The Eleanor Nursing Care Center

Inspectors wroteBased on observation, staff interview and record review during an abbreviated survey (3095819) on 7/20/2026, the facility did not ensure all mechanical, electrical, and patient care equipment was in safe operating condition. Specifically, records for the preventative maintenance and maintenance of the individual air conditioning and heating units in resident rooms were missing and not provided at time of survey. This was observed on 3 of 3 resident floors.

Inspectors wroteBased on record review and interviews during a survey, the facility did not ensure the resident's legal representative upon written request was provided with a copy of the resident's medical records within 2 working days for 1 of 3 residents (Resident #117) reviewed for medical records. Specifically, on 3/10/25 Resident #117's representative requested copies of Resident #117 complete medical record. Resident #117's representative submitted an Authorization for Release of Health Information form to the facility on 3/10/25. The facility did not provide Resident #117's representative with copies of the medical records until 4/22/25.

Inspectors wroteBased on observations,, interviews, and record reviews during the survey, the facility did not ensure that there was adequate staffing to provide nursing and related services to assure resident safety and attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by the facility assessment and individual plans of care. Specifically, the actual staffing was reviewed from 03/20-04/20/2026. During that time the staffing did not meet the minimal staffing numbers for nurses on 03/24/2026, 04/01/2026, 04/05/2026, 04/07/2026, and 04/13/2026 for at least one shift. Additionally, the facility had minimal staffing numbers of certified nurse aides on at least one unit and one shift on 28 of the 30 days reviewed. [...]

Inspectors wroteBased on observation, interview and record review, it was determined the Governing Body failed to ensure consistent and responsible management of the facility. Specifically, 1) the facility has had a change in Director of Nursing seven times in the last two (2) years. 2) the facility has had 3 Administrators in the last two years. 3) The facility had 11 repeat deficiencies from the recertification survey of 05/06/2025, and 12 repeat deficiencies from the recertification survey of 09/17/2024. 4) The facility has had one (1) elevator that has been out of service for at least 3 years, and a 2nd elevator that has not been functional at times and has caused residents to miss appointments (see F698).

Inspectors wroteBased on interviews and record review during the post-survey revisit from 06/24/2026 to 06/29/2026, the facility did not ensure an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. Specifically, the Director of Nursing/Infection Preventionist was unable to provide documentation of facility antibiotic surveillance / line listing from 06/18/2026 through 06/25/2026.

Inspectors wroteBased on observations, interviews, and record review conducted during the survey, the facility did not ensure residents' rights to a safe, clean, comfortable, and homelike environment on three (3) of three (3) units (Unit 1, 2 and 3). Specifically, 1. On Unit 2, room [ROOM NUMBER] had stains on the floor, a puddle of water near the radiator, spackle stains, molding peeling under the window, and the closet door was missing. In the bathroom, brown stains were on the toilet, wall tiles were missing. There were brown stains on the ceiling, and insect or debris accumulation inside the light fixture. room [ROOM NUMBER] had unpacked cardboard boxes, no closet doors, and broken drapes. 2) On Unit 1, room [ROOM NUMBER] had a hospital bed electrical power cord plugged into an electrical outlet that did not have an outlet cover in place. Exposed wires were observed in the electrical outlet. [...]

Inspectors wroteBased on observation, record review and interview during the survey, the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene for three (3) of nine (9) residents (Resident #114, Resident #6, Resident #1) reviewed for activities of daily living. Specifically, 1) Resident #114's did not receive showers or assistance as planned for activities of daily living. 2) Resident #6 did not receive showers as scheduled; and 3) Resident #1 was observed with scruffy stubble whiskers and stated they wanted to have their face shaved.

Inspectors wroteBased on interview, observation and record review during the Recertification Survey conducted from 04/20/2026 to 04/28/2026, the facility failed to ensure residents received care consistent with professional standards of practice, to prevent pressure ulcers and to prevent worsening of pressure ulcers for one (1) of four (4) residents (Resident #115) reviewed for pressure ulcer. Specifically, Resident #115 was assessed at risk for pressure ulcers, had excoriation to the coccyx on admission and developed a Stage 3 sacral wound. The resident had deep tissue injury to both heels and a right post-surgical metatarsal toe amputation wound. Wound care treatments were not completed as ordered. The resident was not seen on wound rounds and there was no wound assessments documented from 04/21/2025 until 06/18/2025.

Inspectors wroteBased on record reviews and interviews conducted during a survey, the facility did not ensure that each resident received adequate supervision/assistance to prevent accidents for two (2) of five (5) residents reviewed for falls. Specifically, Resident #116 required two (2) person assistance for bed mobility and was provided one (1) staff assistance by Certified Nurse Aide #10 which resulted in a fall from bed. 2) Resident #114 sustained an unwitnessed fall on 06/04/2025. A thorough investigation to prevent re-occurrence was not completed, the Accident/Incident report dated 06/04/2025 did not document injuries sustained due to the fall, or notification of the resident representative and physician. Neurological checks were not completed as per facility policy for a head injury. The Accident/Incident Report was not reviewed by the Medical Director. The findings Include: [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the survey, the facility did not ensure that residents that receive dialysis receive such services consistent with professional standards of practice for one (1) of two (2) residents reviewed for dialysis. Specifically, Resident #46 missed dialysis appointments that needed to be rescheduled due to a malfunctioning elevator. Additionally, the hemodialysis communication book for Resident #46 was reviewed from 03/13 to 04/27/2026. The documentation of the assessments before and after dialysis was inconsistent with no documentation in the electronic medical record elsewhere.

Inspectors wroteBased on observations, interviews, and record review conducted during the survey, the facility did not ensure the attending physician documented in the resident medical record, review of identified drug regimen review recommendations, and completion of any actions taken to address the recommendations for two (2) of five (5) residents (Resident #4 and Resident #23) reviewed for unnecessary medications, psychotropic medications, and medication regimen review, and one (1) of one (1) resident (Resident #13) reviewed for psych/opioid medications. Specifically, 1) Resident #4 had five (5) drug regimen reviews from 11/19/2025to 03/22/2026, with no documented evidence the Medical Director reviewed; 2) Resident#23 had five (5) drug regimen reviews from 10/28/2025 to 03/18/2026 and there was no documented evidence that the Medical Director reviewed; [...]

