oxygen tank was effectively monitored so that the oxygen tank did not run empty. The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented that the resident was understood, usually understands and assessed with [REDACTED]. The Physician order [REDACTED]. The Comprehensive Care Plan (CCP) dated 02/04/2014, for Respiratory: Oxygen Use documented that the resident requires the use of oxygen due to episodes of shortness of breath, with a goal to have oxygen saturation levels within normal limits. Documented interventions on the CCP included: to provide oxygen as ordered by the medical doctor; pulse oximetry as ordered by the physician; and to report to the Physician if oxygen saturation levels were below normal limits. On 07/30/2015 at 5:00 pm, the resident was observed in the main dining room with an empty oxygen tank on the back of his wheelchair, and a nasal cannula in his nose. The Registered Nurse Manager (RNM) was informed by the surveyor, that the resident's oxygen tank was empty. At 5:15 pm the resident was observed in the main dining room with a full oxygen tank. During an interview with Licensed Practical Nurse (LPN) #7 on 07/31/2015 at 9:03 am, the LPN reported that she would check the oxygen tanks frequently to ensure the oxygen tanks were at a sufficient level to prevent the resident from any respiratory struggles. She also stated that if any difficulty was noted she would check the resident's pulse oximetry. Additionally, she stated that she would inform the Registered Nurse if the resident's pulse oximetry was not ok and move forward as directed. She further stated she checks oxygen tanks every hour. Resident #22: The facility did not ensure that there were care planned interventions to ensure that this resident was receiving the prescribed # of liters of continuous oxygen, when this resident had a history of [REDACTED]. This resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented that the resident was cognitively intact, was able to make himself understood and could understand others. The Comprehensive Care Plan (CCP) for Alteration in Respiratory Function with an effective date of 8/2015, documented that the resident was on oxygen for his risk of respiratory distress secondary to [MEDICAL CONDITION]. Nursing interventions included: administer oxygen as per MD order; observe, record and report effectiveness and adverse reactions of medication; monitor/observe for changes in respiratory rate and depth; check symmetry, dyspnea, tachypnea and use of accessory muscles; restlessness; and confusion. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. The Progress Notes for 6/2015 and 7/2015, documented that the resident received oxygen at 3 liters each minute daily. During an observation on 7/30/15 at 9:05 am, the resident's oxygen tank was set at 2 liters rather than the 3 liters ordered by the physician. During an observation and interview on 7/31/15 at 10:20 am, the resident's oxygen tank was set at 2 liters. The resident stated that he wanted the oxygen to stay on 2 liters instead of 3 liters, as ordered by the physician. During an interview on 7/31/15 at 10:58 am, Licensed Practical Nurse (LPN) #1 stated that he had set the resident's oxygen level at 3 liters and that the resident always changed the flow rate to 2 liters. The LPN did not know how long the resident had been self-adjusting his oxygen flow, but when he saw the flow at 2 liters, he changed it back to 3 liters as ordered by the physician. During an interview on 7/31/15 at 9:30 am, LPN #2 stated that this resident frequently changed his oxygen flow rate on his own, and that if it was found different than what it was supposed to be, she changed it back to the flow rate as ordered by the physician. During an interview on 7/31/15 at 10:30 am, the physician stated that he often found this resident's oxygen flow rate lower than what he ordered. He stated that he had alerted the staff to watch this resident because this resident changed his flow rate. Resident #89: The facility did not ensure that care planning interventions for physician ordered oxygen were in place. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented that this resident was moderately impaired in cognitive skills for daily decision making, usually understood and understands. A Physician order [REDACTED]. maintain sats (saturation) greater than 90%. Review of the resident's Comprehensive Care Plan (CCP) on 07/30/2014, revealed a care plan for alteration in respiratory function as evidenced by cough with no documented evidence of the resident's need for continuous oxygen. Additional care plans reviewed included: at risk for Pneumonia; Comfort Care; at risk for cariovascular dysfunction; and at risk for Influenza. These additional care plans did not include documented evidence of the resident's need for continuous oxygen. The resident was observed and noted to be receiving oxygen via nasal canula at 2 liters per minute for the following observations: 07/30/2015 at 9:45 am in the unit hallway; 07/30/2015 at 2:35 pm in the unit television lounge; 07/31/2015 at 10:52 am in bed; and on 08/03/2015 at 11:50 am in the unit hallway. During an interview on 7/29/15 at 8:57 am, Licensed Practical Nurse (LPN) #5 stated that when residents were on oxygen tanks, the LPN's were supposed to check the volume remaining in the tanks every two hours. If a tank was empty, it was supposed to be changed. She stated that she had never been instructed as to how low the remaining volume on the oxygen tank should be at the two hour check that would require the tank to be changed. She stated that her understanding was to change the oxygen tank when it was empty. During an interview on 7/29/15 at 8:57 am, the Licensed Practical Nurse Manager (LPNM) stated that staff were supposed to check the amount of oxygen left in residents' oxygen tanks every two hours. She stated that she did not know how long the oxygen flow would last at different flow rates and tank volumes. She stated that she had never seen a flow rate chart, but she could search for one on the Internet. During an interview on 7/31/15 at 9:04 am, the Registered Nurse Manager (RNM) stated that oxygen was supposed to be provided to residents in accordance with the physician orders. The RNM stated that he and the other nurses were responsible for checking the oxygen tanks every two hours to ensure that they did not run empty. The RNM stated that occasionally oxygen tanks ran empty, but that staff tried very hard to get to them in time. The RNM also stated that there was no oxygen flow chart on the unit that explained how long oxygen lasted at varying volumes and flow rates. The RNM stated that he thought the oxygen tanks in use at the facility generally lasted 2 to 3 hours. During an interview on 7/31/15 at 9:30 am, LPN #2 stated that oxygen tanks were supposed to be checked by nursing every two hours, but sometimes they ran empty so they also relied on the Certified Nursing Assistants to let them know if a tank was empty. During an interview on 7/31/15 at 10:04 am, the Director of Nursing (DON) stated that nursing staff were supposed to monitor