Every finding on record at Achieve Rehab And Nursing Facility

Based on observation, record review, and interviews, the facility failed to ensure that residents received adequate supervision to remain free from sexual abuse for one (Resident #80) of one reviewed for abuse. Specifically, on 03/12/2026, Maintenance Worker #9 observed the visitor of Resident #66 (roommate of Resident #80) lying on top of Resident #80 with their hands beneath Resident #80's blouse while touching their breasts. Subsequently, Resident #80 was transferred to the hospital on [DATE] for evaluation and returned to the facility. On 03/16/2026, there was documented evidence that Resident #80 reported severe difficulty sleeping, with no sleep the previous night. This resulted in actual psychosocial harm that was not Immediate Jeopardy. The findings include:The facility's policy and procedure titled Abuse of Residents policy revised 10/24/2025, documented that all residents have the right to be free from abuse, neglect, exploitation, and misappropriation. The facility prohibits any form of abuse physical, verbal, sexual, mental, or psychological by anyone, including employees, consultants, volunteers, family members, or other residents. Resident #80 had diagnoses that included, but were not limited to, non-Alzheimer's dementia (loss of memory, thinking or reasoning skills), anxiety, Schizophrenia (chronic, severe brain disorder that causes individuals to interpret reality abnormally), and encephalopathy (malfunction of the brain that alters structure).The 11/22/2025 quarterly Minimum Data Set (a resident assessment tool) documented that the resident was cognitively intact and that they had feelings of being down, depressed, or hopeless.The Care Plan for impaired cognition initiated 01/05/2026 documented discussion with family/caregivers regarding capabilities and needs. Discuss concerns about confusion, disease process, placement with family/caregivers. There was no documented evidence that the Comprehensive Care Plan addressed risk of abuse.The Facility Visitor and Guest Log documented the visitor of Resident # 66 signed into the facility on [DATE], 03/04/2026, 03/08/2026, 03/11/2026, and 03/12/2026. The Incident Report dated 03/12/2026 documented the visitor of Resident #66 signed in to the facility and was later found on top of Resident #80 (both fully clothed). Maintenance Worker #9 intervened, and nursing staff assessed the resident. Resident #80 denied being touched below the waist or genitals and had no injuries. Law enforcement arrived, and Resident #80 was sent to the emergency room, where no trauma or abuse was found. A rape kit was performed at the hospital with family consent in the emergency room, confirming no trauma. The Assistant Director of Nursing/Nurse Managers #2 progress note dated 03/12/2026 at 5:03 PM, documented that at approximately 1:40 PM, Maintenance Worker #9 reported the visitor of Resident #66 was observed on top of Resident #80. Resident #80 was interviewed and reported feeling okay. Resident #80 stated the visitor was on top of them, kissed them, and went under their blouse. Resident #80 stated they asked the visitor to stop, but the visitor did not stop. Resident #80 was evaluated for pain or discomfort. No obvious signs of injury were observed. Resident #80's vital signs were at baseline. Resident #80 was to be evaluated in the emergency room.The emergency room progress note dated 03/12/2026 at 6:25 PM, documented the resident son is at bedside along with advocates, The resident with power of attorney, makes decisions on resident's behalf considering dementia. Informed of need for head-to-toe exam, including potentially conducting a rape kit. Residents' son states they would like to peruse a rape kit including internal exam.The court order dated 05/13/2026 documented the visitor of Resident #66 should stay away from Resident #80.Psychiatrist Nurse Practitioner #2's progress note dated 03/16/2026 at 4:28 PM, documented that the resident's primary complaints were worsening insomnia and schizophrenia. The residents' mood was good, and they denied feeling down, depressed, anxious, or experiencing auditory or visual hallucinations. The resident reported severe difficulty sleeping, with no sleep the previous night, but reported eating well.During an observation and interview on 05/17/2026 at 10:49 AM, Resident #80 was resting in bed. Resident #80 stated they had no recollection of a visitor entering the room, crawling on top of them, or touching their breasts. During an interview on 05/19/2026 at 12:38 PM, Maintenance Worker #9 stated they were doing monthly rounds to check call bells on 03/12/2026. They stated when they entered Resident #80's room, the visitor of Resident # 66 was present and asked them a question about the television. Maintenance Worker #9 stated they stepped out of the room but then remembered they needed to check the other call bell. They stated when they re-entered Resident #80's room, the visitor of Resident #66 was leaning on top of Resident #80, with their hands under Resident #80's blouse, and they were touching Resident #80. Maintenance Worker #9 stated the room privacy curtain was closed. They stated they shouted at the visitor of Resident #66, who then left, and the incident was reported to Licensed Practical Nurse Supervisor # 10. During an interview on 05/19/2026 at 1:49 PM, Registered Nurse Unit Manager # 6 stated after the alleged sexual abuse incident, the Administrator asked them to assess Resident #80. They stated after Resident #80 undressed themselves, they conducted a head-to-toe assessment and asked Resident #80 where they had been touched. They stated Resident #80 pointed to their breast. They stated there was no redness, bruising, or abnormality on Resident #80's body. They stated Resident #80 reported that the person had not touched anything below their waist. They stated at the time the Director of Nursing was on their way to the facility.During an interview on 05/19/2026 at 2:00 PM, the Assistant Director of Nursing/Licensed Practical Nurse Unit Manager #2 stated that on 03/12/2026, Maintenance Worker #9 reported that the visitor of Resident #66 was on top of Resident #80 and was told to leave. The Assistant Director of Nursing/Licensed Practical Nurse Unit Manager #2 and Licensed Practical Nurse supervisor #10 asked Resident #80 if they were uncomfortable after the incident and Resident #80 told them a visitor got on top of them, went under their blouse, and touched their breast, but nothing else happened. They stated Resident #80 told them that they asked the visitor of Resident #66 to stop, but they did not stop. They stated the Director of Nursing and Administrator called 911, and Resident #80 was sent out to the hospital. During a telephone interview on 05/20/2026 at 9:29 AM, Police Officer # 1 stated they received a call about the sexual assault of Resident # 80. Police Officer # 1 stated Maintenance Worker # 9 saw the visitor on top of Resident # 80, with hands under the Resident #80 blouse, and asked, What are you doing? They stated Resident #66's visitor was alone with Resident #80. They stated they interviewed Resident #66's visitor at their job, and they admitted to climbing on top of Resident #80 and kissing them. Police Officer #1 stated an order of protection was issued. During an interview on 05/20/2026 at 10:50 AM, the Director of Nursing stated their arrival occurred within 15 minutes to the facility after the incident. They stated Police Officer # 1 and the Administrator responded to the 03/12/2026 incident. The Director of Nursing stated they were told the visitor of Resident #66 was on top of Resident #80, who was fully dressed. They stated Assistant Director of Nursing/Licensed Practical Nurse Unit Manager #2 confirmed the visitor of Resident #66 left the facility. They stated to avoid contamination; Registered Nurse Unit Manager #6 assessed the top half of Resident #80. They stated after they spoke with Police Officer #1 and Emergency Medical Services and Resident #80 was sent to the hospital. During an interview on 05/20/2026 at 11:05 AM, the Administrator stated they received a text message from Assistant Director of Nursing/Licensed Practical Nurse Unit Manager #2, which reported that the visitor of Resident #66 was involved in an incident with Resident #80. They stated that they could not remember whether the police officer spoke to Resident #80, and that Resident #80's family member had been notified and was upset. They stated that they had interacted with the visitor of Resident #66 in the past and had observed no red flags. They stated Resident #66 attended therapy on the day of the incident, and Resident #80 was left in the room with the visitor of Resident #66. During a telephone interview on 05/20/2026 at 11:45 AM, Psychiatric Nurse Practitioner #2 stated Resident #80 had encephalopathy which caused memory impairment. They stated that many of their contacts with Resident #80 were appropriate. They stated after the incident, they asked Resident #80 whether they were hurt and provided emotional support. They stated that due to memory impairment, Resident #80's account of the incident became confused. They stated the resident had a blunted effect and did not recall or remember what happened because of the resident's liver disease. During a follow-up interview on 05/21/2026 at 11:00 AM, Psychiatric Nurse Practitioner #2 stated they came to the facility once a week to see residents. They stated that the sexual assault, in theory, would have effect on quality of life. However, it was difficult to assess this in Resident #80 because of dementia with cognitive decline. They stated Resident #80 minimized their feelings by saying it was okay. During an interview on 05/20/2026 at 12:55 PM, Social Service Assistant #4 stated they visited Resident # 80 after the sexual abuse incident to provide support and ensure Resident # 80 felt safe in the facility. Social Service Assistant #4 stated Resident # 80 did not remember the sexual abuse incident. 10 New York Codes Regulations and Rules 415.4(b)(1)(i)