Inspectors wroteBased on observation and interviews conducted during the survey, the facility did not ensure residents were provided with food and drink that was palatable, and at an appetizing temperature. Specifically, 1) during a lunch observation on Unit 1, temperatures take at the time the last resident tray was served, revealed the chicken parmesan had a temperature of 107.6 degrees Fahrenheit, the pasta was 95.5 degrees Fahrenheit, the green beans were 105 degrees Fahrenheit and milk was 63 degrees Fahrenheit; and 2) for the lunch meal on 04/20/2026, hotdogs and french fries were served with no condiments (ketchup and/or mustard) available.

Inspectors wroteBased on observations and interviews conducted during the survey, the facility did not store food or maintain equipment with food contact surfaces in accordance with professional standards for food service safety. Specifically, 1) unlabeled and undated food were stored in the kitchen freezer, and dry storage; 2) insufficient supply of emergency food; 3) food, water and supplies were not stored six (6) inches off the floor; and 4) food preparation and service equipment was not maintained.

Inspectors wroteBased on interviews and record reviews conducted during the post survey revisit from 08/12/2026 to 08/14/2026, the facility failed to ensure resident records were complete, accurately documented, accessible, and systematically organized in accordance with professional standards of practice for four (4) of four (4) residents reviewed (Residents #18, #24, #126 and #127). [...]

Inspectors wroteBased on observation, interview, and record review during the survey, the facility did not ensure the residents right to participate in care planning meeting for 1 of 3 residents (Resident #68) reviewed for Activities. Specifically, Resident #68's quarterly care plan meeting was cancelled due to snow in January 2026 and not rescheduled.

Inspectors wroteBased on observation and interview during the survey, the facility did not ensure residents needs and preferences were considered to create an individualized home-like environment for one (1) of two (2) residents (Resident #6) reviewed for choices. Specifically, Resident #6 purchased a shelf for their room and asked about purchasing a recliner for their room. The were waiting for approval to install the shelf and purchase a recliner; there was no documented evidence the facility responded to their request. The Personal Items in Resident Rooms policy dated 03/31/2026 documented that the Facility will accommodate, within reason, items of resident choice within the room environment that will enhance the homelike atmosphere. Items that may be considered for screening and approval may include: [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a grievance process that was clear and consistent, and prompt efforts were made to resolve grievances for one (1) of nine (9) residents (Resident #114) reviewed for activities of daily living, and 3 of 12 residents (Resident #61, Resident #107, and Resident #121) at a Resident Council meeting. Specifically, 1) Resident #114's resident representative reported a grievance on 06/16/2025 and there was no documented evidence that a thorough investigation was conducted, and the complainant was notified of the resolution. 2) Resident #7 filed a grievance on 04/07/2026 and did not receive a response. 3) Resident #61, Resident #107, and Resident #121stated at the Resident Council meeting that the grievance process was unclear and inconsistent.

Inspectors wroteBased on observations, interviews, and record reviews, the facility did not ensure that residents remained free from abuse from one (1) of four (4) residents (Resident #23) reviewed for behavioral-emotional concerns. Specifically, Resident #37 was not kept free from abuse when Resident #23 was observed by staff touching Resident #37's breast on 08/23/2025. Additionally, Resident #23 had psychiatric diagnoses that included sexual disorders there were no interventions in place prior to the incident that would ensure Resident #37 and other residents were free from being abused by Resident #23.

Inspectors wroteBased on observations, interviews, and record reviews during the survey, the facility did not ensure that alleged violations involving abuse were reported no later than two hours after the incident for one (1) of four (4) residents reviewed for behavioral emotional. Specifically, Resident #23 was witnessed touching another resident inappropriately on 08/23/2025 and the incident was not reported to the State Agency.

Inspectors wroteBased on observation, interview, and record review conducted during the survey, the facility did not ensure that they initiated and completed a thorough investigation to determine if alleged abuse could have been prevented and to prevent further abuse while the investigation was in progress for one (1) of four (4) residents (Resident #23) reviewed for behavioral-emotional concerns. Specifically, Resident #23 was observed touching another resident inappropriately on 08/23/2025. The Accident/Incident report dated 08/23/2025 did not document a thorough investigation to prevent reoccurrence of the situation and protect other residents during the investigation. Additionally, the Medical Director was not aware of the nature of the incident, and the report was signed by the supervising nurse and only reviewed and signed by the Administrator.

Inspectors wroteBased on interviews and record review during the survey, the facility did not ensure notification to the resident representative or ombudsman regarding transfer or discharge, including the reason for the transfer/discharge, in writing and in a language and manner understood, for three (3) of three (3) residents (Resident #111, Resident #3, and Resident #5) reviewed for hospitalization. Specifically, 1) Resident #111 was hospitalized on [DATE] and the facility did not complete a discharge notice or bed-hold notification, and the ombudsman did not receive notification; 2) Resident #3 was hospitalized [DATE] and the facility did not provide a discharge notice or bed-hold notification to Resident #3's representative and did not notify the ombudsman; [...]

Inspectors wroteBased on record review and interviews conducted during survey, the facility did not electronically transmit encoded and completed Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) system within 14 days of the final MDS completion date, as required for payment information and quality measure purposes. This was evident for one (1) resident (Resident #101).

Inspectors wroteBased on observations, interviews, and record review during the survey, the facility did not ensure a comprehensive person-centered care plan was developed and/or implemented, to meet a resident's needs for two (2) of three (3) residents (Resident #46 and #106) reviewed for Respiratory, one (1) of three (3) residents (Resident #29) reviewed for Urinary Catheters and Urinary Tract Infections, and one (1) of three (3) resident reviewed for Dental. Specifically, 1) Residents #46 and #106 received oxygen and did not have a respiratory care plan; 2) Resident #29 had an indwelling catheter placed on 04/01/2026 and did not have a care plan in place for catheter care; and 3) Resident #98 did not have a comprehensive care plan to address dental issues.