oxygen tanks every two hours, and to ensure they did not run empty, they were supposed to change the tanks if they were at 1/4 of a tank full or less at the 2 hour check. She stated that oxygen tanks should never run empty, and if they did, staff should report that to a supervisor. She stated that she was not aware of any tanks that ran empty. The DON also named two residents who self-adjusted their oxygen flow rates, and stated that CCPs should have been written with interventions to assist in preventing residents from doing that. During an interview on 7/31/15 at 10:30 am, the physician stated that if he wrote an order for [REDACTED]. Resident #3: The facility did not ensure documentation of the measurable effectiveness of PRN (as needed) pain medications, or non-pharmacological interventions prior to administration of PRN pain medications. The Policy and Procedure (P&P) for Pain Management, with effective date of 1/01, documented that each resident will be evaluated with regard to pain or discomfort experienced. The P&P also documented that a pain assessment would be completed at the time of admission or readmission to the facility and at any time there is new onset of pain or worsening of existing pain. The P&P further documented that pain assessments would also be completed as part of all comprehensive Minimum Data Set (MDS) Assessments. The resident's MDS dated [DATE], documented that the resident had been experiencing pain almost constantly within the last 5 days, and that the resident experienced a numeric rating scale for pain of a 10 within the last 5 days of the assessment, with zero being no pain and 10 as the worst pain. The Comprehensive Care Plan (CCP) for Skin Integrity: Surgical Wound with effective date of 7/10/15, documented that the resident was admitted to the facility from the hospital on [DATE]. It also documented that the resident had surgery to his left leg with eleven (11) staples, a graft site wound to the back of the leg, and an open wound to the left lower top portion of his leg. It further documented that the resident was admitted with a pressure ulcer to the sacral area with surgical sutures and six (6) staples due to debridement. The CCP for Pain: At Risk for Alteration in Comfort secondary to the presence of a surgical wound dated 7/15/15, documented interventions that included instructions for nursing to provide pain medications as ordered by the MD (Medical Doctor), to assess for drug effectiveness, and adverse effects. The CCP included documentation for staff interventions to involve residents in diversional activities/distraction measures, such as music and television, and to encourage participation in activity programs. There was no documented evidence in the CCP review, of interventions demonstrating the measurable effectiveness of pain medications were monitored using the pain scale. Also, there was no documented evidence that staff used non-pharmacological interventions to attempt to reduce the resident's pain prior to administering the pain medication. A physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. There was no documented evidence on the MAR indicated [REDACTED]. Additionally, there was no documented evidence of any non-pharmacological interventions prior to administration of the PRN pain medication. A physician's orders [REDACTED]. The MAR for 7/2015 documented that the resident received [MEDICATION NAME] (narcotic pain medication) PRN on July 10, 11, 12, 13 14, 15, 16, and 17, 2015. There was no documented evidence on the MAR indicated [REDACTED]. Also, there was no documented evidence of any non-pharmacological interventions prior to administration of the pain medication. A physician's orders [REDACTED]. The MAR for 7/2015 documented that this resident received PRN [MEDICATION NAME] on July 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and July 31, 2015. The MAR for 8/2015 documented that this resident received PRN [MEDICATION NAME] on August 1, 2, and August 3, 2015. There was no documented evidence on the MAR indicated [REDACTED]. Additionally, there was no documented evidence of any non-pharmacological interventions prior to the administration of the pain medication. During an interview on 7/30/15 at 9:30 am, the Nurse Manager stated that there was no documentation in the MAR indicated [REDACTED]. He also stated that there should be documentation in the progress notes of the pain level before and after medication was given. The nurse manager also stated that non-pharmacological interventions should be documented in the progress notes prior to medication being administered. During an interview on 7/30/15 at 10:00 am, Licensed Practical Nurse (LPN) #4 stated that documentation should occur before and after resident receives pain medication if a numeric pain scale measure is used. LPN #4 also stated that the resident should be asked if the pain medication was effective. During an interview on 7/31/15 at 3:25 pm, the resident stated that in order to receive a dose of his PRN pain medication, he would request the pain medication from nursing as he would seldom be asked if he needed it. Resident stated that when he received the pain killer it would take 30 to 45 minutes for the pain to subside to bearable. The resident stated his pain seldom went below an 8 on the pain scale but presently it is down to a 4 as recovery is taking place. The resident states his left leg wound hurts an awful lot. The resident stated that he has told numerous nurses that his pain is still present after being medicated but the nurses do not get back to him. The resident stated that he has not seen the doctor about his pain. 10NYCRR415.12

Based on medical record review and staff interview during a complaint investigation (Case #NY 538) 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 for one (Resident #1) of six resident's reviewed for advance directives. Specifically, the Certified Nurse Aide (CNA) found Resident #1 unresponsive and alerted other staff to call for help. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) assessed Resident #1 and determined cardiopulmonary resuscitation (CPR) should not performed as Resident #1 "had expired prior to discovery and resuscitation would be fruitless," despite Resident #1's care plan stating she wished to be resuscitated and physician's orders [REDACTED]. This resulted in actual harm to Resident #1 that is not immediate jeopardy. This was evidenced by: The Policy and Procedure (P&P) entitled Cardiopulmonary Resuscitation, reviewed ,[DATE] documented the following: If a resident exhibits signs or symptoms of cardiac/respiratory arrest and is a non-do not resuscitate (CPR), CPR will be initiated until Emergency Medical Services (EMS) arrives on the scene. The first licensed staff member on the scene will: a. Identify that an arrest is present. b. Summon help from the immediate area and instruct staff to call "911" c. Begin CPR The Registered Nurse (RN) present will document all efforts on the blue colored "Code Blue" flow sheet using standardized time. This is a blue form located on top of the emergency cart. This form MUST be