Based on observation, interviews, and record review, the facility failed to ensure that a resident received the appropriate treatment and services to prevent complications of enteral feeding for one (Resident #129) of one reviewed for tube feeding. Specifically, Resident #129 was not administered enteral fluids for nutrition/hydration per physician orders. Subsequently, Resident #129 was hospitalized on [DATE] with a diagnosis of hypernatremia (high concentration of sodium in the blood). This resulted in actual harm to Resident #129 that was not Immediate Jeopardy The findings included: The facility policy titled, Kangaroo Enteral Feeding Pump Use and Management, revised 04/2026 documented only trained licensed nursing personnel shall initiate, adjust or discontinue enteral feedings. Residents receiving enteral nutrition shall be monitored routinely for hydration status and pump functionality. Residents receiving tube feedings shall be monitored every shift for formula amount remaining, intake/output if ordered, and hydration status. Resident #129 had diagnoses that included aphasia (inability to express speech caused by brain damage), seizure disorder (uncontrolled electrical activity in the brain), and anoxic brain damage (no oxygen to the brain). The quarterly Minimum Data Set (a resident assessment tool) dated 04/15/2026 documented Resident #129 was unable to communicate, was dependent on staff with all cares and had a gastrostomy tube (feeding tube). The Physician Order dated 06/20/2025 documented Osmolite 1.5 at 70 milliliters x 18 hours (7:00 PM-1:00PM). Total volume of 1260 ml.The Physician Order dated 12/10/2025 documented six times a day water flushes 150 milliliters (ml) every four hours for a total of 900 milliliters every 24 hours (excluding medication flushes). The Care Plan for nutrition and tube feeding, revised 01/14/2026, documented monitor/document/report to the physician; monitor lab work; registered dietitian to evaluate quarterly and as needed, monitor calorie intake, estimate needs, make recommendation or changes to the tube feeding as needed: Osmolite 1.5 (nutritional formula) at 70 milliliters/hour for 18 hours (7:00 PM-1:00PM) with water flush 150 milliliters every 4 hours and 30 milliliters flush before, between and after medications. The Treatment Administration Record for April 2026 documented monitor intake every shift, including all fluid intake. The 8:00 AM to 8:00 PM intake documented 800 ml for 24 of 27 opportunities, 840 ml for one of 27 opportunities, 450 ml for one of 27 opportunities, and 900 ml for one of 27 opportunities. The 8:00 PM to 8:00 AM intake documented 800 ml for 20 of 25 opportunities, 840 ml for one of 25 opportunities, 860 ml for one of 25 opportunities, 900 ml for one of 25 opportunities, 960 ml for one of 25 opportunities, 1000 ml for one of 25 opportunities and two were blank. The Laboratory Report dated 04/22/2026 documented Sodium 165 reference range 135-147 (hypernatremia), Chloride 126 reference range 96-108 (dehydration), and Blood Urea Nitrogen (measure of nitrogen in the blood that comes from urea) 64 reference range 6-20 (dehydration). The Physician Order dated 4/23/2026 documented Osmolite 1.5 at 70 milliliters/hour for 18 hours (8:00 AM - 2:00 AM). Total volume of 1260 milliliters. The Progress Note dated 04/23/2026 written by Nurse Practitioner #1 documented Resident #129 with hypernatremia likely due to inadequate overnight water flushes with the tube feeding. The Progress Note dated 04/24/2026 written by Nurse Practitioner #1 documented persistent hypernatremia despite IV hydration of Dextrose 5% Water. Sodium 164. Concerns for ongoing free water deficit. Clinical course concerning for life threatening electrolyte derangement (abnormal concentration of minerals in the body) and will require hospitalization. The Progress Note dated 05/04/2026 written by Physician #1 documented Resident #129 was status post hospitalization for hypernatremia/unresponsive episode. Thought to be due to inadequate free water intake via gastrostomy tube and was found to be 2.4 liters in deficit. During an observation on 05/17/2026 at 11:40 AM, Resident #129's tube feeding formula, Osmolite 1.5 and water bag were hanging with no date, and no name on the bottle. The Kangaroo pump (mechanical feeding pump) was running at 70 milliliters per hour. The total feed on the Kangaroo pump indicated 5,561 milliliters had been administered. During an observation on 05/18/2026 at 8:38 AM, Resident #129's Kangaroo pump was beeping and had an indicator of blocked tube on the display. The Osmolite 1.5 1,000 milliliters bag was hung and had been labeled with the date of 05/18/2026 and 8:00 AM start time; and a 1,000 milliliters bag of water was hung and labeled with the date 05/18/2026. During observations on 05/18/2026 from 8:56 AM through 11:41 AM, the Kangaroo pump was beeping and indicated blocked tube at 8:56 AM, 9:07 AM, 9:23 AM, 9:39 AM, and 10:11 AM. At 11:31 AM the Kangaroo pump was running and had provided 91 milliliters of formula since 8:00 AM. At 11:41 AM the Kangaroo pump was providing a flush and displayed a flush of 42 milliliters. During an observation and interview with the Assistant Director of Nursing/Unit Manager #2 on 05/19/2026 at 11:44 AM, both water bag and formula were labeled/dated. The Kangaroo pump displayed 70 milliliters per hour, and the total feed administered of 1,301 milliliters. There were 900 milliliters left in the 1,000 milliliters bag of formula. The Assistant Director of Nursing/Unit Manager #2 stated the nurse who started the new bag of formula at 8:00 AM probably did not clear the pump from the day before and the pump continued to calculate from what had already been administered the day before. They stated if the pump was not cleared it would give incorrect information. The Assistant Director of Nursing/Unit Manager #2 stated they were not sure how or where the nurses were getting the numbers documented on the intake/output monitoring. During an interview on 05/19/2026 at 12:16 PM, Registered Dietitian #1 stated there was no change in the formula or water flush for Resident #129 despite the elevated sodium levels. They stated that formula and water flushes were changed to the day shift to keep more eyes on the pump and make sure it was running properly. The Assistant Director of Nursing/Unit Manager #2 stated they thought the issue was that the nurses were not clearing the pump when they hung a new bag of formula and water. During an interview on 05/19/2026 at 12:22 PM, Registered Nurse #21 stated when they calculated the intake for Resident #129 during their shift, they thought they added four water flushes of 150 milliliters, total of 600 milliliters and then added the water for the flushes during medication administration. During an interview on 05/19/2026 at 12:37 PM, the Director of Nursing stated Resident #129's intake should be calculated from the total formula, water flush and medication water flushes given. The nurses could read the pump for the amount administered if the pump is cleared properly. The Director of Nursing stated the staff was probably trying to calculate the amount themselves and that could be the inconsistency documented on the intake monitoring. They stated the Enteral Feeding policy did not spell out how to calculate and document intake. During an observation and interview on 05/20/2026 at 7:45 AM, Licensed Practical Nurse #17 was starting the Kangaroo pump for Resident #129. Licensed Practical Nurse #17 flushed 30 milliliters of water before they started the feeding, programed the pump to start at a rate of 70 milliliters per hour, and did not clear the pump. The pump displayed 1,944 milliliters already administered when it was started. Licensed Practical Nurse #17 stated they documented the intake by calculating 70 milliliters per hour multiplied by the number of hours the pump was on during their shift; they did not look at the pump to see what was administered. They also stated that certified nurse aides could stop and start the Kangaroo pump to provide cares for Resident #129. They stated that was the only time the pump would be off during their shift. They stated this could affect the intake. During observation and interview on 05/22/2026 at 7:50 AM, Licensed Practical Nurse #17 started the Kangaroo pump and did not clear the pump. The pump displayed 1,122 milliliters to start at 8:00 AM. During a telephone interview on 05/22/2026 at 9:16 AM, Physician #1 stated Resident #129 had a Kangaroo pump and the water flushes should be automatic. When Physician #1 was made aware that the pump was not cleared out by staff when they started it on 05/17/2026 at 8:00 AM and that on 05/17/2026 at 11:40 AM the pump was observed to have administered 5,561 millilitersPhysician #1 stated that the hospitalization for hypernatremia could have been avoided since the flushes were not as automatic as user error. Furthermore, they stated this could have been a stressful situation for Resident #129. During an interview on 05/22/2026 at 10:50 AM, the Director of Nursing stated the facility purchased the Kangaroo pumps in 12/2025 in hopes of better accuracy and resident outcomes. They stated the training of the operation of the Kangaroo pump education had a five-question quiz, but there was no competency demonstrations completed with the nursing staff. 10 New York Code Rules Regulations 415.12(g)(2)

Based on interview and record review the facility failed to ensure that resident assessments were transmitted within the required time frame for ten (10) of ten (10) residents reviewed for resident assessments (Resident #15, Resident #46, Resident #78, Resident #81, Resident #87, Resident #97, Resident #120, Resident #127, Resident #128, and Resident #146). Specifically, 1) Resident #15 had an assessment reference date of 01/26/2026 and a submission date of 03/01/2026; 2) Resident #78 had an assessment reference date of 08/18/2025 and a submission date of 09/11/2025; 3) Resident #127 had an assessment reference date of 08/15/2025 and a submission date of 09/21/2025. Additionally, Resident #46, Resident #81, Resident #87, Resident #97, Resident #120, Resident #128, and Resident #146 all had at least one assessment that was filed late in 2025 or 2026.The findings included:The undated Minimum Data Set Guidelines for Completion facility policy documented that it is the policy of the facility to ensure accurate and timely completion of Minimum Data Set Assessments for all residents in accordance with Federal and State Operation Manual. The Registered Nurse Assessment Coordinator is responsible for scheduling the Assessment Reference Date, assigning the reason for the Assessment, ensuring completion of all sections and timely transmission of assessments to the Centers for Medicare and Medicaid. 1)Resident # 15 had diagnoses that included diabetes, hyperlipidemia, and repeated falls.The Annual Minimum Data Set, dated [DATE] documented that the assessment was signed by the Minimum Data Set Coordinator and confirmed as completed on 02/08/2026. The Simple Long Term Care Minimum Data Set Transmission Activity Log documented that the assessment was uploaded on 03/01/2026.2)Resident #78 had diagnoses that included generalized anxiety disorder, depression, and sepsis. The admission Minimum Data Set, dated [DATE] documented that the assessment was signed by the Minimum Data Set Coordinator and confirmed as completed on 08/25/2025.The Simple Long Term Care Minimum Data Set Transmission Activity Log documented that the assessment was uploaded on 09/11/2025.3)Resident #127 had diagnoses that included heart failure, diabetes, and chronic pain. The Annual Minimum Data Set, dated [DATE] documented that the assessment was signed by the Minimum Data Set Coordinator and confirmed as completed on 09/01/2025.The Simple Long Term Care Minimum Data Set Transmission Activity Log documented that the assessment was uploaded on 09/21/2025.During an interview on 05/22/2026 at 10:17AM, the Minimum Data Set Coordinator stated that they have been late on many assessment submissions but have been working with the interdisciplinary team to get the submissions back on schedule. They stated that Resident #15, Resident #46, Resident #78, Resident #81, Resident #87, Resident #97, Resident #120, Resident #127, Resident #128, and Resident #146 have all had late submissions with varying levels of lateness and provided the Simple Long-Term Care Minimum Data Set Transmission Activity log that they use to track the submission of assessments. They could not provide a specific reason why they were late, just that they were aware and know they should not be late. They stated they hope that some of the changes they have made will help improve the timeliness of submission. 10 New York Code Rules Regulations YCRR 415.11

