Palatine Nursing Home

Based on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure a resident was assessed by the interdisciplinary team to determine a resident's ability to safely administer their own medications if clinically appropriate for one (1) (Resident #49) of 22 residents reviewed. Specifically, Resident #49 was observed self-administering insulin without an interdisciplinary team assessment, care plan or physician order. In addition, Licensed Practical Nurse #2 provided wrong instructions when Resident #49 looked to them for directions.This is evidenced by:The facility's Policy and Procedure titled, Self-Administration of Medication, undated, documented the purpose is to provide a standardized process for evaluating, approving, and monitoring resident self-administration of medications, supporting resident independence while ensuring safety and regulatory compliance. The facility may permit residents to self-administer medications when the interdisciplinary team (IDT) determines it is safe and clinically appropriate. The facility retains responsibility for oversight, storage safety, and documentation of all medications self-administered.Eligibility & Assessment:1. A comprehensive assessment must be completed prior to approval, evaluating:o Cognitive ability and judgmento Physical ability (vision, dexterity, mobility)o Understanding of medication regimeno Ability to safely store medications2. The Registered Nurse and Interdisciplinary team must document all findings in the electronic medical record.3. The attending physician/Nurse Practitioner must provide a written order authorizing self-administration.1. Provider order must specify:o Medications approved for self-administrationo Required supervision level (independent, cueing, partial assist)o Storage requirements2. The resident's care plan must reflect self-administration goals, education, and monitoring intervals.Nursing staff must educate the residents on: Medication name, purpose, dose, route, frequency Possible side effects and when to report symptoms Safe handling and infection-control principles Facility-approved medication storage methods Education must be documented. Resident #49 was admitted to the facility with a diagnoses of alcoholic cirrhosis of liver (permanent scarring that damages your liver related to alcohol use), type 2 diabetes mellitus (where the pancreas cannot make or fail to use insulin properly and eventual insulin deficiency) and gait abnormality (difficulty walking). The Minimum Data Set (an assessment tool) dated 07/21/2025 documented the resident usually could understand and was understood by others with intact cognition.The Comprehensive Care Plan for Resident #49 last revised, 10/17/2025 did not have documented evidence of a focus, goal and or intervention for resident to self-administer medication.The Medication Administration Report for Resident #49 dated January 2026 documented give FlexPen Subcutaneous Solution Pen, injector 100 Unit/ml (Insulin Aspart) Inject 12 units subcutaneously before meals for diabetes. Start date 11/19/2025 at 4:30 PM.The Physician orders for Resident #49 documented FlexPen Subcutaneous Solution Pen, injector 100 Unit/ml (Insulin Aspart) Inject 12 units subcutaneously before meals for diabetes. There was no documented evidence of physician order for Resident #49 to self-administer their medications.There was no documented evidence of assessments by the interdisciplinary team for Resident #49 to self-administer medications.During an observation on 1/20/2026 at 11:30 AM, Licensed Practical Nurse #2 stated Resident #49 was to self-administer their medication in preparation for discharge to home. Licensed Practical Nurse #2 entered Resident #49's room and handed them Insulin Aspart Flex Pen and told them to administer 12 units. During an interview on 1/20/2026 at 12:13PM, Director of Nursing #1 stated Resident #49 self-administer their medications. The nursing staff had been observing resident self-administer in preparation for discharge home. Director of Nursing #1 stated prior to self-administering medications the resident would be assessed for capacity by a multidisciplinary team, a physician writes order to self-administer medication and care plan updated to reflect resident could self-administer medications. The resident would be educated and nurse observing resident documents observation. Director of Nursing #1 was unable to locate any documentation of a physician order, assessment by interdisciplinary team and or care plan for Resident #49 to self-administer medications. 10 New York Code Rules and Regulations 415.3(e)(1)(vi)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during a recertification and abbreviated survey (Case #s777608, 777666, and 777668), the facility did not ensure that alleged violations involving abuse, were reported immediately, but not later than two (2) hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to officials (including to the State Agency). Additionally, the facility did not ensure a report of the results of all investigations were submitted to the State Agency, within five (5) working days of the incident, in accordance with State law for four (4) (Residents # 58, 76, 78. and 80) of five (5) residents reviewed for abuse. Specifically, (a.) for Resident #58 and 76, a resident-to-resident abuse incident occurred on 02/09/2025 at 18:15 PM and was not reported to the New York State Department of Health until 02/10/2025 at 15:53 PM and the investigation report was not submitted until 02/20/2025; (b.) Resident #78 and 80 allegations of physical abuse were investigated by facility staff and not reported to the New York State Department of Health.This is evidenced by:The Facility Policy titled, Resident Abuse was last reviewed 1/2026 and documented, it is the responsibility of any employee of this facility to report any case of suspected abuse, neglect, mistreatment and exploitation, including injuries of unknown origin, immediately to the facility Administrator and/or Director of Nursing or to the abuse hotline number. If you have reasonable suspicion that a crime that involved serious bodily injury including criminal sexual abuse, you must report it immediately but no later than 2 hours after forming suspicion.1.Resident #58 was admitted to the facility with diagnoses including dementia (symptoms associated with a decline in cognitive function), anxiety disorder (an overwhelming sense of fear), and depression (persistent feeling of sadness). The Minimum Data Set (an assessment tool) dated 1/16/2025, documented the resident could be understood, could understand others, and had moderate cognitive impairment.Resident #76 was admitted to the facility with diagnoses including dementia, hypoxia (low levels of oxygen), and depression. The Minimum Data Set, dated [DATE], documented the resident could be understood, could understand others, and had severe cognitive impairment.A facility document titled, Incident and Accident Report documented an unwitnessed resident-to-resident altercation took place on 2/09/2025 at 6:15 PM that resulted in Resident #76 having a small cut on their nose, possibly caused by being struck with a broken table by Resident #58. A Nursing Home Incident Submission Report documented the facility submitted a report of the resident-to-resident abuse to the New York State Department of Health on 2/10/2025 at 15:53.The New York State Department of Health Nursing Home Investigative Report Submission form documented the investigation report was submitted on 02/20/2025 at 13:11.2.Resident #78 was admitted to the facility with diagnoses of anxiety disorder, dementia, and atrial fibrillation (irregular heart rhythm). The Minimum Data Set, dated [DATE], documented the resident could usually be understood, could usually understand others and had severely impaired cognition for decisions of daily living.A Progress Note dated 08/17/2024, documented Resident 78's family member reported the resident had been hit by an aide. The Director of Nursing was called for direction; the Administrator and Social Worker were e-mailed.A facility document titled, Internal Investigation, documented that on 08/17/2024 Resident #78 reported an aide was mean and struck them in the stomach. The investigation was completed, and abuse was ruled out.Review of the Internet Quality Improvement & Evaluation System (iQIES) revealed no facility submission related to this incident. 3.Resident #80 was admitted to the facility with diagnoses of dementia, aortic stenosis (narrowing of heart valve opening), and congestive heart failure (heart is unable to pump blood efficiently). The Minimum Data Set, dated [DATE], documented the resident could be understood, could understand others and had intact cognition for decisions of daily living.A Facility Investigative Report dated 08/09/2022 documented that on 08/08/2022 Resident #80 reported a nurse hit them. The investigation was completed with no evidence of abuse found.Review of the Internet Quality Improvement & Evaluation System (iQIES) revealed no facility submission related to this incident.During an interview on 1/22/2026 at 10:50 AM, Administrator #1 stated the previous Director of Nursing was responsible for submitting the reports of abuse, neglect, or mistreatment but they were responsible now. They stated they would first ensure the resident's safety, remove the accused staff and begin an investigation. If it looked like it may be found, then it would be reported to the Department of Health. Administrator #1 stated they were not aware it had to be reported within 2 hours even if it was unfounded or that the complete investigation had to be submitted within 5 days of the allegation. 