completed/signed by an RN, however, any staff member present can begin documenting a timeline and then hand it off to the RN. After each Code Blue, the Code Blue Flow Sheet will be reviewed and completed. Any other necessary information is to be documented in the nurse's notes. The Investigation of Arrests, Near Arrests, and Medical Emergency will also be completed. Resident #1 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having severely impaired cognition. The Comprehensive Care Plan (CCP) entitled Advance Directives: CPR reviewed [DATE] documented Resident #1 wishes to continue as a full code with current health care proxy (HCP). Care plan continued. The physician's orders [REDACTED]." The Resident Certified Nurse Aide (CNA) Documentation History Detail documented Resident #1 was toileted on [DATE] at 6:32 am. In the Progress Note dated [DATE] at 8:28 am the Director of Nursing (DON) documented staff called code blue to second floor. Upon arrival, resident found unresponsive with no pulse or respirations. Sternal rub attempted with no result. Resident flaccid with +jvd (jugular vein distension). Time of death called by this RN at 8:24 am. MD notified at 8:26 am. 911 enroute. The Summary regarding Resident #1's death provided by the facility dated [DATE] documented at approximately 8:15 am, ADON received a call from the second floor requesting immediate attention to Resident #1. DON and ADON responded with with AED (automated external defibrillator) as Resident #1 was a full code. Enroute to the room a "code blue" was called overhead alerting all staff. Upon entrance to the room, Resident #1 had no pulse and no respirations. Her skin was cool and extremities flaccid. Her feet had started to mottle. Sternal rub was attempted to no avail. Pupils were fixed. It was determined that the resident had expired prior to discovery and resuscitation would be fruitless. Time of death called at 8:24 am, after which time family, MD, hospital REMO (Regional Emergency Medical Organization) doctor, Sheriff's office and medical examiner were notified. During an interview on [DATE] at 3:30 pm the Occupational Therapy Student stated that she usually arrived to the facility around 6:30 am. She stated Resident #1's roommate was the first resident she would go to see in the morning. She stated she was not exactly sure what time she was in the room, but when she went in she walked by Resident #1. She stated at that time Resident #1 appeared to be sleeping in bed comfortably. During an interview on [DATE] at 11:00 am CNA #1 stated that CNA #2 came to her and stated Resident #1 did not look right. CNA #1 stated at that time she did not hesitate and called a Code Blue over the intercom to get help. She stated the DON and Assistant DON (ADON) were the first to respond to the code. She stated she saw them listening for a pulse and then the DON stated Resident #1 was gone and pronounced her at 8:24 am. She stated all of the staff were waiting for them to start performing CPR, but they did not. She stated she asked if she should call an ambulance and was told no. She further stated Resident #1 could not have been gone long, and she did not understand why CPR was not initiated, as that went against everything they have been taught. During an interview on [DATE] at 12:00 pm CNA #2 stated that Therapy was in Resident #1's room around 7:40 am getting Resident #1's roommate up. CNA #2 stated she had not entered Resident #1's room until about 8:00 am as she was confused and did not realize Resident #1 was on her assignment. She stated she was going to get the resident up and ready for an appointment. She stated she was trying to wake Resident #1 up, she was shaking her and she was not responding. She stated she alerted CNA #3 and they left the resident's room to get more help. She stated everyone was saying Resident #1 was a full code and she was surprised CPR was not performed. She stated she did not think they would have been able to bring Resident #1 back but her order was to perform CPR and they did not follow Resident #1's order. During an interview on [DATE] at 1:50 pm CNA #3 stated that CNA #2 came to her and stated Resident #1 would not wake up. CNA #3 stated Resident #1 was unresponsive and they called a code. She stated she got out of the way at that time as staff was coming in with equipment. She stated she did not know who saw Resident #1 last, however they do complete walking rounds at the beginning of the shift. She further stated people were questioning what had happened, but she did not want to get involved. During an interview on [DATE] at 2:00 pm CNA #4 stated she had taken care of Resident #1 on the ,[DATE] shift. She stated she worked for the agency but was familiar with Resident #1. She stated she had asked Resident #1 if she needed to use the bathroom around 6:30 am. She stated Resident #1 stated she was fine and did not need to use the toilet. CNA #4 further stated that Resident #1 seemed okay and was not any different than usual on her shift. During an interview on [DATE] at 10:35 am Licensed Practical Nurse (LPN) #1 stated that she assisted in bringing the crash cart to Resident #1's room when the code was called. She stated when she arrived the DON and ADON were already in Resident #1's room. She stated you could not tell how long the resident had been gone, that there were no obvious signs observed to make this determination. She stated she did not understand why CPR was not done as Resident #1 wanted to be resuscitated and not performing CPR went against everything she was ever taught. During an interview on [DATE] at 10:45 am RN #1 stated that when he arrived to Resident #1's room the DON and ADON were already in the room. He stated he was told Resident #1 was already gone and they did not need his assistance. He stated he touched the resident and she was not really cold, but not really warm. He stated he did not know what happened prior to his arrival, however if he was the first responder to the room he would have initiated CPR as "that's what we have to do." During an interview on [DATE] at 11:30 am RN #2 stated that she assisted in bringing the crash cart to Resident #1's room when the code was called. She stated the DON and ADON were already in Resident #1's room upon her arrival. She stated they told her the resident was gone and they did not need her help. She stated she did not know if they had initiated CPR before her arrival or not. She stated the only reason you would not initiate CPR was if the resident was a "do not resuscitate" (DNR). She further stated that was the point of CPR, when you found someone without a pulse or respirations you should initiate CPR in attempt to revive them. During an interview on [DATE] at 11:26 am the Physician stated the facility called him to let him know that Resident #1 had been found stiff, cold, and mottled. He stated they said she was "far gone," two hours or more, and there was no point to do CPR. He stated he had recently spoken to the resident about Hospice services, as her condition was terminal, however she did not want Hospice and she did not want to be a DNR despite