Based on observation, interview, and record review, the facility failed to ensure that food was stored or prepared in accordance with professional standards for food service safety. Specifically, 1) during kitchen tour on 05/17/2026, food was not properly labeled, refrigerator #1 was not maintained at a temperature to ensure food safety, and appliances and food prep/storage areas were not well maintained for cleanliness; 2) four (4) of four (4) units (1 East, 2 East, 1 West, and 2 West) pantries and refrigerators contained unlabeled and expired food items and were not well maintained for cleanliness; 3)Kitchen Aide # 20 was observed without a beard net on 05/17/2026 while in the kitchen collecting recyclables.The findings included:The Food Storage Policy last reviewed 07/15/2025 documented that all food products in the facility are stored, handled, and maintained under sanitary and safe conditions that prevent contamination, support nutritional adequacy, and comply with state/federal regulations. Refrigerated foods will be maintained at temperatures less than or equal to 41 degrees Fahrenheit. All stored food will be labeled with item name, resident name if applicable, date opened/prepared, and expiration/discard date. Resident personal food will be stored in designated refrigerators and must be labeled with the residents' name and date. Dairy foods should be discarded within seven (7) days, leftovers within 72 hours, and per manufacturer expiration if in commercial original container. 1) On 05/17/2026 starting at 10:29AM with Head [NAME] #11, the following were observed during the initial tour of the kitchen. The thermostat for refrigerator #1 read 50 degrees Fahrenheit. In refrigerator #1, two (2) open, undated one (1) gallon mayonnaise jars and one (1) open, undated one (1) gallon golden Italian dressing bottle, juices in carafes with plastic wrap covers and no labels indicating when they were poured, and a partially used cucumber wrapped in plastic wrap without a date were observed. In refrigerator #2, boxes of bananas and chicken were on the floor of the refrigerator. Boxes of lettuce, onions, and bananas had no date indicating when they were received. In the dry storage area, one (1) open bottle of soy sauce and one (1) open bottle of barbeque sauce were observed stored without refrigeration or a date indicating when they were opened.The floors in the kitchen, dry storage food area, and 3-day emergency supply room were visibly soiled with dirt and/or loose debris. The stove top and ovens had built up black grime and grease. The three (3) day emergency supply room had a loose drain hole cover and mouse droppings on one of the stored boxes. Two wall tiles were missing in the area where recyclables were stored exposing the sub wall. A wheeled three shelf cart used to move items in the kitchen was visibly soiled and actively used.During an observation and interview on 05/17/2026 at 11:30AM, the thermostat for refrigerator #1 read 46 degrees Fahrenheit. Head [NAME] #1 stated that refrigerator #1's temperature was too high but was within range at 38 degrees Fahrenheit when checked that morning as indicated on the log. They stated it was likely high because of the frequent opening and closing of the door that morning. They stated that items should not be stored on the floor in or out of the refrigerator. Items should be dated when received and opened. During a follow up observation and interview on 05/17/2026 at 1:22PM, refrigerator #1 was 48 degrees Fahrenheit. Head [NAME] #11 checked the temperature of a container of milk in refrigerator #1 with this surveyor and it read 47.4 degrees Fahrenheit. They stated they would move all items to refrigerator #2 and dispose of the milk and other perishables that may be affected. Maintenance would be notified of the high temperatures. 2) On 05/17/2026 at 11:40AM, the following were observed in the unit pantry cabinets and refrigerator on 2 West. In the refrigerator, two (2) one quart milk bottles and a 32-ounce container of Med Plus vanilla had no date indicating when they were opened. Six (6) plastic containers with leftover food had names or room numbers and the following dates written on the containers, 04/28/2026, 05/03/2026 on two (2) containers, 05/08/2026, 05/10/2026, and 05/12/2026. A plastic clear container with a yellow butter-like substance with no name or date. Two (2) plastic containers of leftover food in a plastic bag with an illegible name or date on the bag. The unit refrigerator was visibly soiled at the base and in the drawers. In the pantry cabinet a container of honey thickened apple juice was observed stored with an expiration date of 04/26/2026.On 05/17/2026 at 11:50AM, the following were observed in the unit pantry cabinets and refrigerator on the 2 East Unit. In the refrigerator, three (3) open bottled drinks (Fanta orange soda, Pure Leaf tea, and Vitamin water) and one (1) small black plastic container with a white soft substance with no name or date. An open bottle of Kens Ranch Salad dressing with no name or date, and an expiration date of 03/25/2024. An open quart of milk without an open date. In the pantry cabinet, one loaf of bread with an expiration date of 04/29/2026. One (1) container of thickened apple juice had leaked into the cabinet and dried, adhering it to the surface. The countertop around the sink was visibly soiled with partially used carafes of juice. There were soiled dishes left in the sink. During an interview on 5/17/26 at 12:00PM, Kitchen Aide #13 stated that the kitchen staff were responsible for cleaning the unit refrigerators and checking the contents and temperatures. They should dispose of expired items or unlabeled items. Nursing staff should also dispose of expired items if observed. They were not responsible for the rest of the room or cabinets. On 05/17/2026 at 12:08PM, the following were observed in the refrigerator and freezer on the 1 [NAME] Unit. In the refrigerator, a plastic container of potato salad with an illegible name and an expiration date of 04/22/2026. A bag with a name but no date with a plastic container of seedless grapes with a use by date of 05/10/2026. Two 60-ounce open cranberry juice bottles with no open date. One (1) white and orange bag containing leftover food from an outside restaurant with no name or date. A plastic container with leftover food contained in a plastic bag with an illegible name and date. Three hardboiled eggs on a paper plate covered with clear plastic with no name or date. In the freezer, one (1) open cake, half gone, unsealed, and no name or date. On 05/17/2026 at 12:15PM, the following were observed in the refrigerator and freezer on the 1 East Unit. In the freezer, one (1) Mc Donald's plastic cup with frozen liquid half full and a straw exposed and three (3) frozen meals with no name or date. Three (3) plastic containers with frozen leftover food with freezer burn with a name but no date. In the refrigerator, one (1) open 60-ounce bottle of cranberry juice, one (1) open thickened apple juice, one (1) quart of milk, and one (1) open Mott's applesauce with no open date. One (1) [NAME] Donut coffee cup with no name or date. One (1) plastic container with leftover food with no name or date. One (1) plastic container with a label that indicated it was cucumber salad, with a name, and dated 05/09/2026. One (1) carton of one (1) dozen eggs with no name or date. One (1) plastic container of cantaloupe with a name and use by date of 05/16/2026. Three (3) plastic containers with leftover food observed with an illegible name or date. The refrigerator surfaces were visibly soiled. 3) On 05/17/2026 starting at 10:26AM, Kitchen Aide #20 was observed working in the kitchen disposing recyclables with facial hair and no beard net.During an interview on 05/17/2026 at 11:30AM Head [NAME] #1 stated that hair nets, including beard nets, should be used when in the kitchen. During an interview on 05/18/2026 at 3:11 PM, the Director of Food Services stated that kitchen staff should be labeling the stored food with dates when received and when opened. Kitchen staff were responsible for cleaning the appliances and floors in the kitchen daily. They stated the mouse droppings in the 3-day supply room were new and they had not received any reports of mouse sightings. They do have a regular pest control company and would report the droppings. They were unaware of the loose drain cover but would inform maintenance as it could be a slipping hazard. They stated that the food service handler is responsible for checking the unit refrigerators for contents, cleanliness, and temperatures. Leftover food should be stored for three (3) days then discarded, and expired unlabeled food should be discarded. 10 New York Code Rules Regulations 415.14 (h)

Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals were maintained in accordance with currently accepted professional principles for labeling, expiration dates, and tracking of controlled substances. Specifically, nebulizer treatments were found in a clear unlabeled plastic bag in the refrigerator in one (1) of two (2) medication rooms reviewed for medication storage. A labeled partially used insulin pen was found without an open date on one (1) of two (2) medication carts reviewed for medication storage. The controlled medication change in shift log was missing a nurse's signature on two dates in one (1) of two (2) medication rooms reviewed for medication storage. The findings included:The facility Medication Storage policy last reviewed 11/2025 documented that drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. The nursing staff is responsible for maintaining medication storage. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.During an observation and interview starting on 05/19/2026 at 09:35 AM in the 1 East Medication room with Registered Nurse #21, a clear unlabeled plastic bag containing eight (8) packages of Formoterol Fumarate 20 micrograms per two (2) milliliters was observed on the refrigerator door of the medication room. Registered Nurse #21 stated that the Formoterol Fumarate should have been in a box or bag with a resident information label. During an observation and interview starting on 05/19/2026 at 10:31 AM, the 2 [NAME] Medication Room was observed with Licensed Practical Nurse #26. When reviewing the controlled medication change of shift log, the signature was missing from the nurse that relieved Licensed Practical Nurse #26 on the evening of 05/18/2026. There was also no signature from the same nurse when they handed the keys over to Licensed Practical Nurse #26 on the morning of 05/19/2026. Licensed Practical Nurse #26 stated the count was correct, otherwise they would not have accepted the keys. They stated that the incoming and outgoing nurses should sign the log to indicate that the controlled medication count was completed with two (2) nurses and is correct. During an observation and interview starting on 05/19/2026 at 12:37 PM, the 2 East medication cart was observed with Licensed Practical Nurse #14. An open labeled insulin glargine pen was on the cart without a date indicating when it was opened. Licensed Practical Nurse #14 stated the date the pen was opened should have been indicated on the packaging because they dispose of them 28 days after opening. 10 New York Code Rules Regulation 415.18(e)(1-4)

Based on observation, interview, and record review the facility failed to ensure the residents' right to a safe, clean, comfortable, and homelike environment on four (4) of four (4) units (1 East, 2 East, 1 West, and 2 West) reviewed for environment. Specifically, 1)1 East, rooms [ROOM NUMBERS] had malfunctioning air conditioners, and room [ROOM NUMBER] had a sharp sink edge; 2) 2 East, room [ROOM NUMBER] had a sink that continuously dripped; 3) 2 West, room [ROOM NUMBER] had worn and peeling wallpaper under the sink and the endcaps on the handrails outside of room [ROOM NUMBER] were loose and not affixed properly. Additionally, on 1 West, the wall and wallpaper in the common area near the sink were damaged and the wallpaper was peeling up. The findings included:The Homelike Environment policy last reviewed 02/2026 documented that residents are provided with a safe, clean, comfortable and homelike environment. Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. 1) During an interview on 05/18/2026 at 9:29 AM, Resident #134 stated that their air conditioner was broken and wanted it fixed.During resident council on 05/18/2026 at 10:26AM, Resident #134 stated that the air conditioner in their room was not functioning properly. They stated they resided in room [ROOM NUMBER]. Resident #127 stated they resided in room [ROOM NUMBER] and that their air conditioner was not working and was not fixed as requested. During an observation on 05/18/2026 at 1:58 PM, the edge of the sink in room [ROOM NUMBER] was observed to be rough and unfinished.During an observation and interview on 05/19/2026 at 10:18 AM in room [ROOM NUMBER], Resident #127 was sitting in their wheelchair. They stated that it was hot. A loud rattling noise was heard when the air conditioner was turned on. They stated they told maintenance but had not heard back. They stated they did not use the air conditioner even though the room was warm because of the loud noise.During an observation on 05/19/2026 at 1:41 PM on the 1 East Unit, the edging of the sink in room [ROOM NUMBER] had an exposed sharp edge on the underside of the sink cabinet. 2) During an observation on 05/17/2026 at 9:34 AM, the sink in room [ROOM NUMBER] was running. Resident #91 stated the sink would not turn off and was noisy. They stated maintenance was aware and tried fixing it, but it was still broken. During an observation and interview on 05/18/2026 at 09:23 AM, Resident #91 was out of bed in a wheelchair in their room. Water was running from the faucet in the room. An attempt was made to turn off the water, but it continued to run. Resident #91 stated the building was antique and things did not get repaired when they were broken.During an observation on 05/19/2026 at 11:35 AM, the faucet in room [ROOM NUMBER] had running water that could not be turned off.3) During an observation on 05/19/2026 at 11:20 AM on 2 [NAME] in room [ROOM NUMBER], the wallpaper was peeling under the sink. In the hallway between rooms [ROOM NUMBERS], six end caps for the handrails were loose and not secured.During an interview on 05/19/2026 at 12:22 PM, Certified Nurse Aide #28 stated that any staff member could report something in need of repair. There was an electronic form, and it went directly to maintenance.During an interview on 05/19/2026 at 12:27 PM Licensed Practical Nurse #14 stated that there was a form that any staff member could complete if maintenance was needed for a repair. During an interview on 05/19/2026 at 12:54 PM, Registered Nurse Unit Manager #25 stated that there was an electronic program to report issues to maintenance. They stated they were aware of the dripping water from the sink in room [ROOM NUMBER] but Resident #91 would not allow them to fix the problem and wanted it to remain that way. During an interview and walking rounds starting on 05/19/2026 at 1:35 PM, the Director of Maintenance stated that they were not aware of the sharp edge in room [ROOM NUMBER] but when observed with this surveyor, they stated it would need a protective edge applied. They stated they spoke with the resident in room [ROOM NUMBER] today and would be checking the air conditioning in that room. They stated they were aware of the problem in room [ROOM NUMBER] and were working to fix the air conditioning issue. They stated they had repaired the dripping sink in room [ROOM NUMBER] in the past but would have to check it again. They stated that the end caps for the handrails needed to be affixed and would make sure that it was completed. They stated that room [ROOM NUMBER] was one of the oldest rooms so they were not surprised that the wallpaper was peeling up and needed repair. They stated that they do daily rounding, but more for safety checks not for repairs. They expected staff to complete a request for maintenance service if something was observed or reported as broken.10 New York Code Regulations Rules 415.3

