Clove Lakes Health Care And Rehabilitation Center,

is no cause to believe an alleged abuse, mistreatment, or neglect regarding this resident has occurred.

group chat and they saw a message approximately on [DATE] between 2:00 AM to 3:00 AM from

9:49 PM, emergency was called, cardiopulmonary resuscitation was initiated until the 911 emergency took over the scene and pronounced Resident #1 expired at 10:24 PM.

Director of Nursing stated they were not notified of Resident #1 reported missing prior to the incident and they heard it only yesterday ([DATE]).

Director of Nursing stated the Infection Control Director, aware of the Resident #1 was reported to them initially missing and was not reported to them in the morning meeting on [DATE].

Director of Nursing stated looking at the Certified Nursing Assistant accountability on [DATE] from 3:00 PM-11:00 PM shift; there was no documentation for dinner, the hourly safety checks the last documentation was 2:45 PM meaning Resident #1 was not accounted for and reviewing the medications administration record that there were no medications received by Resident #1.

Director of Nursing stated with all of this information and if it was investigated thoroughly the investigation would draw a different conclusion.

Therefore, the allegation of abuse or neglect was not investigated or reported to the Department of Health.

During an interview on [DATE] at 4:00 PM, Administrator stated the first time they made aware of the incident was through the hospitalization chat received on [DATE] at 12:20 AM.

Administrator stated they were not aware that Resident #1 was initially missing prior to the incident, not aware that Resident #1 was not monitored hourly, had no record if they had eaten their dinner meal and not received their medication at 4:00 PM to 9:00 PM, not aware when Registered Nurse #1 has not seen Resident #1 from 4:15 PM, had called the Adult Child #1 to look for Resident #1 and called the Registered Nurse Supervisor #1 to report they were missing.

Administrator stated they made aware of Resident #1 that they were initially missing yesterday [DATE].

The Administrator stated it was not reported to Department of Health because they were not aware of the other information that was left out in the investigation. 10 New York Codes, Rules, and Regulations 415.4(b)(1)(i)

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Clove Lakes Health Care and Rehabilitation Center, 25 Fanning Street Staten Island, NY 10314

During an interview on [DATE] at 4:00 PM, Administrator stated the first time they made aware of the incident was through the hospitalization chat received on [DATE] at 12:20 AM.

Administrator stated they were not aware that Resident #1 was initially missing prior to the incident, not aware that Resident #1 was not monitored hourly, had no record if they had eaten their dinner meal and not received their medication at 4:00 PM to 9:00 PM, not aware when Registered Nurse #1 has not seen Resident #1 from 4:15 PM, had called the Adult Child #1 to look for Resident #1 and called the Registered Nurse Supervisor #1 to report they were missing.

Administrator stated they made aware of Resident #1 that they were initially missing yesterday only, [DATE].

Administrator stated it was not reported to Department of Health because they were not aware of the other information that was left out in the investigation and had it known, the facility would re-investigate the incident.10 New York Codes, Rules, and Regulations 415.4(b)(3)

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Clove Lakes Health Care and Rehabilitation Center, 25 Fanning Street Staten Island, NY 10314

Current Tobacco Use in Section J1300.5) Resident #11 was admitted to the facility with diagnoses

smoking room, seated in the wheelchair and smoking with other residents. A Smoking Regulation

signature present. A Smoking assessment dated [DATE] documented Resident #11 was a smoker.A care plan tilted Known Smoker initiated as 08/16/2025 documented Resident #11 is a smoker, and Resident will smoke safely within the designated smoking area.

The Significant Minimum Data Set assessment dated [DATE] documented that Resident #11 was cognitively intact and the assessment did not document Current Tobacco Use in Section J1300.On 04/22/2026 at 5:28 PM, Minimum Data Set Manager was interviewed and stated that the Current [NAME] Use section on Minimum Data (J1300) Assessment was completed by Minimum Data Set Department.

Minimum Data Set Manager stated that they collected information from residents' assessments, staff interviews, and reviewed of the medical records to complete the Minimum Data Set assessments.

Minimum Data Set Manager also stated that they obtained smoking residents' list from Recreation department for about every two weeks in regular basis and each Minimum Data Set nurse have responsible for accuracy for section of J1300 (Current [NAME] Use).