this. During an interview on [DATE] at 10:25 am the ADON stated that she had received a phone call from the CNA that Resident #1 did not look right. She stated upon her arrival, the resident was cold, did not respond, was flaccid, and her feet were mottled. She stated they did not initiate CPR as Resident #1 was already gone. During an interview on [DATE] at 10:00 am the DON stated Resident #1 was a full code, so when she responded she grabbed the AED and told staff to call 911. She stated when she arrived to the room the resident was cold, had no pulse or respirations. She stated the resident had expired so she felt performing CPR would be pointless. She pronounced the resident and stated she canceled the call to 911. She stated they did not complete a "Code Blue" flow sheet as they never initiated CPR. She stated when she contacted the hospital REMO and informed the MD of the resident's passing, she was advised to call the Sheriff's department and the coroner. She stated a County Investigator came in, she was told this was protocol, and reviewed the incident and gave permission to release the body. 10 NYCRR 415.12

Based on medical record review and staff interviews during an abbreviated survey (Case #NY 499) it was determined that the facility did not ensure that a resident having pressure sores receives necessary treatment and services to prevent avoidable sores from developing. Specifically for one (#1) of three residents reviewed, the facility did not ensure the resident was assessed as a high risk for pressure ulcer development, did not initiate a care plan with interventions and goals that addressed the risk factor of a [MEDICAL CONDITION]. Then after the resident developed active pressure ulcers the care plan was not revised. Additionally, there was no documented evidence that a registered dietician and the physical therapist were notified when the resident experienced pressure ulcers. The development of numerous unstageable pressure ulcers resulted in actual harm to Resident #1 which 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 assessed the resident had moderately impaired cognition on 1/19/13. The facility policy titled "Pressure Ulcer Management & Treatment" dated 6/2011, documented "If a pressure ulcer develops or a resident is admitted with pressure ulcers, the comprehensive care plan (CCP) team will immediately and aggressively treat the ulcer using established protocols. Weekly rounds on all residents with pressure ulcers will be completed; all resident will be assessed on admission using the Braden scale; The admission assessment will assist in identifying pre-existing signs of deep tissue damage which could lead to an unavoidable Stage III or IV pressure ulcer, or the progression of a Stage I pressure ulcer to an ulcer with eschar or exudate within days after admission." The "Pressure Ulcer Treatment Protocol" documented for pressure relief use rehabilitation interventions and to notify the Dietician for a nutritional consult. The Comprehensive Care Plan (CCP) dated 11/16/12 and titled "Resident is at risk for pressure ulcer development" due to diabetes, incontinence and obesity documented the following interventions; inspect skin with morning and afternoon care; identify, report, & intervene for any high risk area; pressure relief/wheelchair cushion; monitor intake and nutritional status; provide nutritional supplementation as ordered, skin checks every two hours; skin barrier cream; monitor labs as ordered. There was no evidence of preventative measure ie off loaded heels or turning and positioning. The physician progress notes [REDACTED]. The facility form titled "Braden Scale for Predicting Pressure Ulcer Risk" (undated) documented that the assessment should be completed upon admission, weekly for four weeks then quarterly and as needed. A care plan for each risk factor identified should be developed. Additionally, it documented that if the resident has any contributing factors, care plan for high risk regardless of the Braden Scale. Examples documented included recent hospitalization , diabetes and obesity. A pressure ulcer risk assessment dated [DATE] documented the resident had a score of 16 (indicating moderate risk for pressure ulcers). Nurse's notes dated 11/9/12 documented at 1:30 pm that the resident's skin was intact except for a hip (surgical) incision with staples and bruises noted to his arms. No contributing factors were documented. A facility form titled "Skin Observation" dated 11/9/12 documented that the resident was at risk for pressure ulcers. A facility form titled "Weekly Skin Check" dated 11/20/12 and 11/27/12 did not contain any documentation regarding the resident's skin. The forms were signed by the Licensed Practical Nurse (LPN) and the Certified Nursing Assistant (CNA). The weekly skin check forms dated 12/11/12 , 12/18/12 and 1/8/13 did not contain any documentation regarding the resident's skin. All were signed only by the CNA. The weekly skin check dated 1/18/13 documented no new issues, and did not include any documentation on the form regarding the condition of the skin. It was signed by the CNA and the LPN. The weekly skin check dated 1/24/13 documented dressing to the ischial was changed. There was no specific information on the form regarding the condition of the skin. The form was signed by the CNA and the LPN. There was no additional documentation regarding weekly skin checks. The Caregiver Activities of Daily Living (ADL) Card (which provided information about the care the resident was to receive) dated 11/19/12, documented under the section titled "Skin Care" diabetic foot care and lotion everywhere. The resident required 2 assist for bed mobility and was frequently incontinent of bowel and bladder. Under the section titled equipment/devices "foam cushion" was documented. There were no preventative interventions ie heels off loaded and turning and positioning, to prevent avoidable pressure sores. The facility form titled "Weekly Wound Surveillance Report" documented on 1/11/13 a Stage II, two by two centimeters (cm) was noted to the posterior thigh, 50% granulation and 50% necrotic tissue Santyl ointment (an active enzymatic therapy that continuously removes necrotic tissue from wounds at the microscopic level) was applied. ( There was no physicians order until 1/24/13 for the Santyl) The Treatment Administration Record (TAR) for 11/9/12 through 11/23/12, documented skin prep to bilateral heels every shift. There was no further orders for the heels. The TAR for January 2013 documented [MEDICATION NAME] to the posterior left thigh after cleansing with wound cleanser, change every three days. It was documented that it was completed on 1/9 and 1/14/13. There was no additional documentation. The TAR for January 2013 documented Santyl ointment apply to ischial fold after cleansing with wound cleanser, cover with a four by four border gauze; change every shift. Nurse's notes date 1/1/13 at 11:00 pm documented that the resident oral intake was poor. Nurse's notes date 1/5/13 documented that the resident had a urinary tract infection and a new order was received for [MEDICATION NAME] (antibiotic) twice a day for seven days. Nurse's notes dated 1/6/13 at 11:00 pm documented the resident had skin issues. Left heel dark area 2.5 cm. Resident has an open area at the top of left thigh where it meets the buttock, 2 cm. in length and an open area 1.5 cm on base of scrotum. Barrier cream applied and heel coated with skin prep. Physician to be notified. Nurse's notes dated 1/8/13 at 4:10 am documented new orders received: [MEDICATION NAME] to posterior left thigh after cleansing with wound cleaner, change every three days. Cleanse scrotum with wound cleanser, apply A&D ointment every shift until healed. Skin prep to bilateral heels every shift. Nurse's notes dated 1/24/13 at 9:45 pm documented the treatment to the left ischial fold was changed to Santyl with border gauze every shift after cleansing with wound cleaner. Supervisor was made aware. Nurse's notes dated 1/31/13 documented at 10:00 pm that the resident White Blood Count (WBC) was 24.2 (normal 5,000 to 10,000) (elevated WBC indicates infection) Blood Urea Nitrogen (BUN) was 69 (normal 10-20) (elevated BUN indicated dehydration) and that the resident was transferred to the hospital. Review of the hospital medical record dated 2/12/13 documented that the resident was admitted with sacral and coccyx pressure ulcers Stage IV and left buttock ulcer, present on admission, requiring debridement. Right and left heels were noted with eschar (dead tissue). The Registered Dietician (RD) was interviewed on 2/21/13 at 2:00 pm and stated she was not aware of any pressure ulcers until the resident was readmitted from the hospital on [DATE]. The RD stated she would have expected to be notified when the pressure ulcers were first identified. The Registered Nurse supervisor (RNS) was interviewed on 2/21/13 at 4:00 pm and stated she was unsure when she first was made aware of the pressure ulcers. The RNS stated she completed the initial skin assessment when the resident was admitted . She stated she never did complete a care plan for the resident, and was unsure what happened after the resident went to another unit on 1/9/13. The RNS stated she did not know why there was lack of documentation regarding the resident's skin condition. The Physical Therapist (PT) was interviewed on 2/21/13 at 4:30 pm and stated she had no record of communication regarding skin integrity for the resident. Normally, if notified,PT would evaluate the residents devices that were in place to determine if they were adequate. 10 NYCRR 415.12 (c)(1)(2)

Based on medical record review and interviews during a partial extended abbreviated survey (Case #NY 726) it was determined that the facility failed to ensure that the resident has the right to be free from verbal, physical, and mental abuse, and involuntary seclusion. Specifically, multiple staff witnessed abuse and involuntary seclusion bt another staff member for Resident 31 and staff also witnessed abuse for Resident #4. This resulted in Immediate Jeopardy to residents' health and safety and Substandard Quality of Care for Resident #1 and Resident #4. This is evidenced by the following: 1. Resident #1: The resident was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident to have severe cognitive impairment. The facility policy titled "Resident Abuse Prevention and Reporting" dated 5/2011, documented that it is the responsibility of every employee, agency staff member and private duty personnel working at the facility who has first hand knowledge to report their observation or knowledge to their supervisor immediately. All supervisors are required to assure that an incident/accident report if filled out, that notification is made to the facility administration and that appropriate action is taken. Failure to report suspected abuse is considered a serious job performance infraction. All facility personnel are obligated to report and failure to do so will result in disciplinary action. If it is determined that an employee knew of abuse or suspected abuse was occurring and they failed to report it, the employee will be suspended and investigation into the employee's conduct regarding the case will be made. The potential outcome of a failure to report abuse is the continued abuse of a resident. Therefore, failure to report is a form of abuse in and of itself. As a result, discipline applied in response to sustained cases of failure to report may include termination and notification to the Department of Health, as well as any applicable certification and or licensing agency. The administrator or designee shall see that each reported incident and accident is investigated and appropriate individuals and agencies are notified. Furthermore, the administrator or designee shall see that findings from all investigations are analyzed and discussed at the Quality of Improvement Committee. A facility form titled "Investigation Summary" dated 8/22/12 for the 11:00 pm to 7:00 am shift, documented that on 8/22/12 at 11:00 pm the Registered Nurse (RN) night supervisor was seen pulling the resident into his room. Then the RN supervisor held the door closed so he could not exit his room. Later in the shift the resident attempted to exit his room and was pushed by the same RN supervisor. Under the section titled "Investigation Summary" it was documented that the RN night supervisor was on administrative leave for three days pending the investigation, received additional education on dealing with residents with dementia and was re-inserviced on reporting requirements. This form was signed by the Director of Nursing (DON) and the Administrator on 8/27/12. It was also documented that this was not reported to the state health department. Review of a facility form titled "Witness Statement of Occurrence" the RN evening supervisor documented that on 8/22/12 at approximately 11:00 pm she observed the RN night supervisor pulling the resident by his arms, trying to get the resident into his room. The RN night supervisor told the RN evening supervisor that the resident had to stay in his room on the night shift. Review of a facility form titled "Witness Statement of Occurrence" Licensed Practical Nurse #1 (LPN #1) documented that on 8/23/12 during the night shift, at approximately 4:00 am the resident wanted to leave his room and the RN supervisor spoke to the resident in a gruff and intimidating way. The RN supervisor then put both of her hands on the resident's forearms and pushed the resident backwards into his room, telling him to give up because he wasn't going to win. This action was repeated three times. The RN supervisor also held on to the door knob so he couldn't get out. LPN #1 documented that she questioned the RN supervisor about her behavior and the RN supervisor responded she was going to keep doing this until the facility installed cameras. Review of a facility form titled "Witness Statement of Occurrence" LPN #2 (evening LPN) documented that on 8/22/12 (untimed) the RN night supervisor told the resident that it was late and he had to go to his room. The RN night supervisor then physically escorted him by pulling his arm into his room. Review