Based on interview and record review the facility failed to ensure that residents' financial records were available to the resident and/or representative through quarterly statements for one (1) of three (3) residents reviewed for personal funds. Specifically, Resident #129's representative stated they did not receive quarterly statements, and the facility financial office was not able to provide proof that they had provided quarterly statements. The findings include: The policy titled Quarterly Financial Statement Policy for Residents reviewed 05/2025 documented the facility shall maintain accurate accounting records for all resident personal funds managed by the facility and provide quarterly financial statements to residents and/or their responsible parties in accordance with CMS and New York State Departement of Health requirements. Quarterly financial statements shall be issued every three (3) months. Residents and/or responsible parties shall receive copies of statements. Resident #129 diagnosis included cerebral palsy, quadriplegia, and severe intellectual disability. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #129 was unable to communicate. During an interview on 05/17/2026 at 3:14 PM, Resident #129's sister (representative) stated they had not received any quarterly financial statements from the facility. During an interview on 05/21/2026 at 8:30 AM the Business Office Director stated the Resident Fund Management System did not automatically send statements to the facility as it had in the past and now the Business Office Director had to make requests for the statements to be sent. They stated they had not sent a quarterly statement to Resident #129's sister/representative because the sister had not requested a quarterly statement and they had difficulty reaching Resident #129's sister (representative) on the phone. 10 New York Code Rules Regulations 415.26(h)(5)(i)

Based on observation, interview, and record reviews the facility failed to ensure residents' rights to a dignified existence for two (2) of five (5) residents (Resident #11 and #152) reviewed for dignity and one (1) of 11 residents (Resident #97) observed during dining. Specifically, 1) Resident #11's uncovered nephrostomy drain bag was visible from the hallway 2) Resident #125 was observed dressed in a ripped/torn hospital gown and 3) Residents were served drinks in disposable plastic cups during meals. Additionally, Certified Nurse Aide #8 stood while they assisted Resident #97 with feeding during lunch on 05/17/2026. The findings included: The policy titled Dignity last reviewed 04/2025 documented that all residents are always treated with dignity and respect. When assisting with care, residents are supported in exercising their rights including being provided with a dignified dining experience. Staff are expected to promote dignity, including keeping drainage bags covered. Demeaning practice that compromises dignity is prohibited. 1) Resident #11 had diagnoses that included but were not limited to multiple sclerosis, calculus of kidney and hypothyroidism. The care plan titled Resident with left side nephrostomy tube dated 12/29/2025 documented the nephrostomy bag is to be changed each week and to record the output each shift. The quarterly Minimum Data Set Assessment (assessment tool) dated 04/18/2026 documented Resident #11 had moderately impaired cognition. The Care Plan for resident with left side nephrostomy tube dated 12/29/2025 documented the nephrostomy bag is to be changed each week and to record the output each shift. During observations on 5/18/2026 at 11:16 AM and 5/20/2026 at 9:07 AM, Resident #11's uncovered covered nephrostomy drain bag was hanging on the left side of the bed and visible from the hallway. During an interview on 5/20/2026 at 9:10 AM, the Director of Nursing stated the nephrostomy drain bag should be covered. They stated the cover must have fallen off. They stated this was a dignity issue. During an interview on 5/20/2026 at 1:11 PM, Nurse Manager #2 stated the drain bag should have been covered since it could be seen. They stated certified nurse aides received training on nephrostomy and catheter bags and there should have been a dignity cover on the bag. 2) Resident #125 had diagnoses that included but were not limited to Parkinsons Disease, type II diabetes mellitus, and depression. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #125 was cognitively intact and received supervision or touching assistance with upper body dressing. During an observation on 05/18/2026 at 1:42 PM Resident #125 was sitting in a wheelchair in hospital gown, ripped in the front. On the same day at 3:04 PM, Resident #125 was on the elevator in a wheelchair in same hospital gown with a rip on the front of the gown. During an interview on 05/20/2026 at 8:50 AM, the Director of Housekeeping stated when facility gowns were washed and dried, staff inspected for rips or tears when items were folded. They stated if a gown was damaged, the staff would put it in a closed container for the supervisor to inventory/dispose of the damaged gown and a new gown would be ordered. They stated laundry staff may occasionally put a damaged gown back into rotation if they don't see it while folding. They stated maybe once a year there is a complaint about a ripped gown. During an observation and interview on 05/21/2026 at 9:40 AM, Resident #125 stated that they can sometimes dress themself but at times required assistance from the certified nurse aide. Resident #125 stated that they did not remember what they were wearing on Sunday (5/17/2026) and if it was torn/ ripped. During an interview on 05/21/2026 at 10:31 AM, Certified Nursing Aide #23 stated they were assigned to Resident #125 on Sunday, 05/17/2026 and that Resident #125 generally dressed independently. During an interview on 05/22/2026 at 11:06 AM, the Director of Nursing stated that facility gowns could have been torn by residents, especially if they pull at the gown near the snaps. They stated if a certified nurse aide noticed a gown was torn or soiled in any way, they were instructed to change it as soon as possible and throw the damaged gown away. 3) During an observation on 05/17/2026 starting at 12:40PM in the 2 East Dining Room, all residents in the dining room were served cold drinks in disposable plastic cups. During an interview on 05/17/2026 at 1:10PM, Certified Nurse Aide #8 stated they always used disposable plastic cups for the cold drinks for residents. During an observation in the 1 East Dining Room on 05/18/2026 at 12:37 PM, all juices and soda were served to residents in disposable plastic cups during lunch. During additional observations of meal services on all units on 05/17/2026 and 05/18/2026 residents were served milk, juice and water in disposable plastic cups. During an interview on 05/19/2026 at 1:08 PM the Food Service Director stated the beverage carts were sent to the units with handled cups for hot beverages only. They stated nursing staff used the disposable plastic cups from the medication cart to serve the cold beverages. The Food Service Director stated they asked the food service company about this procedure and were told it was okay to use the disposable plastic cups. During an observation on 05/20/2026 at 8:57 AM, breakfast was being served in the 1 East dining room. Juice and milk were being served to residents in disposable plastic cups. During an interview on 05/22/2026 at 1:01 PM, the Administrator stated they were not aware that disposable plastic cups were being used. They stated they were ordering new cups. They stated disposable plastic cups did not promote dignity. 10 New York Code Rules Regulations 415.3(d)(1)(i)

Based on observation, interview, and record review, the facility failed to ensure a safe, sanitary, and comfortable environment was maintained to help prevent the development and transmission of communicable diseases and infections for all residents when reviewing the water management plan and three (3) of eight (8) residents (Resident #95, Resident#124, and Resident #157) reviewed for medication administration. Specifically, 1) a water management plan was missing and not provided at the time of the survey; 2) on 05/19/2026, after using the community glucometer on Resident #65, Licensed Practical Nurse #14 was stopped and asked to sanitize the glucometer before using it on Resident #124; 3) on 05/21/2026, after administering medications to Resident #40, Licensed Practical Nurse #22 did not sanitize their hands prior to medication administration for Resident #95. Additionally, when administering dorzolamide eye drops to Resident #157, Licensed Practical Nurse #7 used the same tissue to wipe both eyes after administration of the medication. The findings included:1) Review on 5/20/26 at 11:10 AM of the facility legionella logs revealed that a water management plan was missing and not provided at the time of survey.During an interview with the Director of Maintenance on 05/20/2026 at approximately 1:40 PM, the Director of Maintenance stated that the legionella water management plan could not be located. 2) During an observation and interview starting on 05/19/2026 at 12:01PM, Licensed Practical Nurse #14 performed a fingerstick on Resident #65 using a community glucometer. At 12:07 PM they prepared the same glucometer to perform a fingerstick on Resident #124 but failed to sanitize the glucometer. This surveyor stopped Licensed Practical Nurse #14 before proceeding into the room. Licensed Practical Nurse #14 stated that they should have sanitized the shared equipment and would do so now before performing the fingerstick. 3) During an observation starting on 05/21/2026 at 9:09 AM, Licensed Practical Nurse # 22 administered medications to Resident #40. After the medication administration for Resident #40, at 9:22AM they prepared and administered medications to Resident #95 without sanitizing their hands. During an interview on 05/21/2026 at 9:27 AM, Licensed Practical Nurse #22 stated that they were distracted and did not provide hand hygiene between Resident #40 and Resident #95 when administering their medications. They should have sanitized their hands between the two residentsDuring an interview on 05/21/2026 at 9:37 AM, Registered Unit Manager #6/Interim Infection Preventionist stated that nurses should sanitize their hands between residents when medications are administered. Community equipment should be wiped down with the available sanitizing wipes between residents. They also stated that when nurses administer eye drops, a separate tissue should be used for each eye when wiping the eyes after administration. During an interview on 05/22/2026 at 11:46 AM, the Director of Nursing stated nurses should sanitize their hands between residents when administering medication. Shared equipment should also be sanitized between residents. 10 New York Code Rules Regulations

Based on observation, interview, and record review, the facility failed to ensure that drinks served during meals were at appetizing temperatures. Specifically, during the observed meal services from 05/17/2026 until 05/22/2026, the cold drinks were stored in an open bin with a small level of ice that melted quickly. As a result, the drinks did not maintain appetizing temperatures. The findings included: The Dining Services Policy last reviewed 09/2024 documented that the facility shall provide meals that meet residents' nutritional needs, preferences, physician orders, and regulatory requirements. Proper food temperatures and sanitation practices shall be maintained. During an observation and interview on 05/20/2026 at 8:57 AM, breakfast was being served in the 1 East dining room. The drink cart was observed with an open top bin holding the drinks. Melted ice was in the base of the bin about 1-2 inches in depth. During an observation and interview on 05/20/2026 at 09:04AM, the Food Service Director obtained the temperatures of the milk and orange juice that were being served. The milk was 53 degrees, and the orange juice was 52 degrees. The Food Service Director stated that they were concerned about keeping the drinks cold during the dining services and have decreased the time that the drinks sit out but have not achieved desired temperatures yet. During an observation and interview on 05/22/2026 at 9:04 AM, the breakfast meal was served on unit 1 East. The beverage cart was observed to have very little ice in beverage bin. The Kitchen Supervisor/Head [NAME] #11 obtained the temperature of the milk poured from the carton that was in the beverage bin. The temperature of the milk was 49 degrees Fahrenheit. Kitchen Supervisor/Head [NAME] #11 stated they needed to add more ice to the beverage bin to keep the milk at 41 degrees or less. The milk was sampled and it was palatable. 10 New York Code Rules Regulations 415.14 (d)(1)(2)