10 New York Codes, Rules, and Regulations 483.12(c)(1)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during a recertification survey, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for two (2) (Resident's #66 and 67) of 22 residents reviewed. Specifically, Resident 66's continuous tube feed pump was stopped for more than 20 minutes, and Licensed Practical Nurse #2 did not receive instruction from the Medical Provider when Resident #67 gagged or had difficulty swallowing their medications and crushed resident's medication. This is evidenced by: The facility policy titled Medical Practitioner Notification of Change in Condition reviewed/updated on 1/2026, documented the facility would ensure quality of care for all residents by notifying the Primary Care Practitioner or the on- call Practitioner with changes in resident condition to prevent a delay in treatment. Resident #66 Resident #66 was admitted to the facility with diagnoses of acute respiratory failure (lungs cannot release enough oxygen into the blood), type 2 diabetes (an endocrine dysfunction causing unregulated blood glucose levels), and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). The Minimum Data Set (an assessment tool) dated 10/20/2025, documented the resident was moderately cognitively impaired, could be understood and understand others.Resident #66's Comprehensive Care Plan for Tube Feeding initiated 11/25/2025, documented the resident required tube feeding related to dysphagia. Goals included: the resident would maintain adequate nutrition and hydration status as evidenced by weight stable, no signs or symptoms of malnutrition or dehydration through review date and the resident would remain free of side effects or complications related to tube feeding through next review date. Some interventions included: monitor/document/report as needed any signs of symptoms of aspiration, fever, shortness of breath, tube dislodged, infection at tube site, self-extubating tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pian, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydrationA Physician Order dated 11/25/2025 at 6:00 AM, documented enteral feed order every shift enteral nutrition via continuous: novasource renal amount:40 cubic centimeters per hour via gastrostomy tube (G-tube).During an observation on 1/04/2026 at 12:45 PM, Resident #66 was observed in bed and their tube feed pump was stopped with an error message and alarm sounding for more than 10 minutes. Call light was put on and there was no response for another 10 minutes. Surveyor then found a staff member and alerted them that the pump needed attention. Resident #67Resident #67 was admitted to the facility with diagnoses of Wernicke's Encephalopathy (a severe, acute neurological condition caused by a critical deficiency of thiamin (vitamin B1), dementia (a group of conditions that cause a progressive decline in cognitive abilities), and adult failure to thrive (a geriatric syndrome characterized by complex multi-factorial decline in physical, mental, and functional health). The Minimum Data Set, dated [DATE], documented the resident was usually understood , usually understand others, and had severe cognitive impairment. A nursing progress note dated 7/16/2025 at 2:31 PM written by Registered Nurse #1, documented Resident #67 appeared weak and continued to refuse food. The Nurse Practitioner was made aware and ordered clysis (a safe method of delivering fluids into the subcutaneous fatty tissue). It further documented that they spoke with the resident's representative and Resident #67's Medical Orders for Life Sustaining Treatment (MOLST) was changed to Do Not Resuscitate (DNR), Do Not Intubate (DNI), Comfort Care, no feeding tube, no dialysis, use antibiotics, intravenous fluids, and send to the hospital if pain cannot be controlled. A nursing progress note dated 7/25/2025 at 6:10 PM written by Registered Nurse #1, documented lab results were reviewed with the Nurse Practitioner and new orders were obtained for Cipro, Flagyl, and probiotic for colitis. Resident #67's appetite remained poor and fluids were encouraged. They required extensive assistance for activities of daily living, were dependent on toileting, and refused to get out of bed. A nursing progress note dated 7/26/2025 at 10:02 PM written by Licensed Practical Nurse #2, documented Resident #67 started gagging when medications were put in their mouth and the resident spit them out. If further documented that Licensed Practical Nurse #2 crushed the resident's medication and reattempted to give them to the resident. Resident #67 started gagging and brought them back up.There was no documented evidence that Licensed Practical Nurse #2 received instruction from the medical provider to crush the resident's medications on 7/26/2025. There was not documented evidence that the Medical Provider was informed of Resident #67's gagging or swallowing difficulties when taking their medications on 7/26/2025.During an interview on 1/21/2025 at 12:13 PM, Nurse Practitioner #1 stated the facility would normally contact them if a medication was not administered or if a resident refused a medication.During an interview on 01/22/2026 at 11:23 AM, Licensed Practical Nurse #2 stated if a resident gagged on their medications, they would first get the medications out of the resident's mouth, then call the Medical Provider for any recommendations. They stated the Medical Provider might recommend crushing the medications. Licensed Practical Nurse #2 further stated they would never crush medication without a physician's order, because certain medication could not be crushed. During an interview on 1/20/2026 at 12:13PM, Director of Nursing #1 stated certified nurse aides are not licensed to monitor tube feeds and the Licensed Practical Nurse should have monitored the tube feed infusion.During an interview on 1/22/2026 at 11:12 AM, Director of Nursing #1 stated if a resident gagged on pills or had difficulty swallowing pills, they would hold the medication and contact the Medical Provider. They would also contact the pharmacy to see if the medications could be crushed or if they could come in a different format. They stated the Medical Provider would let them know how to proceed. Director of Nursing #1 stated that if a resident was nearing end of life, they would follow the same process. The Medical Provider might transition the resident to comfort medications at that point. 10 New York Codes, Rules and Regulations 415.12

Based on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed 5% for four (4) (Resident #s 36, 49, 56 and #62) of 14 residents observed during a medication pass for a total of 25 observations. This resulted in a medication error rate of 32.0%.This is evidenced by:The facility's Policy and Procedure titled, Medication Error Policy reviewed 1/2026 documented the facility shall maintain systems to ensure medications are administered accurately, safely, and in accordance with physician orders, professional standards of practice.Medication Error: Any preventable event that may cause or lead to inappropriate medication use or resident harm, including: Wrong resident Wrong medication Wrong dose Wrong route Wrong time (outside acceptable time frame) Omission Unauthorized medication Improper preparation or documentationNear Miss: An error identified and corrected before reaching the resident.Resident #36Resident #36 was admitted to the facility with a diagnoses of anxiety (excessive fear of or apprehension about real or perceived threats, leading to altered behavior), depression (persistently low mood, loss of interest or pleasure in activities, and, often, low energy), and morbid obesity (a chronic, life-threatening condition defined by excessive weight-typically 100 pounds or more over ideal body weight). The Minimum Data Set (an assessment tool) dated 12/27/2025 documented the resident usually could understand and was understood by others with intact cognition.Resident # 49Resident #49 was admitted to the facility with a diagnoses of alcoholic cirrhosis of liver (permanent scarring that damages your liver related to alcohol use), type 2 diabetes mellitus (where the pancreas cannot make or fail to use insulin properly and eventual insulin deficiency) and gait abnormality (difficulty walking). The Minimum Data dated 07/21/2025 documented the resident usually could understand and was understood by others with intact cognition.Resident #56Resident #56 was admitted to the facility with a diagnoses of type 2 diabetes mellitus (where the pancreas cannot make or fail to use insulin properly-and eventual insulin deficiency), unspecified intervertebral disc disorder (damage, degeneration, or undisclosed disorders of the spine's cushioning discs, commonly causing chronic back or neck pain), and chronic kidney disease (long-term, progressive, and irreversible loss of kidney function). The Minimum Data Set (an assessment tool) dated 10/10/2025 documented the resident usually could understand and was understood by others with moderate cognitive impairment.Resident # 62Resident #56 was admitted to the facility with a diagnoses of unspecified sequelae of cerebral infarction (long-term, lasting effects or complications following a stroke (ischemic brain injury), hemiplegia and hemiparesis left non-dominant side (motor impairments affecting one side of the body following a stroke) and generalized muscle weakness. The Minimum Data Set (an assessment tool) dated 10/7/2025 documented the resident usually could understand and was understood by others with intact cognition.During an observation on 1/20/2026 at 11:15 AM, Licensed Practical Nurse #2 was observed drawing up 15 units of Humalog insulin to administer to Resident # 56 and proceeded to administer the insulin. Writer asked, Licensed Practical Nurse #2 if they had checked for the expiration date. Licensed Practical Nurse #2 then looked at the bottle for the expiration date. At that time, they provided surveyor with the preprinted expiration date on the vial of insulin. When asked, Licensed Practical Nurse #2 when the vial of insulin was opened, they stated they were not sure and were not aware of shortened expiration dates after opening for insulin vials. Licensed Practical Nurse #2 discarded the insulin vial after being prompted and stated they would get a new vial to administer the insulin.During an observation on 1/20/2026 at 11:20 AM, the 8:00 AM dose of Lidocaine 4% patch was highlighted not given for Resident #36. Licensed Practical Nurse #2 stated they did not give the medication because it was not available. They stated they called pharmacy the previous day and were waiting for the medication. Licensed Practical Nurse #2 stated the physician or Director of Nursing had not been notified because they were waiting for the medication. They stated they were aware the medication was late but were going to administer when available. During an observation on 1/20/2026 at 11:30 AM, Licensed Practical Nurse #2 stated Resident #49 was to self-administer their medication in preparation for discharge to home. Licensed Practical Nurse #2 entered Resident #49's room and handed resident Insulin Aspart Flex Pen and told them to administer 12 units. Licensed Practical Nurse #2 was prompted to advise resident