Inspectors wroteBased on observations, interview, and record review during the survey, the facility did not ensure that activities were provided based on the comprehensive assessment, care plan, and preferences of each resident that met the interests of and support the physical, mental, and psychosocial well-being for two (2) of three (3) residents (Resident #3 and Resident #68) reviewed for activities. Specifically, 1) Resident #3 was observed in their room on 04/20/2026 and 04/21/2026 and there was no documented evidence of attendance to group or in room visits on those days. 2) Resident #68 was observed in bed on 04/21/2026 and 04/24/2026 and there was no documented evidence of in-room activities on those days. Furthermore, there was no documented evidence of consistent activity attendance on any days.

Inspectors wroteBased on observations, interviews, and record review during the survey, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive care plan for 1 of 2 (Resident # 117) residents reviewed for antibiotics. Specifically, the resident was to receive 18 doses of Amoxicillin for a urinary tract infection, but three doses were omitted, resulting in receiving 15 of 18 doses.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure care consistent with professional standards of practice was provided for two (2) of three (3) residents (Resident #46, #106) reviewed for Respiratory Care. Specifically, Residents #46 and #106 were administered oxygen at a liter flow greater than the physician order.

Inspectors wroteBased on observations, interviews, and record reviews during the survey, the facility did not ensure that they had sufficient staff to provide nursing related services for residents with mental and psychosocial disorders to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of residents for one (1) of four (4) residents (Resident #23) reviewed for behavioral emotional concerns. Specifically, the facility determined that Resident #23 required one-to-one supervision during the day and evening shifts after an incident involving another resident and inappropriate touch on 08/23/2025. However, the need for one-to-one supervision was not documented clearly or consistently and the staffing sheets from 04/01/2026 to 04/27/2026 documented insufficient numbers of staff to cover the one (1) to one (1) supervision.

Inspectors wroteBased on observation and interviews, the facility did not ensure infection control practices and procedures were maintained when handling linens on two of three units (Unit 1 and 2). Specifically, 1) On Unit 2, room [ROOM NUMBER] had bagged soiled linens on the floor that had been there for a prolonged period; Certified Nurse Aide #14 was observed with soiled linens unbagged directly on the floor while changing the bed in room [ROOM NUMBER]; and carts holding clean linen were observed uncovered in the clean linen room. 2) On Unit 1, Certified Nurse Aide #15 was observed drinking and placing their personal drink cup into the clean linen and supply cart in hallway and then leaving the immediate area with the clean supply cart flaps open.

Inspectors wroteBased upon observation, interviews and record review, the facility failed to maintain mechanical equipment in a safe condition for one (1) of two (2) elevators (Elevator #2). Specifically, Elevator #2 was observed not operating and was reported to be out of service for more than three (3) years causing delays and restricting personal movement throughout the facility.

Inspectors wroteBased on record review, observations, and interviews during an abbreviated survey (2596130) the facility did not ensure that sufficient nursing staff were available to meet the needs of residents as determined by the facility's own assessment. Specifically, the facility assessment date reviewed 03/25/2025 by Quality Assurance and Performance Improvement documented that the day shift would have a Charge Licensed Practical Nurse and a Med nurse per unit, this was not reflected in the staffing assignments. This staffing pattern contributed to medications being administered late for residents on the units with only 1(one) nurse providing care. The facility's documented assessment dated [DATE] indicated that on day shift each unit would be staffed with a medical nurse and a Charge Licensed Practical unit manager. [...]

Inspectors wroteBased on observations, interviews, and record review, during an abbreviated survey (2596130) the facility did not ensure that residents received care in a safe, clean, and comfortable environment. Specifically, multiple ceiling tiles in multiple rooms had visible dark water stains: on Unit 1 (one) room [ROOM NUMBER],109, & 110; on Unit 2 (two) in 218 the community room, the bathroom in 220, and room [ROOM NUMBER] & 227; on Unit 3 (three) room [ROOM NUMBER], 325 and 326. There were also multiple rooms with window curtains that were torn as well as tiles missing from under the bathroom sinks. The undated policy titled Policy and Procedure Manual Work Orders documents that maintenance work orders shall be completed in order to establish a priority of maintenance. [...]

Inspectors wroteBased on observations, interviews, and record reviews during an abbreviated survey (2596130) the facility did not ensure that the facility assessment accurately reflected the resources and staff needed to care for residents. Specifically, the facility assessment dated [DATE] reviewed by Quality Assurance and Performance Improvement documented that the day shift would have a Charge Licensed Practical Nurse and a Med nurse per unit, but this was not reflected in the staffing assignments. This staffing pattern contributed to medications being administered late for residents on the units with only 1 (one) nurse providing care. Review of the facility's assessment dated [DATE] reviewed by Quality Assurance and Performance Improvement indicated that each unit would be staffed with a medical nurse and a Charge Licensed Practical Nurse unit manager for the day shift. [...]

Inspectors wroteBased on record review and interviews conducted during the Recertification and Abbreviated survey (NY00360576) from 04/29/25 to 05/06/25, the facility did not ensure that there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, 1. Upon review of the nursing staffing schedule from 3/29/25-5/29/25, for multiple days, on all three shifts of staffing for each unit, the facility did not provide adequate staffing to meet the needs of the residents and as per their Facility Assessment and, 2. Resident Council meeting attendees expressed concerns the facility did not staff enough nurse aides to provide them with necessary activity of daily living care.

Inspectors wroteBased on record review and interviews during the recertification survey conducted 4/29/25-5/6/25, the facility did not ensure certified nurse aides had the specific competencies and skills necessary to care for residents' needs as identified through resident assessments and described in the plan of care for 5 of 5 recently hired certified nurse aides reviewed. Specifically, Certified Nurse Aides #6, #7, #8, #9, and #10) did not receive a facility orientation upon hire and did not receive documented skills competency training that covered key skill-set areas as outlined in the facility assessment.