Minimum Data Set Manager stated for accuracy, they check Minimum Data Set Assessment randomly for random sections for every month.

Minimum Data Set Manager stated that they were not aware of the discrepancies in Resident #6, # 7, #8, #10, and #11's Minimum Data Set assessments.10 New York Codes, Rules, and Regulations 415.11(b)

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Clove Lakes Health Care and Rehabilitation Center, 25 Fanning Street Staten Island, NY 10314

During an interview on [DATE] at 7:10 PM, Registered Nurse

time).

Registered Nurse Supervisor #2 stated they immediately responded to search on the unit, but

right side of their bed.

Registered Nurse Supervisor #2 stated they did not observe oxygen connected to Resident #1's nose.

During an interview on [DATE] at 1:37 PM, the Medical Director stated they never heard Resident #1 was not found for several hours on [DATE] during the evening shift incident.

The Medical Director stated they were not made aware that Resident #1 was missing prior to [DATE].

The Medical Director stated they were not made aware of the incident on [DATE], but they became aware after a day or two (2) after through the hospitalization chat (group chat) received.

Medical Director stated they did not review the chart.

They were not made aware that Resident #1 did not receive medications scheduled for 4:00 PM through 9:00 PM until [DATE].

The Medical Director stated they cannot opine whether Resident #1 missing one (1) cycle of medications caused them to collapse and expire.

During an interview on [DATE] at 3:14 PM, the Director of Nursing stated that on [DATE] between 2:00 AM to 3:00 AM they received a message from Registered Nurse Supervisor #1 through hospitalization chat that on [DATE] at 9:49 PM, Resident #1 was found on the floor unresponsive, and that a stat was called, cardiopulmonary resuscitation was initiated until emergency medical services took over the scene and pronounced Resident #1 expired at 10:24 PM.

The Director of Nursing stated that not until [DATE] were they notified that Resident #1 had been reported missing by nursing staff.

The Director of Nursing stated that the Infection Control Preventionist was on duty, and it was initially reported to them.

The Director of Nursing stated that the Infection Control Preventionist failed to report this information to them during the morning meeting on [DATE].

The Director of Nursing reviewed the Certified Nursing Assistant accountability record for the [DATE] 3:00 PM-11:00 PM shift and acknowledged that there was no documentation for hourly safety checks, or meal consumption for Resident #1 The last documentation was 2:45 PM for hourly safety checks.

The Director of Nursing also reviewed the medications administration record and stated that it revealed that there were no medications administered to Resident #1 from 4:00 PM to 9:49 PM.During an interview on [DATE] at 4:00 PM, the Administrator stated the first time they were made aware of the incident was through the hospitalization chat received on [DATE] at 12:20 AM by Registered Nurse Supervisor #1 that Resident #1 was found unresponsive on [DATE] at 9:49 PM.

The Administrator stated they were not made aware Resident #1 had not been seen by nursing and direct care staff for hours or that the resident had not received ordered medications, or treatments or a meal because staff thought the resident was missing or out with family.

This was not reported to them.

During an interview on [DATE] at 9:42 AM, Medical Doctor #1 stated they were Resident #1's assigned doctor.

Medical Doctor #1 stated they received a call from Registered Nurse #1 and Registered Nurse Supervisor #1 at different times (unsure of time) on [DATE] notifying them Resident #1 was found unresponsive and that emergency measures were provided.

Medical Doctor #1 stated Registered Nurse #1 did not notify them Resident #1 did not receive their medications as ordered on the evening shift of the incident. 10 New York Codes, Rules, and Regulations 415.11(c)(3)(i)

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Clove Lakes Health Care and Rehabilitation Center, 25 Fanning Street Staten Island, NY 10314

received education regarding safe smoking practices on 04/22/2026.

Policy and Procedure on

jeopardy to resident health or Assessments on admission/readmission, quarterly and/or as needed.

Non-compliant smokers, safety monitoring will be increased to every 30 minutes, immediately upon identification.

Care Plan will be updated as necessary.