to prime pen prior to drawing up insulin as ordered. Licensed Practical Nurse #2 then instructed Resident #49 to prime pen with 1 unit of insulin prior to drawing up 12 units as ordered. Licensed Practical Nurse #2 was provided with manufacturer's instructions to prime with 2 units instead of 1 unit. Licensed Practical Nurse #2 stated they were unaware they should prime pen prior to use. Resident #49 had no physician order to self-administer medication.During an observation on 1/21/2026 at 9:20 AM, Licensed Practical Nurse #3 was observed administering medication to Resident #62. Licensed Practical Nurse #3 stated they administered Aspirin 81 milligrams, Keppra 250 milligrams, Losartan 25 milligrams, Metoprolol Extended Release 25 milligrams, Pantoprazole Delayed Release 40 milligrams, Potassium Chloride Oral Solution 60 milligrams / 22.5 milliliters all were due at 8:00 AM. The Medication Administration Record dated January 2026 for Resident #62 documented give the following medications at 07:00AM Aspirin 81 milligrams, Keppra 250 milligrams, Losartan 25 milligrams, Metoprolol Extended Release 25 milligrams, Pantoprazole Delayed Release 40 milligrams, Potassium Chloride Oral Solution 60 milligrams / 22.5 milliliters which were previously signed as given at 8:07 AM by Licensed Practical Nurse #3 although, Licensed Practical Nurse #3 was actually observed administering the medications at 9:20 AM.During an interview on 1/21/2026 at 9:30 AM, Licensed Practical Nurse #3 stated Resident #62 used to receive these medications at 8:00 AM, and there must have been a change in the order to give at 7:00 AM. During an interview on 1/20/2026 at 12:13 PM, Director of Nursing #1 stated Resident #49 self-administer medications. The nursing staff had been observing them self-administer in preparation for discharge to home. Director of Nursing #1 stated prior to self-administering medications the resident is assessed for capacity by a multidisciplinary team, a physician writes order to self-administer medication and care plan updated to reflect resident can self-administer medications. The resident is educated and nurse observing resident documents observation. Director of Nursing #1 was unable to locate any documentation of a physician order, assessment by interdisciplinary team and or care plan for resident #49 to self-administer medications. Consequently, a medication error occurred because there is no physician order for this resident to self-administer medication. Director of Nursing #1 also was unable to verbalize medications that may have shortened expiration dates after opening. They stated they would follow up with pharmacy services.During an interview on 1/21/2026 at 10:00 AM, Director of Nursing #1 stated some resident's medication times were changed to 7:00 AM and some at 8:00 AM to even out the medication pass. They stated the nurse administering medication should follow policy and check for the right patient, right medication, right time, right dose and right route. 10 New York Codes, Rules, and Regulations 41

Based on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure that residents were free of any significant medication errors for two (2) (Resident #s 36 and 62) of 14 residents reviewed. Specifically, (a.) on 1/20/2026 at 08:00 AM, Resident #36's order to administer Lidocaine 4% patch was omitted. (b.) On 1/21/2026, Resident #62 had an order to receive six (6) medications at 07:00 AM; Licensed Practical Nurse #3 documented they administered the medications at 08:07 AM but was observed administering the medications at 09:20 AM.This is evidenced by:The facility's Policy and Procedure titled Medication Error Policy reviewed 1/2026 documented the facility shall maintain systems to ensure medications are administered accurately, safely, and in accordance with physician orders, professional standards of practice.Medication Error: Any preventable event that may cause or lead to inappropriate medication use or resident harm, including: Wrong resident Wrong medication Wrong dose Wrong route Wrong time (outside acceptable time frame) Omission Unauthorized medication Improper preparation or documentationNear Miss: An error identified and corrected before reaching the resident. Resident #36Resident #36 was admitted to the facility with a diagnoses of anxiety (excessive fear of or apprehension about real or perceived threats, leading to altered behavior), depression (persistently low mood, loss of interest or pleasure in activities, and, often, low energy), and morbid obesity (a chronic, life-threatening condition defined by excessive weight typically 100 pounds or more over ideal body weight). The Minimum Data Set (an assessment tool) dated 12/27/2025 documented the resident usually could understand and was understood by others with intact cognition.During an observation of the Medication Administration Record on 1/20/2026 at 11:20 AM the 8:00 AM dose of Lidocaine 4% patch was highlighted not given for Resident #36. Licensed Practical Nurse #2 stated they did not give the medication because it was not available. They stated they called pharmacy the previous day and were waiting for the medication. Licensed Practical Nurse #2 stated the physician or Director of Nursing had not been notified because they were waiting for the medication. They stated they were aware the medication was late but were going to administer when availableResident # 62Resident #56 was admitted to the facility with a diagnosis of unspecified sequelae of cerebral infarction (long-term, lasting effects or complications following a stroke (ischemic brain injury); Hemiplegia and Hemiparesis left non-dominant side (motor impairments affecting one side of the body following a stroke); and generalized muscle weakness. The Minimum Data Set (an assessment tool) dated 10/07/2025 documented the resident usually could understand and was understood by others with intact cognition.During an observation on 1/21/2026 at 9:20 AM, Licensed Practical Nurse #3 was observed administering medication to Resident #62. Licensed Practical Nurse #3 stated they administered Aspirin 81 milligrams, Keppra 250 milligrams, Losartan 25 milligrams, Metoprolol Extended Release 25 milligrams, Pantoprazole Delayed Release 40 milligrams, Potassium Chloride Oral Solution 60 milligrams / 22.5 milliliters all were due at 8:00 AM. The Medication Administration Record for resident #62 documented give the following medications at 07:00AM Aspirin 81 milligrams, Keppra 250 milligrams, Losartan 25 milligrams, Metoprolol Extended Release 25 milligrams, Pantoprazole Delayed Release 40 milligrams, Potassium Chloride Oral Solution 60 milligrams / 22.5 milliliters which were previously signed as given at 8:07 AM by Licensed Practical Nurse #3 although, Licensed Practical Nurse #3 was actually observed administering the medications at 9:20 AM.During an interview on 1/20/2026 at 12:13 PM, Director of Nursing #1 stated Lidocaine 4% patch was available onsite if needed. It was the responsibility of the medication nurse to notify the unit manager, Director of Nursing or physician if a medication was not given.During an interview on 1/21/2026 at 9:30 AM, Licensed Practical Nurse #3 stated Resident #62 used to receive their medications at 8:00 AM, and there must have been a change in the order to now give at 7:00 AM. During an interview on 1/21/2026 at 10:00 AM, Director of Nursing #1 stated some resident's medication times were changed to 7:00 AM and some at 8:00 AM to even out the medication pass. They stated the nurse administering medication should follow policy and check for the right patient, right medication, right time, right dose and right route. 10 New York Codes, Rules, and Regulations 415.12(m)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the recertification survey, the facility did not maintain medical records in accordance with accepted professional standards and practices. The records were not accurately documented or completed for two (2) residents (Resident #7 and Resident #12) of 22 reviewed. Specifically, Resident #7's and Resident #12's Medication Administration Records and Treatment Administration Records were missing documentation indicating that medications and treatments were administered and completed as ordered. This is evidenced by: Resident #7 Resident #7 was admitted to the facility with diagnoses of post-traumatic stress disorder (a mental health condition triggered by experiencing or witnessing terrifying events like war, abuse, or accidents), type 2 diabetes (an endocrine dysfunction causing unregulated blood glucose levels), and chronic atrial fibrillation (an irregular and often very rapid heart rhythm). The Minimum Data Set (an assessment tool) dated 12/27/2025, documented the resident was cognitively intact, could be understood and could understand others.The Medication Administration Record for January 2026 (1/01/2026 to 1/20/2026) documented the following medications were not documented as administered: Acetaminophen Extra Strength 500 milligrams (non-opioid pain medication) on 1/02/2026 at 8:00 AM, 1/06/2026 at 8:00 AM, and 1/19/2026 at 8:00 AM Finasteride 5 milligrams (medication to treat obstructive uropathy) on 1/12/2026 at 6:00 PM Furosemide 80 milligrams (medication to treat congestive heart failure) on 1/19/2026 at 3:00 PM Lantus SoloStar Subcutaneous Solution Pen-Injector 100 unit/milliliter (medication to treat diabetes) on 1/12/2026 at 8:00 PM and 1/14/2026 at 8:00 PM. Metformin 1000 milligrams (medication to treat diabetes) on 1/02/2026 at 8:00 AM, 1/06/2026 at 8:00 AM, and 1/19/2026 at 8:00 AM Metoprolol Succinate 100 milligram (medication to treat atrial fibrillation) 1/02/2026 at 8:00 AM, 1/06/2026 at 8:00 AM, and 1/19/2026 at 8:00 AM Omeprazole 40 milligram (medication to treat gastro intestine) on 1/12/2026 at 8:00 PM and 1/14/2026 at 8:00 PM Potassium Chloride 40 milliequivalent (electrolyte supplement) on 1/02/2026 at 8:00 AM, 1/06/2026 at 8:00 AM, and 1/19/2026 at 8:00 AM Pro-Stat Oral Liquid 30 milliliters (supplement) on 1/02/2026 at 8:00 AM, 1/06/2026 at 8:00 AM, and 1/19/2026 at 8:00 AM Sertraline 100 milligram (anti-depressant) on 1/02/2026 at 8:00 AM, 1/06/2026 at 8:00 AM, and 1/19/2026 at 8:00 AM Spironolactone 25 milligram (medication to treat congestive heart failure) on 1/02/2026 at 8:00 AM, 1/06/2026 at 8:00 AM, and 1/19/2026 at 8:00 AM Stiolto Respimat Inhalation Aerosol Solution 2.5-2.5 micrograms per actuation (inhaler) on 1/02/2026 at 8:00 AM, 1/06/2026 at 