Every finding on record at Affinity Skilled Living and Rehabilitation Center

Based on observations, record reviews and interviews during survey, the facility failed to protect a resident from abuse, psychosocial harm, and to respond appropriately following an allegation of staff-to-resident sexual abuse for one of 16 sampled residents (Resident #1) reviewed for abuse. Specifically, on 06/20/2026 Resident #1 alleged Certified Nursing Assistant #1 raped them while providing incontinence care, and the facility failed to implement interventions to address Resident #1's physical and psychosocial needs. Resident #1 remained in the facility for five and a half hours following the allegation without documentation of a medical or psychosocial assessment. This resulted in actual harm to Resident #1 that was Immediate Jeopardy and likely placed other vulnerable residents at risk for serious harm, serious injury, serious impairment, or death. The Finding is: The facility policy titled Abuse and Neglect Policy reviewed on 06/20/2026, documented all alleged incidents of abuse and or neglect will be investigated. Injuries of unknown origin will be investigated to rule out abuse neglect or mistreatment. The administrator and director of nursing will be immediately notified of any alleged or suspected occurrence of abuse or neglect the administrator, or designee will provide a two-hour notification to the New York State Department of Health for any alleged or suspected or confirmed case of abuse or neglect. Abuse is defined by the willful infliction of injury, unreasonable confinement, intimidation or punishment which also result in physical harm pain or mental anguish. Sexual abuse includes but is not limited to sexual harassment, sexual coercion, or sexual assault. If there are reasons to suspect abuse or neglect, the facility will report the ongoing investigation to the Department of Health within two hours whether the internal investigation is complete, the facility will take prompt action to protect the residents during the investigation. Resident#1 was admitted with diagnoses that include obstructive and reflux uropathy, hemiplegia and hemiparesis following cerebral infarction Resident #1's Minimum Data Set (a resident assessment tool) dated 06/02/2026 documented a Brief Interview for Mental Status score of 15 indicating intact cognition, bed mobility of one assist, toileting and transfer assist of two. Resident #1's Comprehensive Care Plan titled Psychosocial Well-Being dated 06/04/2026 documented interventions of orient resident to environment, staff and facility routines. Introduce to compatible peers. Provide opportunities to ventilate feelings, needs, and concerns. Address and validate concerns. Elicit family input as needed. The facility's Accident/Incident report dated 06/20/2026 at 6:30 AM, documented Resident #1 made an allegation to Licensed Practical Nurse #1 that they were raped by Certified Nursing Assistant #1. Assessment was done by Registered Nurse Supervisor #1 and there was redness in the perineal area. The facility concluded that abuse did not occur because of conflicting statements provided by Resident #1. A statement signed by Licensed Practical Nurse #1 dated 06/20/2026 documented that, Resident #1 stated I was raped. Licensed Practical Nurse #1 asked Are you sure? That's a serious allegation. Resident #1 responded with agitation. I know what it feels like. I want to call my sister. She is a cop. I then said, Let me get a supervisor. I called downstairs and spoke with a supervisor. When the supervisor arrived, we both entered the room and Resident #1 stated while they (Certified Nursing Assistant #1) were cleaning me, they were rough with me all up in the front, I even screamed. Resident #1 was eager to show their bottom at that time. They were composed but upset. A nursing progress note dated 06/20/2026, edited 06/21/2026, documented Resident #1 complained of burning sensation to the sacral and vaginal area after incontinence care. Resident #1 noted with confusion, and accusatory behavior towards care. Director of Nursing Services aware. No male caregiver, and two-person approach initiated this time. Video surveillance reviewed on 06/26/2026 at 9:44 AM with Administrator, revealed that on 06/20/2026 at 4:43 AM Certified Nursing Assistant #1, who was identified by Administrator, entered Resident#1's room and exited at 5:19 AM removing trash and linen. Certified Nursing Assistant #1 spent a total of thirty-six (36) minutes in Resident #1's room. During an interview on 06/25/2026 at 8:55 AM with Certified Nursing Assistant #1, they stated they provided incontinence care to Resident #1 at approximately 4:30 AM and recalled Resident #1 had scabs on their sacrum and complained of vaginal itching and burning. They applied ointment A and D to the Resident's pubis bone, crease of their groin and in their vagina. They stated they applied the ointment anywhere they observed pink skin. Certified Nursing Assistant #1 stated, I did not do anything more than she asked for. They stated they were in the room for over 30 minutes because the resident had multiple bowel movements. They stated that at approximately 6:30 AM, they were removed from shift due to an allegation made by Resident #1. Resident #1's bowel record was reviewed for 06/20/2026, and there was no