Any resident identified smoking in undesignated area/times will be placed on

facility fully implemented their plan to remove the immediate jeopardy as of 04/22/2026 at 7:57 PM. 10 New York Codes, Rules, and Regulations 415.12 (h)(2)

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Clove Lakes Health Care and Rehabilitation Center, 25 Fanning Street Staten Island, NY 10314

Medical Doctor #1 stated they received a call from Registered Nurse #1 and Registered Nurse

unresponsive and that emergency measures were provided.

Medical Doctor #1 stated Registered

Codes, Rules, and Regulations 415.12(m)(2)

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Clove Lakes Health Care and Rehabilitation Center, 25 Fanning Street Staten Island, NY 10314

During an interview on 04/2026 at 6:45 PM, Director of Nursing stated Resident #7 was on hourly checks for safety.

Director of Nursing stated they have not increased the frequency of monitoring or safety checks after each incident, and they do not reassess Resident #7 for safe smoking after each smoking incident.

Director of Nursing stated they did not know that the other residents had smoking materials with them and they did not know any issue with smoking until the surveyors walked in in the facility.

During an interview on [DATE] at 12:00 PM, Director of Social Worker stated the Recreation Department took over the Smoking Assessment on 10/2025 and they were not involved in Smoking Assessment anymore.

Director of Social Worker stated together with the social service department and nursing they conducted room search to all identified smokers with their consent and those found with smoking materials were confiscated and given to Recreation for safekeeping then Director of Social Worker stated they provided reeducation and smoking agreement to all smokers after room search.

During an interview on [DATE] at 4:19 PM, Medical Director stated they were not the direct care giver to Resident #7, so they are not the most appropriate person to answer questions.

Medical Director stated they did not know of Resident #7's noncompliant behavior with smoking.

Medical Director stated if Resident #7 has noncompliant behavior the facility should keep educating them.

Medical Director stated smoking in a room with continuous oxygen is dangerous.

Medical Director stated they cannot determine at this time if Resident #7 was a safe smoker or not.

During an interview on [DATE] at 7:10 PM, the Administrator stated they continuously provide education (to Resident #7) by reviewing the facility policy and procedure and smoking agreement after each incident.

Administrator stated smoking assessment is being done upon admission and as needed.10 New York Codes, Rules, and Regulations 415.26

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Clove Lakes Health Care and Rehabilitation Center, 25 Fanning Street Staten Island, NY 10314

Based on observation, interview, and record review conducted during the abbreviated survey the

necessary to provide the level and types of care needed for the resident population.

This was evident for one (1) out of four (4) smoking monitors.

Specifically, the facility designated the Activities staff to provide assessments of residents who smoke to identify residents who exhibit unsafe smoking practices.

The Activities staff were also designated to conduct monitoring during residents smoking activity. A review of the Facility assessment dated 09/2025 revealed the position for Activity Aide did not identify the knowledge, training and /or skills required in safe smoking monitoring and oxygen safety.

The findings include: The facility policy titled Facility assessment dated 09/2025 documented identifying resident's acuity levels will help evaluate level of care and services needed to provide sufficient care for facility's residents.

The facility's vision is to provide continuous care through consistency.

The facility's staffing plan is based on the resident population and their needs for care and support.

The facility reviews their residents' acuities and census in order to determine if they need to staff enough employees for each position to meet the needs of the residents at any given time. A review of the Facility assessment dated 09/2025 revealed the position for Activity Aide did not identify the knowledge, training and /or skills required in safe smoking monitoring and oxygen safety.

During an interview on 04/27/2026 at 2:29 PM, the Administrator stated when the have a newly hired smoking monitor staff (Recreation Transporter) they made sure they get specific training and are evaluated through demonstration that shows how to properly monitor the residents in the smoking room and residents with oxygen.

Administrator stated that when they have residents with noncompliant behavior in smoking, they continuously reeducate staff on the smoking policy and remind them of the smoking agreement.

Administrator stated their Facility Assessment indicated that they determined that smoking was another special care needs of residents in the facility.

The Administrator said the smoking monitoring was documented in the facility assessment under the other special needs, and on services related to buildings.

However, it did not elaborate on the actual training for monitoring for safe smoking. 10 New York Codes, Rules, and Regulations 415.5(h)(2)