Based on observation, record reviews and interviews, the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene for two (2) of three (3) residents (Resident #12 and #16) reviewed for activities of daily living. Specifically, 1) there was no documented evidence that toileting hygiene was consistently provided for Resident #12 on multiple dates in January, February, March and April 2026 and 2) Resident #16 required staff assistance with personal hygiene and was observed on three (3) occasions with dirty and stained fingernails and long facial hair. The findings include: The facility policy Activities of Daily Living Documentation, last reviewed 5/2024, documented it is the responsibility of the certified nurse aide to sign the activities of daily living flow sheet at the end of each shift. 1) Resident #12 had diagnosis that included but were not limited to left leg below knee amputation, acute congestive heart failure and acute respiratory failure with hypoxia. The Annual Minimum Data Set Assessment (assessment tool) dated 3/31/2026 documented Resident #12 had intact cognition and was dependent on the staff for toileting hygiene. The Care Plan for resident has an activity of daily living self-care performance deficit dated 5/20/2026, documented Resident #12 was dependent with two (2) staff members for toileting hygiene. The certified nurse aide Documentation Survey Report for January 2026 documented 24 shifts for toileting hygiene and 11 shifts for was Resident visualized every two (2) hours that were not documented as being performed or completed. The certified nurse aide Documentation Survey Report for February 2026 documented 20 shifts for toileting hygiene and 13 shifts for was Resident visualized every two (2) hours that were not documented as being performed or completed. The certified nurse aide Documentation Survey Report for March 2026 documented 28 shifts for toileting hygiene and 28 shifts for was Resident visualized every two (2) hours that were not documented as being performed or completed. The certified nurse aide Documentation Survey Report for April 2026 documented 25 shifts for toileting hygiene and 29 shifts for was Resident visualized every two (2) hours that were not documented as being performed or completed. During an interview on 5/22/2026 at 8:43 AM, Resident #12 stated the certified nurse aides were not checking on them every two (2) hours. They must ring the call bell when needed and it takes a while to be cleaned even after talking to the certified nurse aides. During an interview on 5/22/2026 at 9:03 AM, Unit Manager #7 stated they expect all staff to document every shift and expect documentation to be completed. If it is not documented, it did not happen. If the task is not completed, then they expect the staff to document why it was not done. During an interview on 5/22/2026 at 9:56 AM, the Director of Nursing stated they expected all documentation to be done by staff each shift. If it was not documented, then it did not occur. 2) Resident #16 was admitted with diagnoses including atrial fibrillation, peripheral vascular disease and ischemic heart disease. The 3/31/2026 admission Minimum Data Set documented Resident #27 had minimal cognitive impairment and needed maximum assistance with toileting hygiene and bathing. There was no plan of care to address the residents' Activities of Daily Living needs. The certified nurse aide Kardex, documented showers were given on Mondays and Thursdays and the resident required substantial assistance from one member of staff with showering twice a week. During an interview on 5/18/2026 at 12:04 PM Resident #16 stated they wanted their nails cut because they were too dirty and long. They stated they wanted their face shaved because the hair was long and they wanted to look clean. During an observation on 5/18/2026 at 12:04PM Resident #16 was in bed, their fingernails were long with a brown substance under the nails and on the cuticles. Resident #16 had grown hair on their face and there was a urine odor in the room. During observations on 5/19/2026 at 11:33AM and 5/20/2026 at 9:51AM Resident #16 had overgrown facial hair, long nails with a brown substance on the cuticles and under the nails. The certified nurse aide Daily Assignment sheets for the month of April revealed there were nine (9) opportunities for a shower and the resident was provided four (4) showers, two (2) wash ups and three days were blank and not signed. During an interview on 05/20/2026 at 9:53 AM Certified Nurse Aide #23 stated they had the resident on their assignment and did not know if the resident received showers. They stated a bed bath (wash up) did not include nails and a shave. During an interview on 5/20/2026 at 10:15AM Certified Nurse Aide#24 stated they had the resident on their assignment on 5/18/2026 and did not give the resident a shower on 5/18/26 as scheduled because the resident wanted to sleep longer. They stated they provided a bed bath. They stated they did not shave or care for the residents' nails. They stated they were aware of the dirty nails and stated the resident often had feces under their nails. They stated they did not inform the nurse of the bed bath because they were in a rush. They stated they should have let the nurse know. During an interview on 05/20/2026 at 10:12 AM Registered Nurse Unit Manager #25 stated certified nurse aides were to look at the shower sheets daily to check their assignments and determine who will need a shower. They stated nails and shaves were to be performed on shower days. They stated certified nurse aides were supposed to let them know if the resident refuses showers. They stated certified nurse aides also needed to document on the shower sheets why a shower did not occur. They stated showers and clean hands were important because it makes residents feel good. They stated they were not aware of so many missed showers. They stated they were responsible for ensuring care was given. 10 New York Code Rules Regulation 415.12 (a)(3)

Based on interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 (one) of 28 residents (Resident #153) reviewed for quality of care. Specifically, for Resident #153 who received Eliquis (blood thinner) and sustained a fall on 08/20/2024, there was no documented evidence that a physician order was put in place timely to address every one-hour neuro checks and right shoulder/forearm radiographic imaging to rule out fracture as per the 08/20/2024 at 7:01 AM incident report interventions. Subsequently, there was no documented evidence that every one-hour neuro checks were conducted prior to 1:00 PM on 08/20/2024. Additionally, there was no documented evidence that right shoulder/forearm radiographic imaging was conducted prior to Resident #153's transfer to the hospital on [DATE]. The findings included:The policy titled Fall Assessment, Prevention and Management, last reviewed 10-2025, documented the resident physician and responsible party (for incapable residents) would be notified of incidents.Resident #153 had diagnoses including encephalopathy (brain dysfunction), atrial fibrillation (an irregular heartbeat), and chronic kidney disease.The 08/19/2024 Physician Order documented Eliquis 2.5 milligrams one tablet by mouth two times daily. The August 2024 Medication Administration Record documented Eliquis 2.5 milligrams one tablet two times a day was administered 08/20/2024-08/22/2024.There was no documented evidence in the Baseline and/or Comprehensive Care Plan to address goals and interventions related to administration of Eliquis. The Incident Description dated 08/20/2024 at 7:01 AM prepared by Registered Nurse #3 documented this writer was called to the unit to assess the resident on the floor. Resident was laying on the floor next to the right side of the bed. Resident slid from bed and on to the floor, in between the floor and the floor mat. Floor mats down on either side of the bed, due to resident's noted confusion and non-compliance noted from admission assessment the prior evening. Resident assessed for injuries, large 7-8-centimeter skin tear noted to anterior right forearm. Skin tear cleansed and a dressing applied. Resident was assisted back to bed, close monitoring due to the level of confusion and lack of safety awareness. The writer spoke in person to the wife, following the incident. Medical Doctor notification as per protocol. Order for right forearm and shoulder x-rays to rule out fracture. Every 30-minute safety checks placed. Residents' wife advised of resident having history of chronic pain and stiffness, decrease in range of motion to the right shoulder related to history of gunshot wound. Immediate interventions included assessment for pain, range of motion, and possible injury. The resident was safely assisted off the floor while safety precautions were maintained. Radiographic imaging of the right shoulder and right forearm was ordered. Immediate action taken; assessed for pain/range of motion and injury. X-Ray of right shoulder and right forearm. Safety checks and neuro checks x 24 hours. Every 30 minutes safety checks placed. The skin tear was cleansed, and dressing was applied. Imaging of the right shoulder and right forearm were ordered.The Physician Order dated 08/20/2024 at 1:00 PM documented neuro checks every one-hour x 24 hours status post fall out of bed, unwitnessed. Floors mats in place at all times while in bed.There was no documented evidence in the August 2024 Administration Record to indicate neuro checks were conducted on 08/20/2024 between 7:01 AM and 1:00 PM.There was no documented evidence to indicate that a Physician Order was placed for radiographic imaging of the right shoulder and right forearm to rule out fracture after a fall out of bed as per the 08/20/2024 Incident Report.There was no documented evidence in the Electronic Medical Record to indicate radiographic imaging of the right shoulder and right forearm was conducted as per the 08/20/2024 Incident Report.The 08/22/2024 admission Minimum Data Set (an assessment tool) documented Resident #153 had severe cognitive impairment and required staff assistance with activities of daily living.The 08/22/2024 Practitioner Progress Note documented the chief complaint was a fall from bed, with the family requested transfer to the Emergency Room. During interview on 05/18/2026 at 2:00 PM, Resident #153's family stated the facility did not adequately evaluate the resident following the fall. The family reported bruising was present on the right side of the resident's body and they requested transfer to the hospital. The family further stated the facility should have recognized the severity of the resident's condition and initiated hospital transfer without requiring family insistence.During an interview on 05/19/2026 at 6:55 PM, Nurse Practitioner #1 stated Resident #153 did not sustain a head strike during the unwitnessed fall. Nurse Practitioner #1 stated although Resident #153 was prescribed Eliquis, they were not sent to the hospital after the fall because no head strike was identified. Nurse Practitioner #1 stated the resident remained at baseline, although ecchymosis and increased behaviors were observed. Nurse Practitioner #1 further stated the expectation was that Resident #153 would undergo radiographic imaging to rule out fractures. Nurse Practitioner #1 stated radiographic imaging had been ordered, and the technician was present on 08/22/2024. Nurse Practitioner #1 further stated the family expressed concern the radiographic imaging had not been completed sooner and asked that the resident be transferred to the hospital. Nurse Practitioner #1 stated they arranged transfer to the hospital for Resident #153.During an interview on 05/20/2026 at 11:58 AM, Registered Nurse #3 who assessed Resident #153, stated when the resident was found on the floor it would be considered an unwitnessed fall because no staff observed the fall. Registered Nurse #3 further stated normal practice included notifying the physician of injuries and whether the resident received anticoagulant medication. Registered Nurse #3 stated there was no recollection of whether the physician was informed that Resident #153 received anticoagulant medication. Registered Nurse #3 further stated protocol included neurological checks and safety checks every 30 minutes. Registered Nurse #3 stated radiological imaging was ordered, and they did not know why imaging had not been done. 10 New York Code Rules Regulations 415.12