8:00 AM, and 1/19/2026 at 8:00 AM Trazadone 100 milligram (medication to treat insomnia) on 1/12/2026 at 8:00 PM and 1/14/2026 at 8:00 PM Weekly weights every Monday for congestive heart failure/fluid restriction not documented on 1/05/2026, 1/12/2026, and 1/19/2026 Apixaban 5 milligram (medication to treat atrial fibrillation) on 1/12/2026 at 8:00 PM, 1/14/2026 at 8:00 PM, and 1/19/2025 at 5:00 AM Buspirone 10 milligram (anti-anxiety medication) on 1/02/2026 at 8:00 AM, 1/06/2026 at 8:00 AM, 1/12/2026 at 6:00 PM, and 1/19/2026 at 8:00 AM Ferrous Sulfate 325 milligram (supplement) on 1/02/2026 at 8:00 AM, 1/06/2026 at 8:00 AM, 1/12/2026 at 8:00 PM, 1/14/2026 at 8:00 PM, and 1/19/2026 at 8:00 AM Lac-Hydrin Five External Lotion 5% (for dry skin) on 1/12/2026 on 1/12/2026 on 3-11 shift and 1/19/2026 on 7-3 shift Mucinex 600 milligram (allergy medication) on 1/02/2026 at 8:00 AM, 1/06/2026 at 8:00 AM, 1/12/2026 at 8:00 PM, 1/14/2026 at 8:00 PM, and 1/19/2026 at 8:00 AM Pataday Ophthalmic Solution 0.1% (for dry eyes) on 1/12/2026 at 8:00 PM, 1/14/2026 at 8:00 PM, and 1/19/2026 at 8:00 AM Restasis Ophthalmic Emulsion (for dry eyes) on 1/02/2026 at 8:00 AM, 1/06/2026 at 8:00 AM, 1/12/2026 at 8:00 PM, 1/13/2026 at 8:00 AM, 1/14/2026 at 8:00 PM, 1/19/2026 at 8:00 AM. Vitamin C 500 milligram (supplement) on 1/02/2026 at 8:00 AM, 1/06/2026 at 8:00 AM, 1/12/2026 at 8:00 PM, 1/14/2026 at 8:00 PM, and 1/19/2026 at 8:00 AM. Novolog FlexPen Subcutaneous Solution Pen Injector 100 unit per milliliter (medication to treat diabetes) on 1/02/2026 at 8:00 AM and 12:30 PM, 1/06/2026 at 8:00 AM and 12:30 PM, 1/09/2026 at 12:30 PM, 1/12/2026 at 12:30 PM and 5:00 PM, 1/13/2026 at 12:30 PM, and 1/19/2026 at 8:00 AM and 12:30 PM Pen Needles Miscellaneous 30G X 5 MM on 1/02/2026 at 8:00 AM and 12:00 PM, 106/2026 at 8:00 AM and 12:00 PM, 1/09/2026 at 12:00 PM, 1/12/2026 at 12:00 PM, 4:00P PM, and 8:00 PM, 1/13/2026 at 12:00 PM, 1/14/2026 at 8:00 PM, and 1/18/2026 at 8:00 AM and 12:00 PMThe Treatment Administration Record for January 2026 (1/01/2026 to 1/20/2026) documented the following treatments were not documented as administered or completed: Weekly Skin Check not documented on 1/01/2026 and 1/08/2026 Eucerin Daily Hydration External Lotion (for dry skin) on 1/01/2026 7-3 and 3-11 shift, 1/02/2026 7-3 and 3-11 shift, 1/03/2026 7-3 shift, 1/04/2026 7-3 shift, 1/05/2026 7-3 PM and 3-11 PM shift, 1/06/2026 7-3 and 3-11 shift, 1/07/2026 3-11 shift, and 1/08/2026 7-3 shift. Order was discontinued on 1/08/2026 at 2:09 PM Muscle rub (for pain) on 1/01/2026 7-3 and 3-11 shift, 1/02/2026 7-3 and 3-11 shift, 1/03/2026 7-3 shift, 1/04/2026 7-3 shift, 1/05/2026 7-3 and 3-11 shift, 1/06/2026 7-3 and 3-11 shift, 1/07/2026 3-11 shift, 1/08/2026 713 shift, 1/09/2026 7-3 shift, 1/10/2026 7-3 shift, 1/12/2026 7-3 and 3-11 shift, 1/13/2026 7-3 and 3-11 shift, 1/14/2026 7-3 and 3-11 shift, 1/19/2026 7-3 shiftDuring an interview on 1/21/2026 at 2:41 PM, Licensed Practical Nurse #2 stated they did not know why there were blanks or missing documentation on the Medication Administration Record and Treatment Administration Record for Resident #7, although she had worked on some of the days where there was missing documentation. Licensed Practical Nurse #2 stated Resident #7 was given their medications on the days they worked, but they probably did not sign for them. Resident #12 Resident #12 was admitted to the facility with diagnoses of an unspecified fracture of the sacrum, a break or crack in the sacrum, which is the large triangular bone at the base of the spine; cerebral infarction, a medical condition in which blood flow to the brain is interrupted, leading to brain tissue damage; and heart failure, a chronic, progressive condition in which the heart muscle is too weak or too stiff to efficiently pump enough oxygen-rich blood to meet the body's needs. The Minimum Data Set, dated [DATE] documented that the resident could be understood, could understand others, and was severely cognitively impaired.The Medication Administration Record for January 2026 (1/01/2026 to 1/16/2026) documented the following medications were not documented as administered: Aspirin 81 (blood thinner) on 1/02/2026 at 8:00 AM and 1/06/2026 at 8:00 AM Latanoprost Ophthalmic Solution 0.005% (for glaucoma) on 1/06/2026 at 6:00 PM, 1/12/2026 at 6:00 PM, and 1/14/2026 at 6:00 PM Metoprolol 25 milligram (medication to treat hypertension) on 1/02/2026 at 8:00 AM and 1/06/2026 at 8:00 AM Valsartan 40 milligram (medication to treat hypertension) on 1/02/2026 at 8:00 AM and 1/06/2026 at 8:00 AM Tylenol Extra Strength 500 milligram (non-opioid pain medication) on 1/02/2026 at 9:00 AM, 1/06/2026 at 9:00 AM and 6:00 PM, 1/12/2026 at 6:00 PM, and 1/14/2026 at 6:00 PMThe Treatment Administration Record for January 2026 (1/01/2026 to 1/16/2026) documented the following treatments were not documented as administered or completed: Vital signs weekly was not documented as completed on 1/04/2026 and 1/11/2026 Weekly skin check was not documented as completed on 1/02/2026 A Medication Error/Omission Report dated 10/03/2025 at 3:00 PM, documented Licensed Practical Nurse #2 was responsible for a transcription error with comment that the medication was dispensed to the resident on 3 different occasions and was not signed off for in the Medication Administration Record. The order was for morphine sulfate oral solution, 20 milligram per milliliter, give 1 milliliter every hour as needed.During an interview on 1/21/2026 at 11:08 AM, Licensed Practical Nurse #2 stated they worked full time on the unit. They stated if there was a blank or missing documentation in the Medication Administration Record, it meant that the medication was not passed or that the medication was passed but was not signed for. They further stated, they did not want to speak for others, but it generally meant that it was not done. Licensed Practical Nurse #2 stated if they were running late administering medication or a medication was not available, they would contact the Medical Provider, maybe get a new order, check the Omnicell, or call the pharmacy. They stated if a resident refused a medication, they would reapproach the resident a few more times and if they were unsuccessful, they would contact the Medical Provider. They would also provide the resident with education as to why they should take their medications. Licensed Practical Nurse #2 stated that they were not aware of Resident #7 refusing any medications.During an interview on 1/21/2026 at 11:17 AM with Director of Nursing #1, they stated if it was not documented, then it was not done when questioned about blanks or missing documentation on the Medication Administration Record and the Treatment Administration Record. They stated staff might have missed signing for the administration of the medication or maybe the medication was not available. They would have to speak with the specific nurse surrounding the circumstances. Director of Nursing #1 stated if a medication was not given for some reason or refused, the Medical Provider should be called for new orders. It would also need to be documented as a progress note or directly in the Medication Administration Record. When asked who was responsible for reviewing the Medication Administration Records and Treatment Administration Records for completion, they stated the nurse should check their own work at the end of their shift to make sure everything was done.During an interview on 1/21/2025 at 12:13 PM, Nurse Practitioner #1 stated the facility would normally contact them if a medication was not administered or if a resident refused a medication. They stated if a minor medication such as eye drops were not administered or refused, they did not expect staff to call them for that, but rather to write it in the communication book. However, if it were a medication such as an antidepressant or insulin, they stated they should be notified and would make recommendations as appropriate. 10 New York Codes, Rules, and Regulations 415.22(a)(1-4)

Based on observation and interviews conducted during the recertification survey, the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition. Specifically, the self-closing device on the walk-in freezer was not functioning properly as intended. This is evidenced by:During observations conducted on 1/14/2026 at 11:00 AM, as part of the inspection of the walk-in freezer, the self-closing mechanism on the main entry door was found to be inoperable and was not pulling the door closed to ensure a tight seal.During an interview on 1/15/2026 at 12:00pm, Environmental Director #1 stated that they would address the issue immediately as they were not aware of it not functioning properly. 10 New York Codes, Rules, and Regulations 415.5(e)(1)(2)

Based on observation and interviews conducted during the recertification survey, the facility did not provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Specifically, there was an unidentified unpleasant odor of varying levels throughout survey.This is evidenced by:During an observation on 01/22/2026 at 10:55 AM, an odor (pungent, sewer) was noted in the hallway leading to the [NAME] Unit from the Administrator's office to the Nurse's station in front of several resident rooms.During an observation on 01/22/2026 at 1:10 PM, the same odor was noted in the hallway leading to the [NAME] Unit from the Administrator's office to the Nurse's station in front of several resident rooms as it was at 10:55 AMDuring an interview on 01/22/2026 at 1:10 PM, Licensed Practical Nurse #1 stated the odor in the hallway had been present for a while, not sure where it was coming from. They stated they did not believe it was from any of the residents.During an interview on 01/22/2026 at 1:19 PM, Administrator #1 stated a resident in that hallway had a nephrostomy and that was the cause of the odor, and it had been a persistent problem. 10 New York Codes, Rules, and Regulations 415.29

Based on observation, record review and interviews during the recertification survey, the facility did not ensure the personal privacy and confidentiality of personal and medical records for 1 (East Unit) of 2 units reviewed for privacy and confidentiality. Specifically, the facility did not ensure resident rights to personal privacy and confidentiality of their personal and medical records were maintained on 5/31/2023, 6/2/2023, and 6/6/2023, when facility staff left computer screens unattended on the East Nursing Unit Nursing Station.