of a facility form titled "Witness Statement of Occurrence" LPN #3 (night LPN) documented that on 8/23/12 on the 11:00 pm to 7:00 am shift the RN night supervisor pushed the resident into his room. LPN #3 documented that she has seen the RN night supervisor on several occasions holding the door handle so the resident could not get out of his room. The RN night supervisor reportedly then told staff not to go into the resident's room, even if his alarm was sounding. LPN #3 documented that the RN night supervisor stated the resident is "not going to be in my hallways, period." LPN #3 documented she had reported this to other nurses regarding the resident's safety and the physical forcing of the resident. The DON and the Administrator were interviewed on 8/30/12 at approximately 9:15 am and stated that there were no recent incidents of abuse. The DON then stated there was an allegation, but it was unfounded. The RN Nurse Manager (RN/NM) was interviewed on 8/30/12 at approximately 12:45 pm and stated on 8/23/12 at approximately 3:00 pm the RN evening supervisor reported to her that the evening before, on 8/22/12 at 11:00 pm, she had witnessed the RN night supervisor pulling the resident, who then resisted, and she pulled the resident harder. The RN night supervisor then held the door to the resident's room. The RN/NM asked the RN evening supervisor what she did, who responded "nothing." The RN/NM stated she then called the DON. The RN/NM said she was not comfortable with the RN evening supervisor not initiating something as soon as she saw the RN night supervisor pulling the resident. The RN/NM also stated that LPN #1 stated to her that she had witnessed the RN night supervisor pulling the resident by his arm into his room and held the door shut. The RN/NM stated that she told LPN #1 she was investigating. The RN/NM stated about ten minutes later CNA #1 came to her and reported that the evening before the RN night supervisor was rough with the resident and the CNA was uncomfortable working with that RN supervisor. The RN/NM stated that the DON told her that the RN night supervisor would hold the resident's door shut to keep the resident in his room. The RN/NM stated that the DON told her that any one of the staff could have called her regarding the RN night supervisor, but none of the staff reported to her. The RN evening supervisor was interviewed on 8/30/12 at 3:00 pm who stated on 8/22/12 at approximately 11:00 pm she saw the RN night supervisor pulling the resident into his room and the RN night supervisor stated "I want him in his room." The RN evening supervisor stated that other staff members came to her on 8/23/12 with concerns regarding the RN night supervisor and her actions with the resident, and she told them to and report to the DON. The facility Administrator was interviewed on 8/30/12 at approximately 6:45 pm and stated he was not aware of any abusive incident and if he had been made aware he would have investigated and reported it. The DON was interviewed on 8/30/12 at approximately 7:00 pm and stated she had no additional information or documentation to support her investigation of why the RN night supervisor was not causing the resident to be involuntarily secluded. The DON stated she thought it was a witch hunt against the RN night supervisor. Resident #4: The resident was admitted to the facility with [DIAGNOSES REDACTED]. The nursing admission note assessed the resident to be alert and oriented, capable of making needs known. The resident was noted to be very hard of hearing. The CCP titled "Alteration in Cardiac status" documented approaches included low fat diet, blood work and medication as ordered. Physician orders [REDACTED].) ([MEDICATION NAME]) under the tongue every five minutes for chest pain as needed and [MEDICATION NAME] 5 mg (sedative) twice a day as needed. Nurse's notes dated 7/16/12 at 1:45 am by the RN night supervisor, documented that the resident complained of not feeling well, with pain/tingling in the upper extremities. The resident was given a NTG with good effect. Anxiety increased related to shortness of breath. The resident was also medicated with [MEDICATION NAME]. During an interview on 8/30 pm at 12:45 pm the RN/NM stated three staff members had complained about the "gruff" way the RN night supervisor dealt with residents. This information was reported to the DON. During an interview on 8/30/12 at 1:00 pm LPN #4 stated the RN night supervisor was notified that the resident complained of chest pain. LPN #4 stated that the RN night supervisor started asking the resident questions in a demeaning manner when the resident asked for a Nitro for chest pain. The resident pointed her finger at the RN night supervisor, and called her a "[***] ." The RN night supervisor got angry and annoyed. The RN night supervisor told the resident "I'll be the judge of when you need Nitro & when you don't." LPN #4 stated she reported this to the RN/NM and the DON. During an interview on 8/30/12 at 7:00pm the DON stated she was unaware of this incident. During an interview on 9/4/12 at 4:00 pm the resident's daughter stated her mother had complained to her that she had a difficult time getting a Nitro for chest pain from the RN night supervisor, during the night, while at the facility. 10 NYCRR 415.4(b)(1)(i)

Based on medical record review and interviews during an partial extended abbreviated survey (Case #NY 726) it was determined that the Administrator failed to ensure that the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, the Administration failed to ensure that verbal, mental or physical abuse, or involuntary seclusion were not occurring. The Administration failed to produce evidence that all allegations of abuse were thoroughly investigated and reported to the NYSDOH for three (Resident #'s 1, 2 & 4 ) of eight residents reviewed. The Administration failed to protect the residents from exposure to the alleged perpetrator. This resulted in Immediate Jeopardy to the health and safety of the residents. This is evidenced by the following: F 223- Abuse- scope and severity -L F 225- Abuse scope and severity -L Resident #1: The DON and the Administrator were interviewed on 8/30/12 at approximately 9:15 am and stated that there were no recent incidents of abuse. The DON then stated there was an allegation, but it was unfounded. The RN Nurse Manager (RN/NM) was interviewed on 8/30/12 at approximately 12:45 pm and stated on 8/23/12 at approximately 3:00 pm the RN evening supervisor reported to her that the evening before, on 8/22/12 at 11:00 pm, she had witnessed the RN night supervisor pulling the resident, who then resisted, and she pulled the resident harder. The RN night supervisor then held the door to the resident's room. The RN/NM asked the RN evening supervisor what she did, who responded "nothing." The RN/NM stated she then called the DON. The RN/NM said she was not comfortable with the RN evening supervisor not initiating something as soon as she saw the RN night supervisor pulling the resident. The facility Administrator was interviewed on 8/30/12 at approximately 6:45 pm and stated he was