Based on observation, record review, and interview, the facility failed to ensure each resident received adequate supervision and assistance devices consistent with the resident's needs to prevent accidents for two (2) of six (6) residents reviewed for accidents (Resident #92 and Resident #61). Specifically, 1) floor mats were observed by the bed and a bedside commode was observed blocking the bathroom door in the room of Resident #92 who had a history of fall on 05/06/2026. Additionally, there was no documented evidence that a physical therapy evaluation was conducted timely and 2) for Resident #61, there was no documented evidence that the resident was assessed to determine safe usage of an electric coffee pot The findings include: The policy titled Fall Assessment, Prevention and Management, last reviewed 10-2025, documented provide a safe environment to prevent falls and subsequent injuries with fall prevention measures that can be put in place per physician order, and to avoid fall mats with ambulatory residents, which could create an environmental hazard. 1) Resident #92 had diagnoses including Parkinson's Disease, Dementia, and a history of falling. The quarterly Minimum Data Set assessment dated [DATE] documented moderately impaired cognition, partial assistance with walking 10 feet and toilet transfers, and no falls since admission. The Care Plan for activities of daily living deficit dated 03/20/2026 documented partial, moderate assist for ambulation and toileting. The incident/accident summary dated 05/06/2026, documented at 7:40 AM, Licensed Practical Nurse was notified of a new black/blue ecchymotic area above Resident #92's right eye. Resident #92 stated, I fell in the bathroom, had gotten up off the floor, returned to bed, and did not report the incident to the staff. Upon assessment, Resident #92 was noted with bruising above the right eye and pain to the right side of the abdomen. Resident #92 was sent to the emergency department and computed tomography scan revealed 6th and 7th rib fracture. The care plan was reviewed with no deviation noted. The plan was to add a bedside commode upon return from the hospital, make a referral to therapy, and pain management. Resident #92 was re-admitted status post hospitalization on 05/08/2026. The Certified Nurse Aide Kardex documented that Resident #92 required maximum assistance with transfers and was coded as not applicable for ambulation. The comprehensive Care Plan was not updated to reflect Resident #92 maximum assistance for transfers after return from the hospital on [DATE]. During an observation on 05/17/2026 at 10:37 AM, Resident #92 was lying in bed with a three (3) inch blue cushion mat on door side of bed and a flat rubber type mat between the roommate's bed. Resident #92 had a white bandage/patch on the right side of their torso and stated they had fallen in the bathroom and had broken ribs. There was no documented evidence in the Certified Nurse Aide Kardex and/or or Care Plan to address the use of floor mats. The Care Plan for fall risk was last updated on 05/17/2026 documented keep the call light within reach, ensure appropriate footwear, maintain a safe environment with even floors, and provide bedside commode. There was no documented evidence in the electronic record that a physical therapy evaluation was conducted before 05/19/2026 During an observation on 05/18/2026 at 9:43 AM, Resident #92's wheelchair was vacant in the doorway to their room. The bedside commode was positioned next to the bathroom door. Resident #92 was standing in the partially opened doorway of the bathroom. Both floor mats were in place on the floor to the left and right side of Resident #92's bed. During an interview on 05/20/2026 at 8:30 AM, Resident #92 stated they did not use the bedside commode and were using the bathroom in their room independently. During an interview on 05/20/2025 at 3:51 PM, the Director of Rehabilitation stated that before the fall on 05/06/2026, Resident #92 was under supervision for walking and received minimal assistance with toileting. They could not recall any floor mats in use before the fall, as they would have been in the way for Resident #92 to ambulate. The Director of Rehabilitation stated that nursing can request a bedside commode if they feel a resident needs it. During an interview on 05/20/2026 at 4:15 PM, Certified Nurse Aide #15 stated Resident #92 was toileting themself in the room independently. They stated Resident #92 parked the wheelchair in the doorway and walked to the bathroom. Certified Nurse Aide #15 stated the floor mat by the door was placed after Resident #92 fell. Certified Nurse Aide #15 stated they were aware that Resident #92 currently ambulated to the bathroom without assistance. They stated the unit manager made rounds and could decide whether the floor mat needed to stay. During an interview on 05/20/2026 at 4:24 PM, Licensed Practice Nurse #16 stated they were aware that Resident #92 walked to the bathroom in their room. They stated the floor mat and commode blocking the bathroom door would be a hazard. Licensed Practical Nurse #16 stated they should have told the unit manager of their observation but reporting it doesn't always happen right away due to being busy. During an interview on 05/20/2026 at 4:31 PM, the Assistant Director of Nursing/Nurse Manager #2 stated the floor mat should not be removed yet because if the Resident falls and there is no mat, they could be injured; if the mat stayed, it would protect Resident #92. During an interview on 05/22/2026 at 10:57 AM, the Director of Nursing stated the floor mats were not part of the plan of care, and they were not sure who implemented the mats. 2) Resident #61 had medical diagnoses that included encephalopathy (brain dysfunction), low back pain, and depression. The admission Minimum Data Set assessment, dated 03/20/2026, documented that Resident #61 had moderately impaired cognition and required staff assistance with activities of daily living, with staff providing less than half the effort during these activities. The care plan dated 03/23/2026 documented that the resident had impaired cognitive function, dementia, and impaired thought processes related to dementia. The care plan instructed staff to administer medications as ordered and communicate with family caregivers regarding the resident's capabilities and needs. A physician order dated 04/23/2026 prescribed Aricept oral tablet 10 milligrams, one tablet by mouth at bedtime, for dementia. There was no documented evidence in the electronic health records indicating that an assessment had been completed to determine the resident's ability to use the coffee maker safely. During observations conducted on 05/17/2026 at 12:15 PM and 05/18/2026 at 9:43 AM, Resident #61 had a coffee maker in the resident's room with supplies; however, the coffee maker lacked an inspection sticker. During an interview on 05/20/2026 at 12:12 PM, Licensed Practical Nurse #7 stated that Resident #61 did not use the coffee maker. The nurse explained that family members used the coffee maker during visits; however, the resident could potentially attempt to make coffee. During an interview on 05/21/2026 at 9:59 AM, Registered Nurse Unit Manager #6 stated that Resident #61 had a coffee maker in the resident room that family members had brought in. The nurse stated that no assessment had been completed to determine whether the resident could safely operate the coffee maker. The nurse further stated that Resident #61 had not been observed preparing coffee with the machine; however, there was concern that the resident could attempt to make coffee independently. During an interview on 05/21/2026 at 10:00 AM, the Director of Nursing stated that the facility did not have a policy or assessment process regarding residents' use of coffee makers. New York Code Rules Regulations 415.12 (h)(2)

Based on observation, interview, and record review the facility failed to ensure each resident received necessary respiratory care and services that were consistent with professional standards of practice for two (2) of three (3) residents (Resident #24, #102) reviewed for Respiratory Care. Specifically, 1) Resident #24's oxygen humidifier bottle was empty and had a date from three (3) weeks prior, and 2) Resident #102 was administered oxygen at a liter flow greater than the current physician's order and the humidifier bottle was observed empty. The findings included: The facility policy, Oxygen Concentrator, last reviewed 9/2025, documented delivery of a constant supply of concentrated high purity supplemental oxygen therapy to residents who need and cannot get enough oxygen from room air. 1) Resident #24 had diagnoses that included but were not limited to chronic respiratory failure, acute kidney failure, and hypothyroidism. The quarterly Minimum Data Set Assessment (assessment tool) dated 3/19/2026 documented Resident #11 had intact cognition and was receiving oxygen therapy. A physician order dated 10/24/2024 documented Resident #24 oxygen tube and bottle are to be changed weekly and as needed. The tubing and bottle are to be initialed at time of change. A care plan Resident has Oxygen Therapy dated 11/17/2024 documented administer oxygen therapy as ordered. A physician order dated 4/25/2025 documented Resident #24 was to receive oxygen intermittently at three (3) liters per minute via a nasal canula. During an observation and interview on 5/17/2026 at 11:22 AM, Resident #24's oxygen humidifier bottle was empty and dated 4/27. Licensed Practical Nurse #19 stated the oxygen humidifier bottle was empty and they would replace it. During an interview on 5/20/2026 at 1:11 PM, Nurse Manager #2 stated the humidifier bottle should have been changed weekly. During an interview on 5/22/2026 at 9:56 AM, the Director of Nursing stated the oxygen humidifier bottles should have been changed. 2) Resident #102 diagnoses included chronic atrial fibrillation, dementia, and hypertension. The Annual Minimum Data Set, dated [DATE] documented Resident #102 was cognitively impaired and did not require oxygen therapy at the time of the assessment. A physician order dated 7/29/2024 documented change oxygen tubing and bottle weekly and as needed. Rinse oxygen filter with water, pat dry and replace. Initial tubing and bottle at time of change. Place tubing in dated plastic bag when not in use. Every Sunday night shift. A physician order dated 3/04/2025 documented oxygen at two (2) liters per minute via nasal cannula on at bedtime and off in the morning. At bedtime for oxygen saturation less than 90%, notify the doctor for oxygen saturation of less than 90%. During observations on 5/17/2026 at 12:14 PM and 05/18/2026 at 11:02 AM, Resident #102 was observed lying in bed with nasal cannula in place. There was no date on the tubing. The empty water humidifier was dated 05/11, and the concentrator was set at three (3) liters. During an interview on 5/18/2026 at 11:47 AM, Licensed Practical Nurse #16 stated all nurses were responsible for checking oxygen. Resident #102 had orders for pulse oximeter to be taken every shift. Licensed Practical Nurse #16 stated they checked the pulse oximetry that morning and it was 92%, but they did not check the settings on the concentrator. They stated staff could get pulled away in an emergency and not get back to change the humidification bottle. Licensed Practical Nurse #16 checked the oxygen order and stated the concentrator should have been set at two (2) liters. During an interview on 5/20/2026 at 11:59 AM, the Assistant Director of Nursing/Unit Manager #2 stated humidification bottles should be dated and changed weekly on Sundays. 10 New York Code Rules Regulations 415.12 (k)(6)