Inspectors wroteBased on observations, interviews and record reviews conducted during the recertification survey from 4/29/25 to 5/06/25, the facility did not ensure proper storage, preparation, distribution, and service of food in accordance with professional standards for food safety. Specifically, 1) there were multiple containers of unknown food observed in the walk-in refrigerator, 2) the dishwasher did not achieve proper temperatures for the wash and rinse cycles and 3) the stovetop controls and large portable exhaust fan were dirty and covered in dirt and dust.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 4/29/2025 to 5/6/2025, the facility did not ensure the views, grievances, and recommendations of the resident group were considered and promptly acted upon. This was evident for 10 of 10 (Residents #103, 48, 46, 90, 86, 66, 29, 31, 10, and 28) residents who attended the resident council meeting. Specifically, the attendees of the resident council meeting expressed concerns during consecutive monthly meetings without receiving a facility response.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification and abbreviated surveys (NY00370712) from 4/29/25 to 5/6/25, the facility did not ensure the resident's right to a safe, clean, comfortable, and homelike environment. This was evident for 3 of 3 (1st, 2nd, and 3rd Floors) resident units during environmental observation. Specifically, 1) Resident #93 had a broken closet bar preventing clothing from being hung on top of closet unit, 2) Resident #35 was not provided with a lock box resulting in the loss of funds, 3) each resident unit contained heat/air conditioning radiators were dusty, rusty, and had exposed conductor fins that were damaged and bent, 4) room [ROOM NUMBER] had missing closet doors, 5) the 3rd Floor dayroom had inadequate lighting, and 6) the 3rd floor was noisy due to a defective beeping call bell system.

Inspectors wroteBased on record review and interview conducted during the recertification survey from 4/29/25 to 5/6/25, the facility did not ensure certified nurse aides were provided the required 12 hours of training to ensure safe delivery of care. Specifically, the facility was unable to provide evidence that 5 of 5 Certified Nurse Aides (#1, #2, #3, #4, #5) reviewed for nurse aide in-service training were provided 12 hours of mandatory annual in-service training or an in-service on dementia.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 4/29/2025 to 5/6/2025, the facility did not ensure the attending physician, the medical director, and the director of nursing received and acted upon pharmacy irregularity reports. This was evident for and 4 (Resident #s 38, 83, 81, and 80) of 5 residents reviewed for unnecessary medication and 1 (Resident #3) of 2 residents reviewed for psych/opioid medication side effects. Specifically, pharmacy recommendations for Resident #38, #83, #81, #80 and #3 were not addressed by the attending physician.

Inspectors wroteBased on observation and interviews conducted during the recertification survey from 4/29/25-5/6/2025, the facility did not ensure drugs and biologicals were maintained in accordance with currently accepted professional standards for storage, labeling, and the expiration date. Specifically, expired medications and incorrectly labeled eyedrops were found in the medication cart on one of three units (Third Floor Unit), the medication storage refrigerator was observed unlocked and not affixed on two of two units (Second and Third Floor Units), and the medication rooms on two of two units (Second and Third Floor Units) were observed unlocked on two occasions.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 4/29/2025 to 5/6/2025, the facility did not ensure menus were followed. This was evident for 10 of 10 (Residents #103, 48, 46, 90, 86, 66, 29, 31, 10, and 28) during Resident Council Meeting and 2 (Floor 1 and 3) of 3 resident units during Dining Observation. Specifically, 1) the Resident Council consistently reported concerns related to meal tray item accuracy in accordance with the posted menu and meal ticket, 2) multiple residents were observed at mealtime with meal tickets that did not match the items served on their meal tray.

Inspectors wroteBased on observation, record review, and interview conducted during a recertification survey, from 4/29/2025 - 5/6/2025, the facility did not adequately establish and/or maintain an Infection Prevention and Control Program designed to provide a safe and sanitary environment. Specifically, (1) the facility did not provide a site-specific water management plan for legionella; (2) During wound care the Licensed Practical Nurse and the Certified Nurse Aide did not wear a gown; and (3) During medication administration the nurse did not practice hand hygiene prior to administering eye drops.

Inspectors wroteBased on record review and interview conducted during the recertification survey from 4/29/25 to 5/6/25, the facility did not ensure annual performance reviews for nursing staff were completed at least once every 12 months. Specifically, the facility was unable to provide annual performance reviews for 5 of 5 Certified Nurse Aides (#1, #2, #3, #4, and 5) reviewed.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 4/29/2025 to 5/6/2025, the facility did not ensure reasonable accommodation of resident needs for 1 (Resident #6) of 27 sampled residents. Specifically, the door to Resident #6's bathroom was nailed shut and Resident #6 had to ambulate down the unit hallway to the bathroom located in a shower room to toilet themselves.

Inspectors wroteBased on interviews and record review conducted during the recertification and abbreviated surveys (NY00376085 and NY00370712) from 4/29-5/6/2025 , the facility did not ensure the resident representative/emergency contact was notified for 2 of 2 residents (Resident #8 and Resident #201) reviewed for notification of change. Specifically, Residents #8 and #201 were transferred to the hospital and their resident representative was not notified.

Inspectors wroteBased on record reviews and interviews during a recertification survey from 4/29/25-5/6/25 the facility did not ensure a resident's right to be free from misappropriation of resident property for 1 out of 1 resident (Resident #35) reviewed for personal property. Specifically, Resident #35 was missing money which was reported to facility staff and the facility did not complete a timely and thorough investigation of the missing money.

Inspectors wroteBased on interview and record review during the recertification survey from 4/29/25 to 5/06/25, the facility did not ensure that a resident-to-resident physical altercation with injuries was reported to the State Survey Agency for one of three residents (Resident #13) reviewed for abuse. Specifically, Resident #81 entered Resident #13's room and struck Resident #13 causing injuries to their nose and eye. The facility did not report this incident to the State Survey Agency.