not aware of any abusive incident and if he had been made aware he would have investigated and reported it. The DON was interviewed on 8/30/12 at approximately 7:00 pm and stated she had no additional information or documentation to support her investigation of why the RN night supervisor was not causing the resident to be involuntarily secluded. The DON stated she thought it was a witch hunt against the RN night supervisor. Resident #2 During an interview on 8/30/12 at 9:15 am the DON stated there had not been any elopement incidents. However, there was an incident where a resident signed out against medical advise (AMA). The DON stated that this incident had not been reported to the NYSDOH. During an interview on 8/30/12 at approximately 12:45 pm the RN/NM stated that she had received concerns from LPN #4 regarding the way the RN night supervisor dealt with the resident. LPN #4 told the RN/NM that she had reported these concerns to the DON. During an interview on 8/30/12 at 7:00 pm the DON stated that there was no additional information regarding the resident's elopement & AMA. She stated she heard "generalizations" about the RN night supervisor but had nothing concrete. Resident #4 During an interview on 8/30/12 at 12:45 pm the RN/NM stated three staff members had complained about the "gruff" way the RN night supervisor dealt with residents. This information was reported to the DON. 10NYCRR 415.26

Based on interviews and medical record review during a partial extended abbreviated survey (Case # NY 726), it was determined the facility failed to produce evidence that all allegations of abuse were thoroughly investigated, failed to ensure that all alleged violations involving mistreatment, neglect, or abuse, were reported immediately to the administrator of the facility and to other officials in accordance with State law for three (Resident #'s 1, 2 & 4 ) of eight residents reviewed. Specifically, Resident #1 was being kept in his room during the night shift by the Registered Nurse (RN) supervisor which was reported by multiple staff in the facility. Resident #2 had eloped from the facility and was returned by the police. When returned the RN night supervisor was verbally intimidating to the resident and intimidated the resident to sign out against medical advice. Resident #4 complained of chest pain and requested medication. The RN night supervisor told the resident in an intimidating manner, that only she would determine if she had chest pain warranting medication. This is a repeat deficiency from the standard recertification survey of 3/17/12. This resulted in Immediate Jeopardy to residents health and safety and Substandard Quality of Care for the residents. This is evidenced by: The facility policy titled "Resident Abuse Prevention and Reporting" dated 5/2011, documented that it is the responsibility of every employee, agency staff member and private duty personnel working at the facility who has first hand knowledge to report their observation or knowledge to their supervisor immediately. All supervisors are required to assure that an incident/accident report if filled out, that notification is made to the facility administration and that appropriate action is taken. Failure to report suspected abuse is considered a serious job performance infraction. All facility personnel are obligated to report and failure to do so will result in disciplinary action. If it is determined that an employee knew of abuse or suspected abuse was occurring and they failed to report it, the employee will be suspended and investigation into the employee's conduct regarding the case will be made. The potential outcome of a failure to report abuse is the continued abuse of a resident. Therefore, failure to report is a form of abuse in and of itself. As a result, discipline applied in response to sustained cases of failure to report may include termination and notification to the Department of Health, as well as any applicable certification and or licensing agency. 1. Resident #1: The resident was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident to have severe cognitive impairment. A facility form titled "Investigation Summary" dated 8/22/12 for the 11:00 pm to 7:00 am shift, documented that on 8/22/12 at 11:00 pm the Registered Nurse (RN) night supervisor was seen pulling the resident into his room. The RN supervisor held the door closed so he could not exit his room. Later in the shift the resident attempted to exit his room and was pushed by the same RN night supervisor. Under the section titled "Investigation Summary" it was documented that the RN night supervisor was on administrative leave for three days pending the investigation, received additional education on dealing with resident with dementia and was re-inserviced on reporting requirements. This form was signed by the DON and the Administrator on 8/27/12. It was also documented that this was not reported to the state health department. A facility form titled "Witness Statement of Occurrence" the RN evening supervisor documented that on 8/22/12 at approximately 11:00 pm she observed the RN night supervisor pulling the resident by his arms, trying to get the resident into his room. The RN night supervisor told the RN evening supervisor that the resident had to stay in his room on the night shift. A facility form titled "Witness Statement of Occurrence" Licensed Practical Nurse #1 (LPN #1) documented that on 8/23/12 during the night shift, at approximately 4:00 am the resident wanted to leave his room and the RN supervisor spoke to the resident in a gruff and intimidating way. The RN night supervisor then put both of her hands on the resident's forearms and pushed the resident backwards into his room, telling him to give up because he wasn't going to win. This action was repeated three times. The RN supervisor also held on to the door knob so he couldn't get out. LPN #1 documented that she questioned the RN supervisor about her behavior and the RN supervisor responded she was going to keep doing this until the facility installed cameras. A facility form titled "Witness Statement of Occurrence" LPN #2 (evening LPN) documented that on 8/22/12 (untimed) the RN night supervisor told the resident that it was late and he had to go to his room. The RN night supervisor then physically escorted him by pulling his arm into his room. A facility form titled "Witness Statement of Ocurrence" LPN #3 (night LPN) documented that on 8/23/12 on the 11:00 pm to 7:00 am shift the RN night supervisor pushed the resident into his room. LPN #3 documented that she has seen the RN night supervisor on several occasions holding the door handle so the resident could not get out of his room. The RN night supervisor reportedly then told staff not to go into the resident's room, even if his alarm was sounding. LPN #3 documented that the RN night supervisor stated the resident is "not going to be in my hallways, period." LPN #3 documented she had reported this to other nurses regarding the resident's safety and the physical forcing of the resident. The DON and the Administrator were interviewed on 8/30/12 