Based on observation, interview and record review, the facility failed to ensure the medication error rate was less than five percent during medication administration observations on 05/19/2026, 05/20/2026, and 05/21/2026. 32 opportunities for errors were observed, two (2) errors were made, yielding a 6.25% medication administration error rate for two (2) of eight (8) residents observed (Resident #19 and Resident#40). Specifically, 1) Resident #19 was administered two and one half (2.5) milligrams of amlodipine besylate instead of one (1) (5) five milligram tablet as ordered and 2) Resident #40 was going to be administered two (2) 500 milligram tablets of magnesium until the contents of the cup were counted by this surveyor prior to administration. Additionally, they were administered one 500 milligram tablet of magnesium instead of two 250 milligram tablets. The findings included:The Medication Administration Policy dated 04/29/2026 documented that the nurse administering medication must follow the rights of medication administration including the right time, right route, right dose, right medication, right resident, and right documentation. 1)Resident #19 had diagnoses including Alzheimer's Disease, asthma, and hypertension. The quarterly Minimum Data Set, dated [DATE] documented severely impaired cognition and diagnoses included hypertension.During an observation on 05/20/2026 at 10:06AM, Licensed Practical Nurse #7 was observed administering amlodipine besylate, two and one half (2.5) milligrams to Resident #19. During the medication reconciliation, the physician order dated 05/11/2026 was reviewed and documented amlodipine besylate oral tablet, five (5) milligrams. Give 1 tablet by mouth one time a day for hypertension. During an interview on 05/21/2026 at 3:02 PM, Licensed Practical Nurse #7 stated that the incorrect dose of amlodipine besylate was administered on 05/20/2026 at 10:06AM. They administered two- and one-half milligrams (2.5), but the order was for five (5) milligrams. The order was recently changed and there was no alert on the packaging, and the blister pack containing 2.5 milligram tablets was not removed from the medication cart. They stated they should have caught it when checking the blister pack against the medication order. During an interview on 05/22/2026 at 10:01 AM, Registered Nurse Unit Manager #6 stated that the incorrect dose of amlodipine besylate was administered to Resident #19 on 05/20/2026 at 10:06AM. They stated when medication orders change, they put the order change on report and verbally tell the nurse administering medication. The incorrect medication card was not removed from the cart, and the incorrect dose was administered in error. The correct dosage was received from the pharmacy but was in the bottom drawer of the medication cart. The dose should have been confirmed before administration.During an interview on 05/22/2026 at 11:46 AM, the Director of Nursing stated that they were aware that the incorrect dose of amlodipine besylate was administered to Resident #19 on 05/20/2026 at 10:06AM. The dose in the blister pack should have been checked against the order prior to administration. They stated that when the physician orders a change in medication dose, the nurse taking the order should inform the medication administration nurse and the incorrect medication should be removed from the cart to prevent errors. 2)Resident #40 had diagnoses including hypomagnesemia, dementia, and diabetes. The quarterly Minimum Data Set, dated [DATE] documented severely impaired cognition and diagnoses included hypomagnesemia. During an observation and interview starting on 05/21/2026 at 09:09AM, Licensed Practical Nurse #22 was observed drawing up medication for Resident #40. They stated they only keep magnesium 500 milligrams in stock so they will administer one instead of two 250 milligram tablets. When this surveyor checked the count of tablets prior to administration in the medication cup, one additional tablet was observed. Licensed Practical Nurse #22 stated they had drawn up two of the magnesium tablets in error and removed one. During the medication reconciliation, the physician order dated 12/20/2025 was reviewed and documented magnesium gluconate oral tablet 250 milligrams. Give 2 tablet by mouth one time a day for supplement.During an interview on 05/22/2026 at 10:01 AM, Registered Nurse Unit Manager #6 stated that orders should be followed as written and checked prior to administration. The medication nurses should not substitute a medication without an order even if the dose is the same. During an interview on 05/22/2026 at 11:46 AM, the Director of Nursing stated that orders should be checked prior to administration. The medication nurse should always get an order that reflects what is being administered if a substitute is needed, even if the dose is the same. They should not make a substitution without an order. 10 NYCRR 415.12(m)(2)

Based on observation, interview, and record review, the facility failed to ensure menus were followed and posted for six (6) of six (6) residents in Unit 1 East and Unit 2 dining rooms during Dining Observations. Specifically, 1) Residents #56 and #35 reported concerns related to meal tray item accuracy in accordance with the printed tray ticket, Resident #56 stated there were no posted menus and no posted menus were observed, and 2) multiple residents were observed at mealtime with meal tickets that did not match the items served on their meal tray. The findings include: The facility policy titled Dining Services reviewed 09/2024 documented the facility shall provide meals that meet residents' nutritional needs, preferences, physician orders, and regulatory requirements. Residents shall receive diets as ordered and alternate meal choices shall be offered when feasible. Residents have the right to make choices regarding meals, food preferences and dining schedules whenever possible. 1) During dining observation and interview in Unit 2 dining room on 05/18/2026 at 12:45 PM, Resident #56 and their daughter stated there were no menus distributed, so they never knew what they were getting for meals. They stated items on the meal ticket were never the same as what was served on the tray and that today was an exception. When asked about an alternate, Resident #35 stated they could ask for an alternate, but it could take an hour and a half to get it. They stated dinner roll was sometimes on the meal ticket and both Residents #56 and #35 stated they had never seen a dinner roll served on their tray. Resident #56 stated toast was on their tray at breakfast and jelly was listed on the tray ticket, but they never had jelly on their tray. Resident #56's daughter stated there was a sign in the hall for the menu to be posted but they had not seen a menu there for a month. During an interview on 05/18/2026 at 12:52 PM, the Food Service Director was asked if there were menus hanging anywhere. They looked at the three (3) empty sleeves below the menu sign and stated the menu was usually there, but it was not there now. They stated they would let the boss know. 2) During an observation of lunch on Unit 1 East on 05/17/2026, Resident #90's meal ticket listed turkey, cauliflower, sweet potato, fortified mashed potatoes, pudding cake and magic cup. The fortified mashed potatoes and magic cup were not present on the meal tray. During an interview on 5/19/2026 at 1:08 PM, the Food Service Director stated the nursing staff was responsible for passing the magic cup from the unit freezer where the magic cup was stocked daily. They stated they were not sure why the fortified mashed potatoes were missing from Resident #90's lunch meal tray.During an observation and interview on 05/22/2026 at 9:08 AM, Resident #55's meal ticket listed: scrambled egg, cream of wheat, wheat toast, diet jelly, margarine. The wheat toast and diet jelly were missing from the meal tray. Blueberry muffin was served. Resident #47's meal ticket listed: scrambled egg, cream of wheat, wheat toast, diet jelly, margarine, and banana. The tray had 2 hard-boiled eggs, cheerios: missing wheat toast and diet jelly. Blueberry muffin and yogurt were served. Head Cook/Supervisor #11 stated the missing items on the meal trays were likely due to the dietary staff in a rush to serve breakfast. They did not have anyone to check the trays as they are completed. They never have anyone checking trays at any meal. 10 New York Code Rules Regulations 415.14(c)(1-3)

Based on observation, interview, and record review the facility failed to ensure residents were free from physical restraints for one of one resident (Resident #31) reviewed for restraints. Specifically, for Resident #31 who was unable to demonstrate independent release of a Merry [NAME] release bar, there was no documented evidence that ongoing assessment was conducted, and consent was obtained for the continued use of a Merry Walker. Additionally, the care plan was not updated to reflect individualized resident focused interventions to include ongoing assessment, education, and signed consent/s for the use of the Merry Walker. The findings include: The Policy for restraints last reviewed 09/2024 documented ensure the resident is free from physical or chemical restraint imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms. The Therapy Department will make recommendations for least restrictive measures to ensure the resident's safety and forward to Nursing. The Licensed Nurse will notify the physician of the recommendations and a physician's order will be obtained. Physical restraint consent will be obtained from the capable resident or responsible party by the nurse and placed in the resident's medical record. The resident's care plan will address the type of restraint, the reason for application and the duration for the use of the restraint. The Interdisciplinary Team will assess the residents' continued need for restraint on an ongoing basis and at least a quarterly basis via the Restraint Assessment Form. All restraints will be released every two (2) hours for fifteen minutes, activities provided and the restraint will be reapplied. Resident #31's diagnoses included repeated falls, other symptoms and signs involving the musculoskeletal system and unspecified bipolar disorder. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #31 had moderate cognitive impairment and had three falls since last assessment (two with no injury, one with injury). The Physician Order dated 06/19/2026 documented ensure staff offer resident to come out of the Merry [NAME] every two (2) hours every shift. The Care Plan for deficits in mobility and transfers due to diagnosis of hyperosmolality and hypernatremia, last revised 06/19/2026, documented the resident uses a Merry Walker. Offer resident to come out of Merry [NAME] every two (2) hours. The Physician Order dated 06/30/2026 documented the resident must be able to perform release from Merry Walker. A review of the 07/2026 Medication Administration and Treatment Administration Records documented Resident #31 was offered to come out of Merry [NAME] every two hours. A Physical Therapy note dated 06/08/2026 at 12:46 documented therapist instructs resident in lifting safety bar at front of Merry [NAME] under supervision, multiple attempts made, however patient was unable, 2/2 strength and grip deficits. Notified unit manager that therapist is trialing Merry [NAME] during skilled physical therapy sessions and Resident #31 has been unable to lift the safety bar on command. Will continue to assess during next treatment session. During an observation on 07/29/2026 at 9:51 AM, Resident #31 was sitting in the Merry [NAME] near the nurse's station. Resident #31 stated they were unable to exit the Merry [NAME] on their own. They stated they needed staff assistance if they wanted to exit the Merry Walker. Resident #31 stood up in the Merry [NAME] to head towards their room Staff intervened and redirected Resident #31 back to the nurse's station During observation on 07/29/2026 at 9:54 AM Resident #31 was making unsuccessful attempts to stand and ambulate while in the Merry Walker. Resident #31 dropped their book on the floor and was unable to retrieve it During an observation and interview on 07/29/2026 at 2:58 PM, Resident #31 stated they were unable to lift the bar to exit the Merry [NAME] without staff assistance. They stated they did not have the strength to move the bar. Resident #31 stated they did not like the Merry [NAME] and told staff of their dislike. They stated they preferred to be in a wheelchair as they wanted to be able to get up when they wanted. During an interview on 07/29/2026 at 9:54 AM, Certified Nurse Aide #15 stated Resident #31 had a history of falls, was forgetful and was unable to exit the Merry [NAME] on their own. They stated Resident #31 alerted staff when they needed to use the bathroom. During an interview on 07/29/2026 at 10:00 AM, Licensed Practical Nurse #16 stated Resident #31 was unable to exit the Merry [NAME] independently. They stated they could not find a care plan for restraint use and stated there should be a restraint care plan in place since Resident #31 was unable to exit Merry [NAME] independently. Resident #31 was very forgetful, had poor safety awareness and history of falls. During an interview and observation on 07/29/2026 at 10:09 AM and 10:35 AM, Licensed Practical Nurse Manager #2 stated Resident #31 had a history of falls, poor cognition and safety awareness. They stated they were able to exit the Merry [NAME] independently at times, but due to poor cognition they frequently forget how to do so. They stated Resident #31 was offered to exit the Merry [NAME] every two hours and was transferred to a standard wheelchair for meals. They stated they were not aware of a restraint assessment. During an interview on 07/29/2026 at 10:43 AM, the Assistant Director of Rehabilitation stated they were requested to evaluate Resident #31 on 05/06/2026 due to a decline in functional abilities and activities of daily living. They stated Resident #31 had a history of falls and they recommended the Merry [NAME] on 06/08/2026.They stated Resident #31 stood up frequently while in a standard wheelchair and had balance issues. They stated they tried over a few therapy sessions to have Resident #31 lift the release bar on the Merry [NAME] and they were unable to lift it due to poor grip strength and cognition issues. The Assistant Director of Rehabilitation stated the Merry [NAME] was not considered a restraint if the resident was offered to exit the device every two hours and unit nurse staff were in-serviced on the use of a Merry [NAME] and offering the resident to be released every two hours. During a telephone interview on 07/29/2026 at 12:38 PM, Medical Doctor #2 stated they did not recall entering a specific order for Merry [NAME] and that if Resident #31 was unable to exit walker independently, the device could be considered a restraint. They stated they review physical therapy recommendations and sign off on them. They stated physical therapy was responsible for restraint assessments. During an interview on 07/29/2026 at 12:45 PM, the Director of Nursing stated Resident #31 had a Merry [NAME] because they wanted to walk around the unit, had a history of falls, attempted to self-transfer and ambulated without calling for assistance. They stated a referral was made to physical therapy on 05/06/2026 due to Resident #31's deconditioning and a Merry [NAME] was recommended. The Director of Nursing stated Physical Therapy made them aware that Resident #31 was unable to exit the Merry [NAME] independently and there was an order in place for the resident to be offered to exit Merry [NAME] every two (2) hours. They stated Physical Therapy provided an in-service to unit staff and Director of Nursing regarding Merry [NAME] use and offering Resident #31 the opportunity to exit the Merry [NAME] every two hours. They stated a restraint assessment was not completed by Physical Therapy prior to use of the Merry Walker, and they did not obtain a consent, provide family notification and a physician order was not required because the Merry [NAME] was considered a mobility device, such as a wheelchair, and not a restraint. 10 New York Code Rules and Regulations 415.4(a)(2-7)