Inspectors wroteBased on interviews and record review during the recertification and abbreviated surveys (NY00376085 and NY00370712) from 4/29-5/6/2025, the facility did not ensure that the resident, resident's representative(s), or ombudsman was notified of the transfer or discharge, and the reasons for the move, in writing and in a language and manner they understand for 2 of 4 residents (Resident #8 and Resident #201) reviewed for hospitalization. Specifically, 1) the facility did not complete a discharge notice or notification of bed hold for Resident #8 when they were hospitalized on [DATE], 3/3/2025, and 3/17/2025. The ombudsman was not notified of Resident #8's 2/2/2025 hospitalization. 2) The facility did not complete a discharge notice or notification of bed hold for Resident #201 when they were discharged to the hospital on 1/21/2025.

Inspectors wroteBased on interviews and record review, the facility did not ensure the Resident Assessment was accurate for 2 of 8 residents reviewed for Activities of Daily Living (Resident #1, Resident #8). Specifically, for Resident # 1 and #8, the toileting hygiene coding was incorrectly, coded as not applicable.

Inspectors wroteBased on observations, interviews, and record reviews during the recertification survey from 4/29-5/6/2025 the facility did not ensure a comprehensive care plan was developed and implemented for 1 of 2 residents (Resident #38) reviewed for Activities. Specifically, there was no documented evidence that a care plan was developed for Resident #38's activity preferences or involvement.

Inspectors wroteBased on observations, interviews, and record reviews conducted during the recertification and abbreviated surveys (NY00376085) conducted from 4/29-5/6/2025, the facility did not ensure that the Comprehensive Care Plan was revised to reflect the resident's current condition for 3 of 8 residents reviewed for accidents (Resident #8, Resident #9, and Resident #38). Specifically, Resident #8, Resident #9, and Resident #38's Comprehensive Care Plan was not updated to reflect falls that occurred, and the effectiveness of interventions or new interventions implemented after the falls.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey from 4/29/2025 to 5/6/2025, the facility did not ensure residents who required dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) received services consistent with professional standards of practice for 1 of 1 resident (Resident #53) reviewed for Dialysis. Specifically, there was no documented evidence of consistent assessment and oversight before, during and after dialysis treatment for Resident #53 who received hemodialysis treatments at a community-based dialysis center.

Inspectors wroteBased on observations, interviews, and record reviews conducted during the recertification survey from 4/29/25-5/6/2025, the facility did not ensure a medication error rate of no more than 5% during a medication administration observation when 4 of 28 opportunities of error were observed (14%) for 4 of 9 residents (Resident #1, Resident #45, Resident #74, Resident #80). Specifically, Resident #1 was administered latanoprost eye drops instead of timolol eye drops. Resident #45 was administered chewable aspirin instead of delayed release aspirin. Resident #74 was going to be administered 10 milliters of Potassium instead of 7.5 milliters until they were asked to confirm the correct amount of liquid in the cup just prior to administration. [...]

Inspectors wroteBased on record review and interview during the recertification survey from 4/29/2025 to 5/6/2025, the facility did not ensure that an ongoing review of antibiotic use protocols and a system to monitor antibiotic use was completed for 2 of 2 residents reviewed for antibiotic use. Specifically, (Residents #95 and #205), the facility could not provide an infection/antibiotic tracking report as requested on 5/5/2025 at 4:00 PM, ensuring that their antibiotic program was implemented to monitor antibiotic use protocols when prescribed to residents.

Inspectors wroteBased on record review and interview during the recertification survey conducted 04/29/2025 to 05/06/2025, the facility did not ensure each resident was offered pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations for 3 of 5 residents (Residents #14, #57, #204) reviewed. Specifically, there was no documented evidence that residents were offered, declined, or educated on the pneumococcal immunization.

Inspectors wroteBased on interview and record review during the recertification survey conducted 4/29/2025 to 5/6/2025, the facility did not ensure each resident was offered the COVID-19 vaccine and provided education regarding the benefits, risks and potential side effects associated with the vaccine for 2 of 5 residents (Resident #57, #204) reviewed for infection control. Specifically, there was no documented evidence they were offered, declined, or educated about the COVID-19 vaccination.

Inspectors wroteBased on record review and interview conducted during the Recertification Survey from 4/29/2025 to 5/6/2025, the facility did not ensure Minimum Data Set Assessments were submitted within 14 days after the facility completed the resident's assessment for 3 of 3 residents reviewed for Minimum Data Set (Resident #41, Resident #59, Resident #76).

Inspectors wroteBased on observation, and interview conducted during the recertification survey from 9/5//2024 to 9/17/24, the facility did not ensure residents' right to a safe, clean, comfortable and homelike environment for 2 of 3 units. Specifically, during environmental observations on Unit 2, room [ROOM NUMBER] D had missing/broken floor molding, room [ROOM NUMBER] had a rusted/ scratched heater, and the walls had damaged sheet rock/ large gouges. The Unit 3 heater (outside the elevator) was rusty and holes were noted in the wall. The Unit 3 floor tiles near the elevator were dirty and dusty with particles. There was a strong odor of urine noted on the Unit 3 hallway on 9/11/24 and Resident #3, #27, #13 had dusty wheelchairs with ripped arm rests and caked on food. Additionally, One of two passenger elevators on the first floor was out of service and not accessible to residents and staff.

Inspectors wroteBased on observation, record review and staff interviews conducted during the recertification and abbreviated surveys (NY00324750) from 9/5/24-9/17/24, the facility did not protect 5 of 6 residents reviewed for abuse from resident-to-resident abuse/mistreatment. Specifically, the facility did not implement interventions for Resident #84 after escalating behaviors were documented starting on 9/16/23 and Resident#84 punched a Staff in the face and punched Resident #73 in the face on 9/22/23. Resident #84 was sent to the hospital for evaluation. [...]

Inspectors wroteBased on observation, record review and interview conducted during the Recertification and Abbreviated Surveys (NY 00327092, NY 00324750 and NY 00333010) from 9/5/24-9/17/24, the facility did not ensure for 3 (Residents #104, #45, and #73) of 9 residents reviewed for abuse, that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately, but not later than two hours after the allegation was made, to the State Agency in accordance with State law through established procedures. Specifically, 1) For Resident #104 there was no documented evidence that an injury of unknown origin was reported by the facility to the state agency after the family representative reported bruises to the resident's hands; [...]