This is evidenced by:
East Nursing Unit:
The Policy and Procedure (P&P) titled Confidentiality/Health Insurance Portability and Accountability Act (HIPAA), dated 02/2023, documented health care providers may not use or disclose Protected Health Information (PHI), except as permitted by privacy regulations. PHI was any individually identifiable health insurance information in any form or medium, including names, social security numbers, medical record numbers, date of birth , or Medicaid number. This included written, oral, and electronic communications and records.
During an observation on 05/31/23 at 09:09 AM, a list of resident names and images was visible on a computer monitor screen at an unattended medication cart near the East Unit Nursing Station. There were no staff within view of the medication cart.
During an observation on 06/02/23 at 08:46 AM, a resident Electronic Medical Record (EMR) profile was visible on the monitor screen of an unattended medication cart near a wall by the East Unit Nursing Station. There were no staff visible near the cart.
During an observation on 06/02/23 at 02:13 PM, a list of resident names and images was visible from the hallway on an unattended facility computer monitor screen at the East Unit Nursing Station. There were no staff at the nursing station at the time of the observation.
During an observation on 06/06/23 at 08:19 AM, a resident profile was observed from the East Nursing Unit hallway on an unattended computer monitor screen at the nursing station. There were no staff present at the nursing station.
During an observation on 06/06/23 at 11:31 AM, a resident profile was observed from the East Nursing Unit hallway on an unattended computer monitor screen at the nursing station; there were no staff present at the nursing station.
During an interview on 06/02/23 at 08:48 AM, Licensed Practical Nurse (LPN) #1 stated prior to leaving a medication cart, staff needed to ensure the computer screen was locked, so no resident personal information was visible. They were currently assigned to the medication cart that had resident personal information displayed on the monitor screen. Prior to leaving the medication cart unattended, they should have locked the monitor screen or signed out of the EMR to ensure there was no resident personal information displayed.
During an interview on 06/06/23 at 08:20 AM, the Director of Nursing (DON) stated the monitor screen at the East Unit Nursing Station should have been locked out prior to being left unattended by the staff member, as the information on the screen was easily visible from outside the nursing station in the hallway. Prior to leaving any computer, including at the nursing station or at a medication cart, staff were responsible for either logging out of the EMR or locking the monitor screens to ensure no resident information was visible.
During an interview on 06/06/23 at 10:05 AM, Registered Nurse (RN) #1 stated before leaving any computer, staff were responsible for signing out of the EMR, or locking the monitor screen, to make sure there was no resident personal information present and left unattended.
During an interview on 06/06/23 at 11:32 AM, the DON stated the resident profile observed at the East Unit Nursing Station at 11:31 AM should not have been left unattended. This was a HIPAA and resident privacy concern. This was addressed with the staff after the incident that occurred earlier in the day on the East Unit, they were not sure why this was happening again.
10 NYCRR 415.3(e)(1)

Based on observation, record review, and interview during the recertification survey dated 05/30/23 through 06/06/23, the facility did not ensure food was stored, prepared, distributed, or served in accordance with professional standards for food service safety in the main kitchen. Specifically, one (1) of 2 food temperature thermometers were found to be not in calibration when tested in a standard ice-bath method, and the correct test kit to measure the concentration of chemical sanitizer used to manually sanitize food contact surfaces (sanitizer) has color graduations that do not exceed 400 parts per million (ppm) and cannot test sanitizer concentrations exceeding the manufacturer specifications (the label on the bottle of sanitizer states the sanitizer is to be diluted to between 200 ppm and 400 ppm when sanitizing food contact surfaces). This is evidenced as follows:
During observations of the main kitchen on 06/05/23 at 11:49 AM, one of 2 food temperature thermometers was found not in calibration when tested in a standard ice-bath method as follows: 5 degrees Fahrenheit. The label on the bottle of concentrated sanitizer titled Barrier II Disinfectant, Sanitizer, Virucide, Deodorizer (label not dated) states the sanitizer is to be diluted to between 200 ppm and 400 ppm when sanitizing food contact surfaces. The label of the test kit titled QT 10 Hydrion with an expiration date of 06/15/23, documented color graduations that do not exceed 400 ppm and cannot test sanitizer concentrations exceeding the manufacturer specifications.
During an interview with the Administrator and Dietary Manager on 06/05/23 at 12:33 PM, the Administrator stated that the correct test strips will be purchased. The Dietary Manager stated that staff will be re-trained on how to check the thermometer calibration using the ice bath method, and audits will be started for checking thermometer calibration. The Dietary Manager stated that being new to the position, the procedure for checking thermometer calibration was not known, and the vendor was relied upon for providing test papers.
10 NYCRR 415.14(h)

Based on record review, and interviews during the recertification survey, the facility did not ensure residents requiring specialized rehabilitative services were provided with services for 1 (Resident #44) of 1 residents reviewed for rehabilitation. Specifically, for Resident #44, the facility did not ensure a therapy referral entered on 05/24/2023 was addressed by the therapy department in accordance with facility policy.
This is evidenced by:
Resident #44
Resident #44 was admitted to the facility with diagnoses of cerebral infarction, osteoarthritis, and dementia. The Minimum Data Set (MDS - an assessment tool) dated 04/11/2023, documented the resident was able to make themselves understood, able to understand others, and was severely cognitively impaired.
The Policy and Procedure (P&P) titled Therapy Services Evaluation/Referrals, revised 02/2023, documented upon receipt of a rehabilitation referral in the Electronic Medical Record (EMR), therapy staff (Physical Therapy (PT), Occupational Therapy (OT), or Speech-Language Pathologist (SLP) would have 72 hours to respond to the referral, and either complete a screen or an evaluation, and update the care plan and EMR accordingly.
The Comprehensive Care Plan (CCP), titled Activities of Daily Living (ADLs), revised 05/16/2023, documented an extensive assist x 1 for transfers with a front-wheeled walker.
A therapy referral, dated 05/24/2023 at 09:17 PM, documented for a PT referral for a decrease/increase in functional mobility (transfers, ambulation, bed mobility). The referral did not include the response to the referral by the PT department.
During an interview on 06/06/23 at 10:05 AM, Registered Nurse (RN) #1 stated any time there was a change in a resident's ADL status, a therapy evaluation would be entered by an RN. Once the therapy evaluation was entered, the therapy department had 72 hours to respond to the referral. Sometimes there were verbal conversations between nursing and therapy once the therapy evaluations were entered, but they were not sure if there was any kind of formal oversight process to ensure these referrals were completed. They had not heard from therapy regarding Resident #44's referral since it was entered on 5/24/2023. There was no documentation in the EMR that therapy had addressed the referral. This should have been addressed and documented by therapy by 5/27/2023.
During an interview on 06/06/23 at 10:52 AM, Physical Therapist (PT) #1 stated PT and OT referrals were entered into the EMR by nursing and reviewed daily by the therapy department. The therapy department was aware of the PT referral made on 5/24/2023 for Resident #44 on 5/25/2023, but the resident was not seen until 5/31/2023; they were not sure why it took so long to see the resident. On 5/31/2023, they and Occupational Therapist (OT) #1 evaluated the resident, but neither of them documented the results of their evaluation. They both should have done this on 5/31/2023 after their evaluations were completed, they were not sure why they did not do this. OT #1 was currently unavailable due to illness.
During an interview on 06/06/23 at 11:34 AM, the Director of Nursing (DON) stated on 5/24/2023, Resident #44 seemed to be having increased difficulty with transfers, which was why the therapy referral was entered. Once the therapy referral was entered, the therapy department should have responded and documented the results of their evaluation within 72 hours; this was not done. There was no formal process to monitor therapy referrals to ensure they were being completed in a timely manner once they were entered. If PT and OT evaluations were completed on 5/31/2023, there needed to be corresponding documentation in the EMR with the results.
10 NYCRR 415.16(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during a recertification survey and an abbreviated survey (Case #NY00268487), the facility did not ensure comprehensive person-centered care plans were developed and implemented for each resident that included measurable observations and time frames to meet a resident's medical, nursing, mental and psychosocial needs for five (5) (Resident #'s 3, #14, #86, #87, and #285) of nineteen (19) residents reviewed. Specifically for Resident #3, the facility did not ensure the comprehensive care plan (CCP) for swallowing was implemented, for Resident #14, that a CCP was developed and implemented for at risk for pressure ulcers, for Resident #86, the facility did not ensure a CCP was developed for cast care, for Resident #87, the facility did not ensure the intervention for oxygen administration on the comprehensive care plan was consistently implemented. Additionally for Resident #285 the facility did not ensure it implemented the care plan to offer the resident to get out of bed before lunch and dinner.