Based on observation, interview, and record review the facility failed to ensure the residents right to participate in care plan meeting/s for one (1) of two (2) residents (Resident #11) reviewed for care planning. Specifically, Resident #11's quarterly care plan meeting was cancelled in February 2026 and not rescheduled.The findings included:Resident #11 had diagnoses that included but were not limited to multiple sclerosis, and hypothyroidism.The Quarterly Minimum Data Set Assessment (assessment tool) dated 04/18/2026 documented Resident #11 had moderately impaired cognition.The Social Service note dated 2/12/2026 at 1:50 PM documented by Social Worker Assistant #4 revealed the care plan meeting scheduled for that day was postponed.During an interview on 5/18/2026 at 11:32 AM, Resident #11 stated their last care plan meeting was held a year ago. During an interview on 5/19/2026 at 10:26 AM, Social Worker Assistant #4 stated the 2/12/2026 meeting was cancelled due to availability and had to be rescheduled.During an interview on 5/21/2026 at 3:39 PM, the Minimum Data Set Registered Nurse stated the Minimum Data Set assessment completion drove scheduling for care plan meetings. They stated care plan meetings should occur soon after completion of an Minimum Data Set assessment as to allow for care plan review and updates.During an interview on 5/22/2026 at 11:43 AM, the Director of Nursing stated they expected care plan meetings to be held quarterly to review resident changes, improvements, and declines. They stated they wanted the interdisciplinary team to be involved during care planning meetings.During an interview on 5/22/2026 at 2:38 PM, the Health Care Proxy for Resident #11 stated they wanted Resident #11 at the care plan meeting and were not sure why the meeting was not rescheduled. 10 New York Code Rules/Regulations 415.11(c)(2)(i-iii)

Based on observation, interview, and record review, the facility failed to ensure that nurse staffing data was posted daily at the beginning of each shift. Specifically, upon entry to the facility on [DATE], the staffing data posted in the lobby was dated 05/11/2026. The findings included:During an observation on 05/17/2026 at 10:28AM, the staffing data posted in the facility lobby was dated 05/11/2026. During an interview on 05/21/2026 at 10:30 AM, the Director of Human Resources/Staffing Coordinator stated that the overnight nursing supervisor was responsible for posting the staffing data daily. They stated it was updated as needed.During an interview on 05/21/2026 at 12:14 PM, the Director of Nursing stated the staffing data should be posted in the facility lobby daily. The overnight supervisor was responsible for posting the data. They stated the regular overnight supervisor was on leave last week and that was likely why it was missed. They stated the covering staff should know to post the staffing data daily. 10 New York Code Rules Regulations 415.13

Based on record review and interviews during an abbreviated survey (456441), the facility did not maintain medical records on each resident that are complete and accurately documented in accordance with accepted professional standards and practices for 1 out of 3 residents (Resident #2) reviewed for documentation. Specifically, on 13 different dates in December 2024 Resident #2 was due to receive medications at 9:00am and the medication administration audit report indicates that the 9:00am medications were not administered at the scheduled time.The facility medication and administration policy last revised 10/24 documented that the facility staff will provide safe and accurate medication administration to the residents. Medications are administered by licensed nurses, with and in accordance with physician order. Documentation of medication administration is completed at the time of dosage administration. Under the section titled general information: The right medication, is given to the right resident, at the right time, by the right route, in the right dose. Each shift the medication nurse is responsible to administer the medications prescribed for that shift and: the 11-7 medication nurse is responsible to administer all 7am medications and finger sticks, the 7-3 medication nurse is responsible to administer all 3pm medications and finger sticks, and the 3-11 medication nurse is responsible to administer all 11pm medications and finger sticks. The medication administration policy has a numbered section with a sub heading titled Medication Pass where it documented 1. Each shift a nurse is assigned to administer medications for that shift and is responsible for the medication cart and is not to be distracted or disturbed by staff unless absolutely necessary during the medication pass. It further documented under step 10. Documentation of administration of medication is completed on the computer immediately after administration with the nurse's initials, in the corresponding date and time for the medication. 19. At the end of each shift, the medication nurse is responsible to review each MAR, 24-hour report, and the nurses notes, to ensure that documentation of administration of medications for that shift is accurate and complete. 20. Medication errors are to be reported immediately and to the physician responsible for the resident, investigated, tracked and reported a QA, by the DONResident #2 was admitted with Essential hypertension, Adjustment disorder with mixed anxiety and depressed mood, and major depressive disorder, recurrent unspecified.The 12/01/2025 Quarterly Minimum Data Set (resident assessment tool) documented Resident #2 was cognitively intact, they were dependent for most activities of daily living and used a wheelchair for ambulation.Review of the standing medication orders active from May 2024 through December 2024 for Resident #2 found the following:Acidophilus Probiotic Oral Tablet (Lactobacillus) Give 1 capsule by mouth two times a day for probiotic;Breo Ellipta Inhalation Aerosol Power breath activated 100-25 MCG/ACT 1 Puff inhale;Buspirone HCL oral tablet 10mg Give 1 tablet by mouth two times a day for anxiety;Cozaar Oral Tablet 25mg (Losartan Potassium) Give 1 tablet by mouth one time a day for hypertension (HTN);Donepezil HCL Oral Tablet 10mg Give 1 table by mouth one time a day for Dementia;Furosemide Oral Tablet 20mg Give 1 tablet by mouth one time a day for diuretic;Lexapro Oral Tablet 10mg Give 1 tablet by mouth one time a day for depression;Metoprolol Tartrate Oral tablet 25mg Give 1 tablet by mouth two times a day for hypertension (HTN);Nitroglycerin Transdermal Patch 24 hour 0.2 MH/HR Apply 1 patch transdermally one time a day for antianginal agent hold if SBP<106 and remove per schedule;Rivaroxaban Oral Tablet 15mg Give 1 tablet by mouth one time a day for anticoagulant, andSystane Ophthalmic Solution 0.4-0.35 Instill 2 drop in both eyes two time a day for dry eye. Review of the medication administration audit report for the following dates: 12/03/2024, 12/07/2024, 12/08/2024, 12/12/2024, 12/13/2024, 12/17/2024, 12/21/2024, 12/22/2024, 12/24/2024, 12/25/2024, 12/26/2024, 12/27/2024, and 12/31/2024 found discrepancies as to when the medications were scheduled to be administered and when the medications were documented as being administered.During an interview on 03/26/2026 at 10:00am with Registered Nurse #3 they stated that Resident #2 receives a majority of their medications at 9:00am and some again at 5:00pm. Sometimes the computer will time out and the computer logs you out, and there are times when you have it all clicked off and then it will no longer show on the computer. It may have been a computer glitch. It is possible that the medications were given earlier and with rushing so much it did not get clicked off. Registered Nurse #3 stated that the nurses try their best to avoid this. It may state 12pm but that may not be accurate, but they cannot recall the details specifically. Clicking each one, it is possible that they might have just been late to document, and maybe the computer might have logged them out. If the actual administration of the medication takes more than 10 minutes the computer will log you out. Registered Nurse #3 stated it is hard for them to recall December 2024. Registered Nurse #3 stated that it is just so tight on time management, they are always doing everything they can to be on time. Registered Nurse #3 stated that in general they contact the appropriate person if they are late, but they did not recall those days in particular, we are just all running as fast as we can.On 12/03/2024 all medications that were scheduled to be administered at 9:00am were documented as being administered after 12pm but before 1pm, and this exact pattern occurred in the same manner on all the dates (listed above) that Registered Nurse #3 was administering medication to Resident #2. During a telephone interview on 03/26/2026 at 11:00am with the Assistant Director of Nursing they stated they believe the census on the unit where Resident #2 resides has approximately 38 to 40 residents at maximum capacity. The Assistant Director of Nursing stated on this unit one (1) nurse is administering medications to 40 residents and when that one nurse arrives at 8am, the nurse leaving has to do the narcotic count with them and that takes 10 to 15 minutes depending on the situation, then the nurse leaving must report to them regarding each resident on the unit and that can take at least 15 minutes, then the medication pass starts at about 830am. and the nurse has until 10am to administer all the medications. The Assistant Director of Nursing stated this allows for approximately 2 minutes to administer medications to each resident. The Assistant Director of Nursing stated they would like to say medications are never late, but realistically the calculation suggests that to be difficult. The Assistant Director of Nursing stated that management is aware, and it is a work in progress, and they are trying to get a third cart nurse. The Assistant Director of Nursing stated that every unit has a manager and collectively they should all be working to ensure medications are being administered on time.During an interview on 03/26/2026 at 2:19pm with the Administrator they stated that their expectation is that when a medication is late, they monitor the nurses as closely as they can and the Assistant Director of Nursing and the Director of Nursing are rounding and making sure everything is going smoothly and that the medications are not running late. The Administrator stated that when a new nurse is trained and they are running behind, they do a couple of different things, such as, the Assistant Director of Nursing or the Director of Nursing will help the nurse. The Administrator stated that they often find out about medication being administered late through their seeing it themselves or a resident tells them. The Administrator stated they have not seen an alarming trend of nurses that cannot complete the medication pass, but for those that struggle the facility provides them assistance. The Administrator stated that per their policy the nurse that administers the medication, at end of their shift, reviews the Medication Administration Record, and though there is no indication that a second nurse reviews the Medication Administration Record that same day or on the next shift, the Unit Manager runs a monthly report. During a telephone interview on 03/26/2026 at 4:04pm with Resident #2s Doctor, when asked about medication administration delays in December of 2024, they stated that it was a long time ago, that they had no memory of any medication error, and if there had been a negative outcome, they would likely recall the issue. The Doctor stated they do not believe there was ever any issue, and none with Resident #2's medications being late. The Doctor stated that they would recall, for example, if a patient had their Blood Pressure bottom out and then they got called and were told that a medication was given late. The Doctor stated they have no recollection of any history of medications being administered late. The Doctor stated that ideally medications should be given on time, and their expectation is if a medication is administered late by 4 or 5 hours they should be notified, adding that there are several ways to notify them.During an interview on 03/30/2026 at 9:46am with the Pharmacy Consultant they stated that as the Pharmacy Consultant they are just looking at the medication regiment and making recommendations to the physicians, they do not open the Medication Administration Record. The Pharmacy Consultant stated that they assume that nursing would have some internal auditing. The Pharmacy Consultant stated that they look for drug interactions or dosage strength. The Pharmacy Consultant stated they do not open the Medication Administration Record when doing reviews and they do not do any training with staff, and added that any oversight would be done internally by the facility.10NYCRR S415.22(a)(1-4)