Inspectors wroteBased on observations, record review and interviews conducted during the Recertification and Abbreviated Surveys (NY 00327092,), the facility did not ensure for 1 (Residents #104) of 9 residents reviewed for abuse, that all alleged violations involving abuse, mistreatment, or neglect, were thoroughly investigated. Specifically, Resident #104's family member reported to nursing on multiple occasions that they observed bruises to Resident 104's hands which resulted in x rays being done, and the injuries of unknown origin were never investigated by the facility.

Inspectors wroteBased on observation, record review, and interview conducted during the Recertification and Abbreviated Surveys (NY 00324324) from 9/05/24 to 9/17/24, the facility did not ensure adequate supervision was provided and that the residents environment remained as free of accidents hazards as possible for 1(Residents #10) of 10 residents reviewed for accidents. Specifically, Resident #102 who had a history of exit seeking behaviors, eloped on 9/18/23 during the night shift, and was found in the early morning hours by the police department at an address away from the facility's property.

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated surveys (NY00345570) from 9/5/2024 through 9/17/2024, the facility failed to adequately equip the facility to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside and toilet and bathing facilities, or that each resident was consistently provided an alternate method for communicating needs to staff on 1 of 3 units (Unit 3). Specifically, on 9/10/2024 it was revealed there was no functioning centrally located audible call bell system and the current interim system was not functioning throughout the unit. [...]

Inspectors wroteBased on observation, interview, and record review during a recertification survey from 9/5/24 to 9/17/24, the facility did not ensure residents had the right to a dignified experience for 3 of 6 residents. (Residents #80, #401 and # 97) reviewed for dignity. Specifically, 1.) A Registered Nurse was observed standing over Resident #80 and Resident #97 while assisting the residents with their meals. 2.) Resident #401 was observed in the dining room with other residents while wearing a hospital gown and/or sweatshirt with no pants. and 3.) On 9/12/24 on the first floor hallway outside room [ROOM NUMBER] (a resident's room on unit one) Certified Nurse Aide #11 verbally labelled the residents who needed to be fed as Feeders.

Inspectors wroteBased on interview, and record review conducted during the recertification survey from 9/05/2024 to 9/17/2024, the facility did not ensure residents had a right to organize and participate in resident groups in the facility. Specifically, during a Resident Council meeting on 9/9/2024 at 11:32 AM, Residents #96, #66, #88, #70, #30, #4, #33 and #10 stated it had been a couple of months since they last attended a resident council meeting, because they did not know who should be assisting them. There were no documented resident council minutes for April-July 2024.

Inspectors wroteBased on observations, record reviews and interviews conducted during the Recertification survey from 9/05/24 to 9/17/24, the facility did not ensure resident Comprehensive Care Plan was reviewed and revised upon each assessment. This was evident for 2 of 10 residents reviewed for care planning (Resident #31, Resident #88). Specifically, 1) Resident #31 at risk for falls did not have their comprehensive care plan related to falls updated to reflect current interventions in place to prevent falls. 2) Resident #88 did not have documented evidence of quarterly care plan meetings or updates since 2/27/24.

Inspectors wroteBased on interviews and record review conducted during the Recertification and Abbreviated Survey (#NY 00345570) from 9/5/24-9/17/24 the facility did not ensure that sufficient nursing staff was consistently provided to meet the needs of residents on all shifts. Specifically, 1) Several residents reported in a group meeting (Resident Council) that the facility was short staffed especially on various shifts and weekends which resulted in a lack of timely staff response to call bells 2) several nursing staff reported a lack of sufficient staff. 3) resident family members reported staff were not visible during their visits to the facility and 4). an analysis of the actual staffing schedule showed that on multiple occasions from the month of June 2024, and August 5 2024 through September 5 2024, the facility was below their minimum staffing levels. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey on 9/5/2024 - 9/17/2024, it was determined that the facility did not have a process and frequency by which the administrator reported to the governing body, the method of communication was not recorded, and the governing body did not establish and implement procedures for a clear line of communication regarding the management and operation of the facility. Furthermore, due to this lack of communication to the governing body, they did not ensure that the call bells on unit 300 (3rd floor) were in working order and in regulatory compliance. [...]

Inspectors wroteBased on record review, observation and interviews conducted during the recertification survey from 9/5/24 to 9/17/24, the facility did not ensure the Quality Assurance Performance Improvement committee developed and implemented an appropriate plan of action to address identified issues that impacted resident safety or ensured corrective actions addressed gaps in systems, and were evaluated for effectiveness; and that clear expectations were set around safety, quality, rights, choice, and respect. Specifically, the centralized call bell system had not been working since April of 2024. The facility did not ensure the Quality Assurance Performance Improvement committee developed and implemented an appropriate plan of action to address identified issues related to the central call bell system being out of service. [...]

Inspectors wroteBased on record review and interview conducted during the recertification survey and abbreviated survey (NY 00345570) from 9/5/24-9/17/24, the facility did not ensure that a copy of the Notice of Transfer and Discharge was sent to a representative of the Office of the State Long-Term Care Ombudsman or that a resident's representative was immediately notified when the decision was made to transfer the resident from the facility to the hospital, for 2 of 3 residents (Residents #100 and # 34) reviewed for notification requirement before transfer/discharge. Specifically, 1. Resident #100 was discharged to another facility in July 2024 and there was no documented evidence the Ombudsman had been notified and 2. Resident # 34 was transferred to the hospital on 6/10/24 and there was no documented evidence in the electronic medical record to indicate the resident's Health Care Proxy was notified.

Inspectors wroteBased on observation, interview, and record review during the Recertification Survey from 9/5/2024 to 9/17/2024, the facility did not ensure that each resident received an accurate assessment, reflective of the residents status for 1 of 6 residents reviewed for Activities of Daily Living and 1 of 1 resident reviewed for Respiratory Care (Resident #22). Specifically, the 8/8/24 Quarterly Minimum Data Set Assessment for Resident #22 did not accurately code/capture the residents impaired vision and use of oxygen. The Findings Are: Resident # 22 was admitted with diagnoses including but not limited to chronic obstructive pulmonary disease, neuromuscular dysfunction of bladder, and adult failure to thrive. The 3/12/24 admission Minimum Data Set documented Resident #22 was cognitively intact and had highly impaired vision. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 9/05/2024 through 9/17/2024, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 1 of 7 residents (Residents # 40) reviewed for pressure ulcers, and 1 of 5 residents (Resident #19) reviewed for unnecessary medications. Specifically, 1.) Resident #40 was not care planned for an actual Pressure Ulcer and 2.) Resident #19 did not have a plan of care in place to address the residents needs for Psychotropic drug use. Findings Include: Policy and Procedure: [...]