This is evidenced by:
The facility Policy and Procedure titled, Interdisciplinary Care Plans last reviewed 4/21, documented the care plan would be person centered and reflective of the needs and goals of the individual residents that are served.
Resident #86
The resident was admitted to the facility with diagnoses of non displaced fracture of the head of the left radius, impacted cerumen and acute vaginitis. The Minimum Data Set (MDS-an assessment tool) was not yet completed. The resident was alert and oriented.
The Comprehensive Care Plan did not include a care plan for the presence or care of the residents left arm cast.
During an interview on 05/06/21 at 11:32 AM, Certified Nursing Assistant (CNA) #2 stated the cast does not come off. There is no instructions to the CNAs on their Care Cards regarding the residents cast.
During an interview on 05/06/21 at 03:32 PM, Registered Nurse Manager (RNM) #1 stated she was responsible for the care planning. and did not know why there was no care plan in place but there should have been.
Resident #87
The resident was admitted to the facility with diagnosis of cerebral infarction, major depressive disorder and essential (primary) hypertension. The Minimum Data Set (MDS - an assessment tool) dated 3/25/2021, documented the resident was cognitively intact, able to make self-understood and able to understand others and required oxygen therapy.
During observations on 5/3/2021 at 9:50 AM, 5/4/2021 at 10:30 AM, and 5/5/2021 at 10:25 AM, Resident #87 was seated in a common area with an oxygen canister attached to their walker without oxygen tubing connected to the cannister or attached to the resident.
A Medical Doctor's order dated 3/17/2021 documented to administer oxygen at 3 liters per minute via nasal cannula continuously every shift and to check liter flow and placement.
The CCP for Potential for Alteration in Respiratory Function related to COPD (chronic obstructive pulmomary disease) Interventions/Approaches, reviewed on 3/30/2021 included an intervention to administer oxygen as ordered.
A Medication Administration Record dated May 2021, documented the resident received oxygen 3 liters per minute via nasal canula continuously for the day shift on 5/3/2021, 5/4/2021, and 5/5/2021.
During an interview on 5/5/2021 at 11:08 AM, Licensed Practical Nurse (LPN) #1 stated Resident #87 only received oxygen while in their room. LPN #1 stated the resident would remove their oxygen when out in the common area as they felt embarrassed with it in place. LPN #1 stated she did not make the Unit Manager or MD aware of the resident's refusal to wear oxygen continuously.
During an interview on 5/5/2021 at 11:11 AM, Nurse Practitioner (NP) #7 stated she was not made aware Resident #87 was not wearing oxygen continuously.
During an interview on 5/5/2021 at 12:02 PM, Registered Nurse Unit Manager (RNUM) #1 stated she was aware Resident #87 only used oxygen at nighttime. RNUM #1 stated the NP or MD should have been made aware the resident was not receiving oxygen per MD orders, staff should not sign for medication that was not administered and the care plan should followed.
Resident #285
Resident #285 was admitted to the facility on [DATE] with diagnoses of chronic kidney disease, depression, osteoarthritis and pain. The Minimum Data Set (MDS-an assessment tool) dated 1/15/2021, documented the resident required two-person physical assistance for bed mobility and transfers.
Resident #285 was observed in bed on 5/3/2021 at 12:10 PM, 5/4/2021 at 10:01 AM, 5/5/2021 at 10:40 AM 5/7/2021 at 10:05 AM, 5/7/2021 at 11:15 AM, and at 5/10/2021 at 12:15 PM.
A facility document titled Resident/ Resident Representative Grievance Form, documented the resident and resident representative verbalized concerns over the resident being in a recliner for extended periods of time. A resolution/ outcome documented the resident would be scheduled out of bed for lunch and dinner and be placed back to bed in two hours for comfort as allowed.
The Comprehensive Care Plan for Alteration in Comfort/ Pain, updated 11/18/2020, documented the resident would be scheduled out of bed for lunch and dinner and placed back to bed in two hours for comfort as the resident allowed.
A facility document titled, Personal Care Profile, used to direct care given to residents by CNAs, did not include getting the resident out of bed for lunch or dinner, or ensuring the resident was returned to bed within two hours. An evaluation date of 11/19/2020 documented the resident was pleased with the new intervention in place and voiced no concerns.
During an interview on 5/3/2021 at 12:10 PM, Resident #285 stated they do not regularly get out of bed. The resident stated the staff are extremely busy and therefore are not always available to get her back to bed in a reasonable timeframe. Resident #285 stated the staff do not offer them to get out of bed daily, and not before lunch and dinner regularly. Resident #285 stated they have not been out of bed in a couple of weeks.
During an interview on 5/7/2021 at 11:00 AM, CNA #3 stated they only get Resident #285 out of bed when they ask to get up. CNA #3 stated the resident does not have a specific intervention to get out of bed for meals, or to be put back in bed within a certain time frame.
During an interview on 5/10/2021 at 12:28 PM, the Director of Nursing (DON) stated they would expect staff to offer the resident to get out of bed before lunch and dinner. The DON would expect the care plan on paper, the care plan in the electronic medical record and the personal care profile to match. The DON stated if the resident refused to get out of bed, this should be documented in the medical record.
10NYCRR415.4(b)(1)(i)

Based on observation, interview and record review during a recertification survey, the facility failed to 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 infection. Specifically, for 1 (West Unit) of 2 Units, which was on contact and droplet precautions, the facility did not ensure staff consistently wore gowns and gloves prior to direct contact with residents; for 2 (West and East Units) of 2 units, the facility did not ensure staff performed hand hygiene after assisting a resident to ambulate, after administering injectable medications, or after checking a blood glucose level, before touching clean multi-resident areas; and did not disinfect multi-resident use glucometers (machine used to check a blood glucose level) after resident use and before returning the glucometer to the clean multi-resident use medication cart. Additionally, the facility did not ensure it maintained a system of surveillance to identify, investigate or control infections and communicable disease for all residents in the facility.
This is evidenced by:
The Centers for Disease Control and Prevention (CDC) Guidance titled Transmission-Based Precautions (undated), provides: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning Personal Protective Equipment (PPE) upon room entry and properly discarding before exiting the patient room is done to contain pathogens.
The Centers for Disease Control and Prevention (CDC) guidance titled Using Personal Protective Equipment (PPE), updated 08/19/2020, further documents that gloves and gown shall be removed (doffed) before exiting a patient's room.
The Centers for Disease Control and Prevention (CDC) guidance titled Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings, dated 2/23/2021, recommended the following additional strategies to minimize chances for exposure to COVID-19: Hand Hygiene: HCP [healthcare personnel] should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process.
The Centers for Disease Control and Prevention (CDC) guidance titled, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated on 3/29/2021 provides: Because of the high risk of unrecognized infection among residents, a single new case of SARS-CoV-2 infection in any HCP (healthcare provider), or a nursing home-onset SARS-CoV-2 infection in a resident should be evaluated as a potential outbreak and although most care activities require close physical contact between residents and HCP, when possible, maintaining physical distance between people (at least 6 feet) is an important strategy to prevent SARS-CoV-2 transmission. The CDC guidance also documented: -HCP should care for residents using an N95 or higher-level respirator, eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown. -Residents should generally be restricted to their rooms and serial SARS-CoV-2 testing performed. -Consideration should be given to halting social activities and communal dining; if these activities must continue for uninfected residents, they should be conducted using source control and physical distancing for all participants.
The New York State Department of Health (NYSDOH) Revised Health Advisory entitled COVID-19 Cases in Nursing Homes and Adult Care Facilities, dated 3/13/20 and updated 7/10/2020, documented that if there are confirmed cases of COVID-19 in a Nursing Home, all residents on affected units should be placed on droplet and contact precautions, regardless of the presence of symptoms and regardless of COVID-19 status. HCP and other direct care providers should wear gown, gloves, eye protection (goggles or a face shield), and N95 respirators (or equivalent) if the facility has a respiratory program with fit tested staff and N95s. Otherwise, HCP and other direct care providers should wear gown, gloves, eye protection, and facemasks. Facilities may implement extended use of eye protection and facemasks/N95s when moving from resident to resident (i.e. do not change between residents) unless other medical conditions which necessitate droplet precautions are present. However, gloves and gowns must be changed, and hand hygiene must be performed.
The facility Policy and Procedure, Amended Droplet Precautions for COVID-19- Surveillance undated, documented: Gowns will be worn when providing direct care, when close contact with a resident when they are not wearing a mask is anticipated, and anytime in the resident's room.
During an interview on 5/3/21 at 11:30 AM, the Director of Nursing (DON) stated a Certified Nurse Assistant (CNA) that worked on both units in the facility tested positive for COVID-19 on 4/20/21. The DON stated all residents in the facility were on contact and droplet precautions through 5/4/21.
Finding #1
The facility did not ensure staff on 1 (West Unit) of 2 units on contact and droplet precautions consistently wore gowns or gloves prior to coming into contact with residents.