at approximately 9:15 am and stated that there were no recent incidents of abuse. The DON then stated there was an allegation, but it was unfounded. During an interview on 8/30/12 at approximately 12:45 pm the RN/NM stated on 8/23/12 at approximately 3:00 pm the RN evening supervisor reported to her that the evening before, on 8/22/12 at 11:00 pm, she had witnessed the RN night supervisor pulling the resident, who then resisted, and she pulled the resident harder. The RN night supervisor then held the door to the resident's room. The RN/NM asked the RN evening supervisor what she did, who responded "nothing." The RN/NM stated she then called the DON. The RN/NM said she was not comfortable with the RN evening supervisor not initiating something as soon as she saw the RN night supervisor pulling the resident. The RN/NM also stated that LPN #1 stated to her that she had witnessed the RN night supervisor pulling the resident by his arm into his room and held the door shut. The RN/NM stated that she told LPN #1 she was investigating. The RN/NM stated about ten minutes later CNA #1 came to her and reported that the evening before the RN night supervisor was rough with the resident and the CNA was uncomfortable working with that RN supervisor. The RN/NM stated that the DON told her that the RN night supervisor would hold the resident's door shut to keep the resident in his room. The RN/NM stated that the DON told her that any one of the staff could have called her regarding the RN night supervisor, but none of the staff reported to her. During an interview on 8/30/12 at 3:00 pm the RN evening supervisor stated on 8/22/12 at approximately 11:00 pm she saw the RN night supervisor pulling the resident into his room and the RN night supervisor stated "I want him in his room." The RN evening supervisor stated that other staff members came to her on 8/23/12 with concerns regarding the RN night supervisor and her actions with the resident, and she told them to report to the DON. During an interview on 8/30/12 at approximately 6:45 pm the facility Administrator stated he was not aware of any incident and if he had been made aware he would have investigated and reported it. During an interview on 8/30/12 at approximately 7:00 pm the DON stated she had no additional information or documentation to support her investigation of why the RN night supervisor was not causing the resident to be involuntarily secluded. The DON stated she thought it was a witch hunt against the RN night supervisor. 2. Resident #2: The resident was admitted to the facility with [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident to have moderately impaired cognition. A comprehensive care plan (CCP) titled "resident had episodes of resistance to care related to agitation & dementia" dated 3/13/12, documents approaches: assure resident's safety is not in immediate jeopardy, approach in a calm & reassuring manner, reapproach if resident is verbally or physically aggressive, use reasoning but avoid arguing, explain to resident impact of decision when calm, notify physician and social worker as needed, encourage resident to assist in establishing own routine and provide opportunity for choices. A facility form titled "Occurrence Report" dated 7/21/12 at 5:45 am documented that the type of occurrence was an elopement. Under the section titled "description of occurrence" it was documented that the resident was returned to the facility by the police department. Also documented, the police officer stated to the RN night supervisor, that the resident had wanted coffee. Attached to the Occurrence Report were statements from staff who worked that night. During an interview on 8/30/12 at 9:15 am the DON stated there had not been any elopement incidents. However, there was an incident where a resident signed out against medical advise (AMA). The DON stated that this incident had not been reported to the NYSDOH. During an interview on 8/30/12 at 1:00 pm LPN #4 stated that when the resident was brought back to the facility by the police, the RN night supervisor was angry and told the resident she now had a lot of paper work to do because of him. She became intimidating and the resident called her a "[***] ." The RN night supervisor became angry, and intimidated him into signing an AMA. LPN #4 said it was "the RN night supervisor's way or the highway. The resident was pushed out. He signed the AMA paper to save face." LPN #4 stated the two agency aides working that night were very uncomfortable with the way the resident was treated by the night supervisor. She stated she had reported this incident to the DON & the RN/NM. During an interview on 8/30/12 at approximately 12:45 pm the RN/NM stated that she had received concerns from LPN #4 regarding the way the RN night supervisor dealt with the resident. LPN #4 told the RN/NM that she had reported these concerns to the DON. During an interview on 8/30/12 at 7:00 pm the DON stated that there was no additional information regarding the resident's elopement & AMA. She stated she heard "generalizations" about the RN night supervisor but had nothing concrete. Resident #4: The resident was admitted to the facility with [DIAGNOSES REDACTED]. The nursing admission note assessed the resident to be alert and oriented, capable of making needs known. The resident was noted to be very hard of hearing. The CCP titled "Alteration in Cardiac status" documented approaches included low fat diet, blood work and medication as ordered. Physician orders [REDACTED].) ([MEDICATION NAME]) under the tongue every five minutes for chest pain as needed and [MEDICATION NAME] 5 mg (sedative) twice a day as needed. Nurse's notes dated 7/16/12 at 1:45 am by the RN night supervisor, documented that the resident complained of not feeling well, with pain/tingling in the upper extremities. The resident was given a NTG with good effect. Anxiety increased related to shortness of breath. The resident was also medicated with [MEDICATION NAME]. During an interview on 8/30/12 at 12:45 pm the RN/NM stated three staff members had complained about the "gruff" way the RN night supervisor dealt with residents. This information was reported to the DON. During an interview on 8/30/12 at 1:00 pm LPN #4 stated the RN night supervisor was notified that the resident complained of chest pain. LPN #4 stated that the RN night supervisor started asking the resident questions in a demeaning manner when the resident asked for a Nitro for chest pain. The resident pointed her finger at the RN night supervisor, and called her a "[***] ." The RN night supervisor got angry and annoyed. The RN night supervisor told the resident "I'll be the judge of when you need Nitro & when you don't." LPN #4 stated she reported this to the RN/NM and the DON. During an interview on 8/30/12 at 7:00pm the DON stated she was unaware of this incident. During an interview on 9/4/12 at 4:00 pm the resident's daughter stated her mother had complained to her that she had a difficult time getting a Nitro for chest pain from the RN night supervisor, during the night, while at the facility. 10 NYCRR 415.4 (b)(1)(ii)