Inspectors wroteBased on observation, interview and record review conducted during a recertification and abbreviated surveys (NY 00327092 and NY 00337480) from 9/5/24 to 9/17/24, the facility did not ensure residents received the necessary assistance for bathing to maintain personal hygiene for 2 of 6 residents (Resident #104, and #105), reviewed for activities of daily living. Specifically, 1. Resident #104 did not receive 41 scheduled showers between May 2023 and September 2023 and 2. Resident #105 did not receive 12 scheduled showers between December 2023 and January 2024. Additionally, there was no documented evidence that skin checks were consistently done as per physician order for Resident #105.

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey from 9/5/2024 to 9/17/2024, the facility did not ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for 1 of 7 residents (Resident #401) reviewed for pressure ulcers. Specifically, For Resident #401 with a left foot wound, treatments and weekly skin checks were not consistently documented as per physician order and/or care plan, a physician order was not obtained as per wound round recommendations for the implementation of heel booties and an air mattress, and Resident #401 was observed wearing a left air heel boot with velcro straps without a physician order. The Findings Are: [...]

Inspectors wroteBased on observation, record review, and interview during a recertification survey conducted (9/5/2024-9/17/2024), the facility did not ensure the provision of nutrition and hydration care and services for 1 of 5 residents reviewed for Nutrition (Residents # 22). Specifically, the facility did not ensure that For Resident #22 with a 9.79 % weight loss over 6 months, that meal intake was consistently monitored as per care plan. Additionally, Resident #22 with impaired vision was not reassessed to determine the level of assistance needed during meal intake. This is evidenced by: Resident # 22 was admitted with diagnoses including but not limited to Chronic Obstructive Pulmonary Disease, Neuromuscular Dysfunction of Bladder, and Adult Failure to Thrive. The 3/5/24 Activities of Daily Living Care Plan documented eating supervision set up. [...]

Inspectors wroteBased on record review, observation and interview during the Recertification Survey the facility did not ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice for 1 of 1 resident reviewed for Respiratory Care (Resident #22). Specifically, Resident #22 with a physician order to receive continuous oxygen 2 liters/min was administered oxygen 3 liters/min via nasal cannula.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification and Abbreviated Surveys (NY 00324324 and NY 00327092) from 9/05/24 to 9/17/24, the facility did not ensure that the Physician reviewed the resident's total program of care, including medications, and treatments, at each visit for 1 of 10 residents reviewed for Accidents (Residents #102) and 1 of 1 residents reviewed for Change of Condition (Resident #104). Specifically, 1.) Resident #102 who was assessed at high risk for elopement during the 8/12/23 admission, had no physician order in place for placement and checking the function of a wander guard 2.) Resident #104 who was admitted to the facility on [DATE] from the hospital, had no physician order for Oncologist follow up within 1-2 weeks and repeat Computed Tomography Scan within 3-6 months as per Hospital Discharge Instructions.

Inspectors wroteBased on interview, and record review conducted during the Recertification Survey from 9/5/24-9/17/24, the facility did not ensure each Certified Nurse Aide received twelve hours in-service education per year based on their individual performance review for 8 of 8 Certified Nurse Aides (#6, #11, #22, #31, #32, #33, #34, and #35) randomly selected for review of 12-hour yearly mandatory in-services and yearly performance reviews

Inspectors wroteBased on interview and record review conducted during the Recertification Survey completed on 9/5/24-9/17/24, the facility did not ensure that the pharmacist reported irregularities to the attending physician, the facility's Medical Director and the Director of Nursing or that the attending physician documented in the medical record that the identified irregularities had been reviewed and what action should be taken for 3 of 5 residents reviewed for unnecessary medications (# 89, #83, and #19 ). Specifically, 1) Resident # 89 had no documented follow up for drug regimen reviews from 3/24-8/24. 2) Resident # 83 had no documented follow up for drug regimen reviews from 3/24-8/24 and 3)Resident #19 had no documented follow up for drug regimen reviews dated 3/21/24 and 4/15/24.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey and Abbreviated Surveys(NY 00337480) from 9/05/24 to 9/17/24, the facility did not ensure residents were free of significant medication errors for 2 of 8 residents reviewed for medications (Residents #105 and #19). Specifically, 1.) Resident #105 had multiple medication omissions on the Medication Administration Record including antihypertensive's, antibiotics, antidepressants, antianxiety, and thyroid hormones and 2.) Resident #19 had multiple missed does of Insulin (medication used to lower blood sugar levels in people with Type 2 diabetes mellitus).

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted from 09/5/24-09/17/24, the facility did not ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards. Specifically, 1) a cupful of morning medications was left for Resident #45 on their bedside table while the resident was in the bathroom and 2) Dakins' solution and a tube of Silver Sulfadiazine were left on Resident # 90s bedside table.

Inspectors wroteBased on observation, record review and interview conducted during a recertification survey 09/05/24-09/17/24, the facility did not ensure that the necessary dental services were provided in a timely manner for 1 of 1 resident (Resident #70) reviewed for dental services.