During an observation on of the [NAME] Unit 5/3/2021 at 11:41 AM, Licensed Practical Nurse (LPN) #7 entered Resident #135's room with a glucometer in her hand. LPN #7 did not don (put on) a gown prior to checking the blood glucose level of Resident #135. LPN #7 exited the resident's room, obtained insulin from the medication cart, entered Resident #135's room and administered insulin to the resident. LPN #7 did not don a gown prior to entering the resident's room either time.
During an observation of the [NAME] Unit on 5/4/21 at 9:34 AM, Certified Nurse Assistant (CNA) #5 took a resident by the hand and assisted the resident to walk to a chair in the common area. CNA #5 placed her arm around the resident to sit in the chair. CNA #5 did was not wearing a gown or gloves while coming into contact with the resident.
During an interview on 5/3/2021 at 11:45 AM, LPN #7 stated all residents in the facility were on contact precautions. LPN #7 stated staff were expected to don a gown prior to providing personal care to residents. The LPN stated a gown was not needed prior to checking a blood glucose or administering insulin to a resident.
During an interview on 5/4/2021 at 9:38 AM, CNA #5 stated staff were expected to wear a gown when toileting or bathing a resident only. CNA #5 stated she was not expected to wear a gown when assisting a resident to ambulate.
During an interview on 5/4/2021 at 9:53 AM, the Infection Control Practitioner (ICP) stated all residents were on amended droplet and contact precautions due to a staff testing positive for COVID-19 on 4/20/2021. The ICP stated staff were expected to don a gown and gloves at all times prior to coming into contact with a resident and or their environment. The ICP stated staff were expected to wear a gown and gloves when checking a blood glucose level, administering insulin, or when assisting a resident to ambulate.
Finding #2:
The facility did not ensure staff performed hand hygiene after direct contact with residents and prior to coming into contact with clean multi-resident use equipment and surfaces in the environment.
The facility Policy and Procedure titled Standard Precautions for Infection Control last reviewed on 2/2/2021, documented hands would be washed after gloves are removed and between resident contacts.
During an observation of the [NAME] Unit on 5/3/2021 at 11:43 AM, LPN #7 exited Resident #135's room with a glucometer in one hand and gloves in another. LPN #7 placed the gloves in the garbage and placed the glucometer on top of a multi-resident medication cart, opened the top drawer of the medication cart and removed an insulin pen and a needle from the drawer. The LPN did not perform hand hygiene.
During an observation of the [NAME] Unit on 5/4/2021 at 9:34 AM, CNA #5 assisted a resident to ambulate to a chair in the hallway while holding the resident's hand. The CNA walked to a clean linen cart and removed a towel and washcloths, walked down the hall and lifted a cover from a different clean linen cart and touched several items without removing anything. CNA #5 did not perform hand hygiene after coming into contact with a resident and prior to touching a clean multi-resident use linen cart. The CNA walked back up the hallway and picked up a crumbled tissue from the floor and discarded the tissue in the trash. The CNA placed the towel and washcloths on the nurse's station and entered a resident's room to answer the call bell. CNA #5 did not perform hand hygiene after picking up a discarded tissue from the floor and prior to entering the resident's room.
During an observation of the [NAME] Unit on 5/6/2021 at 12:20 PM, LPN #5 prepared and administered oral medication to a resident. LPN #5 exited the resident's room carrying a food tray, placed the food tray on a table and proceeded to prepare another resident's medications. LPN #5 did not perform hand hygiene after exiting the resident room and before preparing medications for administration.
During an interview on 5/3/2021 at 11:44 AM, LPN #7 stated she should have performed hand hygiene after testing the resident's blood glucose and removing her contaminated gloves and prior to entering the medication cart.
During an interview on 5/4/2021 at 9:39 AM, CNA #5 stated she should have performed hand hygiene after coming into contact with the resident and prior to touching the clean linen cart. The CNA stated she should have donned gloves before picking up the soiled tissue on the floor, doffed (remove) the gloves and performed hand hygiene prior to answering the residents call bell.
During an interview on 5/4/2021 at 9:53 AM, the ICP stated staff were expected to perform hand hygiene before and after coming into contact with a resident, a resident's environment and prior to contact with a clean multi-resident use area.
During an interview on 5/6/2021 at 12:20 PM, LPN #5 stated hand hygiene should be done prior to exiting a resident's room or if unable then prior to touching anything.
Finding #3:
The facility did not ensure a multi-resident use glucometer (machine used to check a blood glucose level) was disinfected after resident use and before returning it to the multi-resident use medication cart on 2 (East and [NAME] Unit) of 2 Units.
In 2010, the FDA and CDC issued clinical reminders and public health notifications highlighting the risk of transmission of disease from shared use of fingerstick (lancing) devices and point of care blood testing devices; see e.g.: FDA Public Health Notification: Use of Fingerstick Devices on More than One Person Poses Risk for Transmitting Bloodborne Pathogens: Initial Communication (Original publication: 8/26/2010; Updated: 11/29/2010), and CDC Clinical Reminder: Use of Fingerstick Devices on More than One Person Poses Risk or Transmitting Bloodborne Pathogens (Issued: 8/23/2010) . The aforementioned CDC guidance states, for example: [F]ingerstick devices should NEVER be used for more than one person. This is not a safe practice for several reasons. Improper use or device malfunction can lead to the use of a contaminated lancet blade on more than one patient. POC blood testing devices can also be a source of bloodborne infections if used on multiple patients, because it is difficult for healthcare staff to ensure that all blood has been removed from these devices and the reusable portions of the fingerstick device. If contaminated blood is left on them, this could result in bloodborne pathogen transmission among patients. Failure of healthcare personnel to change gloves between patients could also result in bloodborne pathogen transmission. In 2017, the FDA issued updated guidance on this topic, titled Letter to Manufacturers of Blood Glucose Monitoring Systems Listed With the FDA (updated: 11/27/2017), providing: The disinfection solvent you choose should be effective against HIV, Hepatitis C, and Hepatitis B virus. Please note that 70% ethanol solutions are not effective against viral bloodborne pathogens. And: Point of care blood testing devices such as blood glucose meters should be used only on one patient and not shared. If dedicating blood glucose meters to a single patient is not possible, the meters must be properly cleaned and disinfected after every use.
The manufacturer's instructions for the blood glucose meter used by the facility did not include instructions for multi-patient use.
East Unit
During an East Unit medication administration observation on 5/6/2021; at 12:12 PM Licensed Practical Nurse (LPN) #5 was observed to perform blood glucose testing on a resident and placed the testing device on the multi-patient use medication cart without cleaning the device. When asked, LPN #5 stated, I usually clean it with an alcohol wipe after each use, but I did not, I will now.
During an interview on 05/07/2021 12:24 PM, LPN #6 stated, the glucometer should be cleaned before and after each use with a sanitizing wipe.
West Unit
During an observation on 5/3/2021 at 11:43 AM, LPN #7 exited Resident #135's room with a glucometer in one hand and gloves in the other. LPN #7 discarded the gloves in the garbage and placed the glucometer on top of the clean multi-resident use medication cart. LPN #7 opened the top drawer of the medication cart, removed 2 items placed them on-top of the medication cart, and removed a pair of gloves from a box. LPN #7 donned gloves removed a tissue from a box on-top of the medication cart, squirted hand sanitizer on the tissue and wiped the glucometer off. LPN #7 placed the glucometer in the top drawer of the medication cart.
During an interview on 5/3/2021 at 11:46 AM, LPN #7 stated disinfectant wipes are available in the facility, however she did not have any stocked in her medication cart and thought hand sanitizer was an acceptable replacement as it contained alcohol. LPN #7 stated she did not know CDC's guidance on cleansing multi-resident use glucometers.
During an interview on 5/7/2021 at 1:10 PM, the ICP stated the expectation was that staff would use Sani-wipes for disinfecting glucometers after each resident use. The ICP stated hand sanitizer was not an acceptable replacement to disinfect a multi-resident use item.
Finding #4:
The facility did not ensure it maintained a system of surveillance to identify, investigate or control infections and communicable disease for all residents in the facility.
The facility Policy and Procedure, Surveillance of Nosocomial Infections last reviewed 2/2/2021, documented each unit would maintain a line list with a new line listing beginning each month. Infections would be tabulated according to body site, geographic locations, and type of pathogen.
During an interview on 5/7/2021 at 1:12 PM, the ICP stated the expectation was that the ICP would keep a list of all infections in the facility. The ICP stated there was an incomplete list on the East Unit from April 2021, but this had not been updated and did not contain all of the identified infections on that unit. The ICP stated the ICP was previously the Unit Manager for the East Unit and took over the ICP position last week.
During an interview on 5/10/2021 at 12:12 PM, the DON stated the facility was aware that the previous ICP was not accurately tracking communicable diseases for the facility. The DON stated the expectation was that the ICP would have an ongoing updated list of all infections that occurred within the facility. The DON stated the [NAME] Unit did not have a tracking list since January of 2021. The DON stated the facility did not have a system to track and monitor infections.