Inspectors wroteBased on observations and interviews conducted during the recertification survey from 9/05/24 to 9/17/24, the facility did not ensure that food was stored in accordance with professional standards for food service safety. Specifically, there was open and undated food located in the walk-in refrigerator, there were two metal trays with chicken and tuna salad that passed length of storage and expired half pint boxes of low-fat milk. There were two opened and expired orange juice boxes. In the walk-in freezer there were two boxes of frozen chicken thighs without expiration dates. One of these two boxes was opened to air without the date of opening. In the dry food storage there were Mac orzo and egg noodle pastas' loose in plastic bags without expiration dates.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 9/05/2024-9/17/2024, the facility did not 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 2 of 7 residents (Resident #3 and # 63) reviewed for pressure ulcers. Specifically, 1) Signs identifying resident needs for enhanced barrier precautions or any personal protective equipment were not placed outside the room of Resident #3 with a pressure ulcer and 2) staff were observed not wearing the required personal protective equipment while completing a dressing change for Resident #63 with a stage 4 pressure ulcer.

Inspectors wroteF656-Care Plan Based on observation, record review, and interviews conducted during an abbreviated survey (NY00315819), the facility did not ensure that a Comprehensive Care Plan (CCP) were followed for 3((Residents #4, #5 & #6) of 11 residents reviewed. Specifically, during observation on 4/4/2024 from 12:09 PM to 12:27 PM Residents #4, #5 and #6 who were care planned as needing supervision and/or limited assistance when eating lunch without staff present for supervision.

Inspectors wroteBased on observation, record review, and interviews conducted during an abbreviated survey (NY00315819), the facility did not ensure residents received adequate supervision to prevent an avoidable accident from occurring. This was evident for three (Residents # 4, #_5, & #_6) of eleven residents reviewed for accidents. Specifically during an observation on 4/4/2024 from 12:09 PM to 12:27 PM Residents #4, #5 and #6 was eating lunch with no staff supervision in the dinning rom during lunch.

Inspectors wroteBased on observation, record review, and interviews conducted during an abbreviated survey (NY00331049, NY00330977, NY00330997, NY00331846), it cannot be ensured that the facility disclosed the service limitations to residents and potential residents. This was evident for 7 (Resident #1, #2, #3, #4, #5, #6, #7) out of 10 residents reviewed for notification. Specifically, on 11/28/2023 a water restriction was issued due to the presence of legionella bacteria in the facility's water system. There was no evidence of consistent notification to residents and their families regarding water restriction implementation, the potential risk for legionnaires disease, and the steps being taken by the facility to resolve the issue.

Inspectors wroteBased on observation, record review and interview during an Abbreviated survey(NY00331049, NY00330977, NY00330997, NY00331846), the facility did not ensure that sanitary conditions were being maintained in the kitchen. Specifically, on a tour of the kitchen, the single rinse water temperature gauge on the dishwashing machine was not reaching appropriate temperature, specifically the wash cycle was not meeting temperatures of 165 degrees Fahrenheit (°F).

Inspectors wroteBased on observation, record review and interview conducted during an abbreviated survey (NY00331049, NY00330977, NY00330997, NY00331846), the facility was not administered in a manner that enables the use of its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, on 11/28/2023 a water restriction was issued due to positive legionella bacteria in the facility's water system: (1) the Facility Assessment (FA) was not reviewed or updated to address how the facility can meet the needs of the residents and facility staff; and (2) the facility did not ensure the Quality Assurance Performance Improvement (QAPI) committee developed and implemented appropriate plans of action to correct identified issues with the facility's water system

Inspectors wroteBased on record review, and interviews conducted during an abbreviated survey (NY00331049, NY00330977, NY00330997, NY00331846), the facility did not ensure that it updated and reviewed their facility assessment (FA) annually, or updated any changes in the facility resources and services necessary to provide for the needs of residents. Specifically, (1) the Facility Assessment was not reviewed or updated from 11/31/2020 to 08/14/2023; and (2) the Facility Assessment was not reviewed or updated to address how the facility will meet the needs of the residents and facility staff after they determined on 11/28/2023 that the potable water system was contaminated due to the presence of legionella and were directed by the state and local health departments to implement water restrictions throughout the building. [...]

Inspectors wroteBased on record review, and interviews conducted during an abbreviated survey (NY00331049, NY00330977, NY00330997, NY00331846), the facility did not ensure the Quality Assurance Performance Improvement (QAPI) committee developed and implemented appropriate plans of action to correct identified issues with the facility's water system. Specifically, a water restriction was implemented due to water system contamination with legionella bacteria on 11/28/2023, and members of the Quality Assurance Performance Improvement committee were made aware that the water system was not functional. No quality assurance measures were put in place to identify or address the water issue and to ensure clinical staff and residents were educated on interventions/plans to address the problem during their meeting on 12/19/2023. [...]

Inspectors wroteBased on observation, record review and interviews conducted during an abbreviated survey (NY00331049, NY00330977, NY00330997, NY00331846), the facility did not ensure infection control prevention practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, on 11/28/2023 the facility detected Legionella in their water system. As a result, the facility was directed by state and local health departments to implement water restrictions throughout the building. 1) On 01/26/2024 the kitchen staff were observed using unfiltered tap water for hand washing. There was no signage instructing staff not to use unfiltered tap water to prevent the spread of legionella; [...]

Inspectors wroteBased on record review, and interviews conducted during an abbreviated survey (NY00331049, NY00330977, NY00330997, NY00331846), the facility did not implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, the facility was unable to provide an infection/antibiotic tracking report as requested on 01/25/2024. In addition, the Infection Control Preventionist (Staff #13) stated that there was no infection / antibiotic tracking in place in the facility.

Inspectors wroteBased on observation, record review and interviews conducted during an abbreviated survey (NY00323727) the facility failed to provide diabetic management according to acceptable standards of care to ensure residents remained free from hypoglycemic( caused by lw blood sugar) reactions for 1 of 3 residents (Resident #1) reviewed for quality of care. Specifically, Resident #1 had a diagnosis of Diabetes Mellitus (DM) and had a physician order for blood sugar (BS) testing twice a day, to notify provider if BS less than 70 or above 250. The facility did not provide monitoring of Resident #1's (BS) levels as ordered on 9/8/2023 at 4PM and no BS levels documented on 9/1, 9/2/, 9/3, 9/4 and 9/5. There was no evidence that the physician or nurse practitioner was notified. Resident #1 was transported to the hospital on 9/8/2023 where they were admitted and diagnosed with Hypoglycemia. [...]