10 NYCRR 415.19 (a)(1-3); (b)(4); 10 NYCRR 400.2

Based on observations, interviews and record review during a recertification survey, the facility did not ensure that based on the comprehensive assessment, a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #14) of 2 residents reviewed for pressure sores. Specifically, for Resident #14, who was at risk for developing pressure sores, the facility did not ensure interventions were developed and provided to prevent the development of pressure sores. This is evidenced by:
A facility policy titled Alteration in Skin Integrity: Management and Tracking revised 6/1/2020, documented the facility will identify, monitor and treat all new skin areas according to best practice and CMS regulations to promote healing and prevent further skin breakdown. A new Braden Score Risk Assessment (an assessment tool to determine risk of developing a pressure sore - 18 or less is considered at risk for developing a pressure ulcer) should be completed, and the Registered Dietitian will be notified of any new pressure injury stage 2 or higher.
Resident #14:
The resident was admitted to the facility with diagnoses of Parkinson's disease, dementia, and hypertension. The Minimum Data Set (MDS- an assessment tool) dated 12/17/2020, documented the resident had moderately impaired cognitive skills for daily decision making; required extensive assistance of one staff for transfers, toileting, and personal hygiene and limited assist of one person for bed mobility and walking; and had no pressure ulcers but was at risk of developing a pressure ulcer. Section V of the MDS (used to make decisions on what care planning is needed) documented that the resident triggered as being at risk for pressure ulcer development and that it was addressed in a Comprehensive Care Plan (CCP).
Review of the resident's Braden scales documented the following:
- on 12/14/2020, 12/30/2020, and 3/9/2021, the resident had no sensory perception impairment - (ability to respond meaningfully to pressure related discomfort); Moisture (degree to which the skin is exposed to moisture) - occasionaly moist, Activity - walked occasionally during the day but for very short distances; spends a majority of each shift in bed or a chair, Mobility (ability to change body position) - slightly limited made frequent though slight changes in body or extremity position independently. This gave the resident a score of 18.
- on 4/30/21, the resident had slightly limited sensory perception; Sensory Perception - slightly limited: cannot communicate discomfort or the need to be turned, Moisture- very moist, Activity - walks occasionally during the day but for very short distances; spends a majority of each shift in bed or a chair, Mobility- very limited: makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently, Nutrition- probably inadequate, and Friction and Shear - requires moderate to maximum assistance in moving, complete lifting without sling against sheets is impossible, frequently slides down in bed or chair requiring frequent repositioning. This gave the resident a score of 13.
The Comprehensive Care Plans (CCP) were as following:
-Skin Intergrity dated 12/15/2020 and last reviewed on 4/17/2021, did not include interventions to prevent pressure sores.
-Alteration in skin integrity related to an Actual PU dated 4/23/2021, documented a stage 3 Sacral measuring 4 cm x 38 cm x 0.2 cm. obtain orders, refer to weekly skin tracking for weekly wound assessments, standard pressure reducing, rehab as needed for ROM, mobility and positioning if indicated, ongoing evaluation of alternative pressure reducing cushion, evaluate for changes to current Turning and Positioning (T&P) schedule per skin care at risk, refer to wound care consultant as indicated.
A Personal Care Profile (a care plan for Certified Nursing Assistants (CNA)) to let them know what care they are to deliver to the resident), last reviewed 4/13/2021, documented that on 1/27/2021, comfort (standard) cushion in w/c and leg rests.
A CCP for Alteration in Skin Integrity related to an Actual PU dated 4/23/2021, documented a stage 3 Sacral measuring 4 cm x 38 cm x 0.2 cm. obtain orders, refer to weekly skin tracking for weekly wound assessments, standard pressure reducing, rehab as needed for ROM, mobility and positioning if indicated, ongoing evaluation of alternative pressure reducing cushion, evaluate for changes to current Turning and Positioning (T&P) schedule per skin care at risk, refer to wound care consultant as indicated.
The CCP for At Risk for Alteration in Skin Integrity dated 12/15/21, did not include a turning and positioning, toileting schedule, or referral to the wound care consultant.
A Personal Care Profile (a Care plan for Certified Nursing Assistants (CNA) to let them know what care they are to deliver to the resident), last reviewed 4/13/21, documented that on 1/27/21, comfort (standard) cushion in w/c and leg rests. The resident was an extensive assist of 1 for ambulation, bed mobility, transfers, and toileting
The current Personal Care Profile obtained from the resident's room and copied for surveyor on 5/5/2021, last reviewed 4/29/2021, documented that on 1/27/2021, comfort (standard) cushion in w/c and leg rests. There were offloading interventions added.
The following observations were made:
-05/03/2021 at 10:10 PM -11:35 AM, 05/05/2021 at 09:42 AM, 10:43 AM - 10:47 AM, and 03:07 PM, 05/06/21 at 03:07 PM, and 05/07/21 from 09:21 AM - 9:28 AM, the resident was sitting in a chair across from the nursing station. The resident did not attempt to get up or to reposition.
-05/04/2021 at 10:30 AM - 12:50 PM, the resident did not attempt to get up or change position. At 11:40 AM, the Activity Aid (AA) attempted to toilet the resident but the resident would not stand so she was not toileted.
A Progress Note dated 4/22/2021 at 8:15 AM, written by Registered Nurse Manager (RNM) #1, documented the resident was noted with 2 circular open areas to the sacrum, 2 centimeters (cm) x 2 cm on the lower sacral area. The site was cleaned and Medi-honey alginate (a pressure ulcer treatment) and a dry dressing was applied. The resident's medical record did not include further documentation of this area from 04/22/2021 till the date of survey.
During an interview on 05/06/2021 at 09:30 AM, Certified Nursing Assistant (CNA) #1 stated the resident could not walk and could not turn and position themselves in bed.
During an interview on 05/07/2021 at 11:39 AM, Registered Nurse Manager (RNM) #1 stated she was responsible for care planning and there should have been a care plan in place for the resident's risk for pressure ulcer (PU) development prior to the resident developing the pressure ulcer. RNM #1 stated it was hard to get things done sometimes as staffing was an issue and she sometimes has to take a medication cart.
During an interview on 05/07/2021 on 12:02 PM, Physical Therapist (PT) #9 stated she became aware the resident had a pressure sore today when nursing asked for a ROHO cushion. PT usually assessed for an offloading cushion and nursing for a Turning and Positioning (T&P) and toileting schedule.
During an interview on 05/07/2021, at 09:38 AM, the Director of Nursing stated there should have been an at risk for a PU care plan in place prior to the development of a PU, and this could have contributed to the pressure sore. Based on what she was seeing now the pressure sore could have been avoidable.
10 NYCRR 415.12(c)(1-2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews during a recertification survey, the facility did not ensure residents received adequate supervision to prevent accidents for 1 (Resident #3) of 4 residents reviewed for accidents. Specifically, for Resident #3, who was at high risk for choking, the facility did not ensure the resident was not kept in their room with the door closed.
This is evidenced by:
Resident #3:
The resident was admitted to the facility with diagnoses of dysphasia, dementia, and Wernicke's encephalopathy. The Minimum Data Set (MDS- an assessment tool) dated 9/30/2020, documented the resident had moderately impaired cognitive skills for daily decision making.
The following observations were made:
-05/03/2021 at 10:00 AM and 11:35 AM, the resident was in his/her room with the room door closed.
-05/03/2021 at 12:31 AM, the resident's tray was delivered to his room and the door was closed.
-05/05/21 at 08:40 AM, and 05/07/21, at 09:18 AM, the resident was in his/her room with his /her meal tray. The resident room door was shut.
05/04/2021 at 12:35 PM, staff delivered the residents tray to his/her room, set it up, and left the room.
-05/05/2021 at 09:08 AM, the resident was in the hall eating breakfast, was coughing frequently during the meal and staff were heard telling the resident to slow down.
-05/06/2021 at 03:06 PM, the resident was in their room and the door shut.
Finding #1:
The facility did not ensure the resident who was at risk for choking was not left alone in his/her room with the door shut during meals.
A Speech Therapy SLP Discharge summary dated [DATE], documented the resident required close supervision for oral intake.
The CCP for Swallowing Problem related to coughing during meals or with medications and swallowing evaluation results 10/22/2019, documented the resident had a hospital stay for aspiration pneumonia and interventions were as follows; small bites and sips, alternate between bites and sips and close supervision for meals.
A Medical Doctor Order dated 4/24/2021, documented; diet pureed texture and honey thick consistency.
The Certified Nursing Assistant Care Card obtained from the resident's room and copied for the surveyor on 5/5/2021, documented the resident required setup and supervision. regular honey thick liquids, close supervision for the meal small bites and sips alternate bites and sips.
During an interview on 05/06/2021 at 03:25 PM, Certified Nursing Assistant (CNA) #4 stated they give the resident their meal tray in the room and shut the door; the resident eats by himself.
During an interview on 05/06/2021 at 03:37 PM, Registered Nurse Manager (RNM) #1 stated the resident was at risk for choking and should not be in his room alone while eating.
During an interview on 05/07/2021 at 10:22 AM, the Director of Nursing (DON) stated Speech Therapy recommended close supervision, which means the resident needed to be in a placed where he/she could be seen during meals. It was not appropriate to have the resident in his/her room alone while the resident was eating. He/she should be out in the common area or have someone with him//her if eating in his/her room. Eating alone in their room put the resident at risk for choking.
10 NYCRR 415.12(h)(1)