documented evidence that multiple bowel movements were recorded. During an interview on 06/25/2026 at 1:33 PM with Family Member #1, they stated they received a call from Resident #1 at approximately 7:00 AM and returned Resident #1's call at 9:45 AM. Resident #1 was hysterically crying and stated, You need to come here now. Family Member #1 arrived at the facility and stated Resident #1 was still hysterically crying and stated that a staff member had raped them. Family Member #1 immediately contacted law enforcement and requested Resident #1 be sent to the hospital. They stated Resident #1 was sent to the hospital at 12:00 PM on 06/20/2026. They stated Resident #1 has remained tearful and is not eating. They stated that due to Resident #1's diagnosis, they require long term skilled nursing care and now are fearful and distrusting of facility staff. During an interview on 06/25/2026 at 2:55 PM with Resident #1, while they were in the hospital, they stated Certified Nursing Assistant #1 came in to change their brief because they were wet and had a small bowel movement. Resident #1 stated Certified Nursing Assistant #1 offered to apply cream to their skin tear on their hip. They stated Certified Nursing Assistant #1 began to apply the cream to their hip and then began to apply the cream to their anus and then applied the cream to their vaginal area. They stated they did not ask Certified Nursing Assistant #1 to apply the cream to the vaginal area, there was no pain or burning in their vagina or perineal area prior to the application. They stated they told Certified Nursing Assistant #1 that they were hurting them, and Certified Nursing Assistant #1 apologized and made a moaning sound. They stated they were positioned on their side and could not visualize Certified Nursing Assistant #1. Resident #1 stated they felt, something enters their anus and vagina, it felt soft but was unsure if it was Certified Nursing Assistant #1's finger or penis. They stated it has never taken 25 minutes to clean them after a bowel movement. They stated they asked them to stop. They stated that Certified Nursing Assistant #1 then went into Resident #1's bathroom and adjusted their pants and used tissues and then took the garbage out of the bathroom and took the linens and left the room. Resident #1 stated when they reported the incident to Licensed Practical Nurse #1, they replied, they (Certified Nursing Assistant #1) would not do such a thing like that. They stated when law enforcement arrived, they asked them what happened, but they were males and the nursing supervisor that was present was a male, and they felt embarrassed and ashamed, so they reported that Certified Nursing Assistant #1 was rough. Resident #1 stated they are not sleeping or eating well and felt afraid of returning to another healthcare facility. Throughout the interview with Resident #1, while they were describing the incident, Resident #1 became distressed and tearful with noticeable cracking and trembling in their voice. They paused several times throughout the interview to regain their composure. Resident #1 verbalized a growing fear and distrust of facility staff, loss of appetite, and being frightened to return to a healthcare facility. There is no documented evidence Resident #1 was assessed for fear, anxiety, emotional trauma or other psychosocial effects following the alleged sexual abuse allegation. During an interview on 06/26/2026 at 11:39 AM with the Director of Nursing Services, they stated Family Member #1 called local law enforcement and alleged that Resident #1 was sexually assaulted by a staff member. Certified Nursing Assistant #1 was immediately removed from their shift. Resident #1 reported to local law enforcement that Certified Nursing Assistant #1 was rough during care. The Director of Nursing Services stated due to the change of the allegation, they did not feel that the incident rose to the threshold of reporting to the Department of Health or local law enforcement. The Director of Nursing Services stated rough care can cause psychosocial issues and fear of care. The Director of Nursing Services stated Resident #1 should have had a psychosocial assessment but there was no social worker available. During an interview on 06/25/2026 at 11:51 AM with Administrator, they stated they were made aware of the incident on 06/20/2026 at 9:35 AM. They stated Resident #1 told the Licensed Practical Nurse #1 on shift they were raped and then told the Nursing Supervisor #1 it was rough handling. They stated law enforcement was contacted by the resident's family. They stated it was not reported to the New York State Department of Health because Resident #1 stated it was rough handling during care, and that is subjective. They believe it could be that Resident #1's skin was sensitive because of the numerous bowel movements. They stated the allegation is subjective and Resident #1 retracted their statement which did not require an assessment. During an interview on 06/26/2026 at 2:28 PM with Primary Care Physician #1, they stated they were not informed of the allegation until Resident #1 was transferred to the hospital. They stated that initially, they were told that it was rough handling, then the family member called law enforcement. Primary Care Physician #1 stated the facility should have called law enforcement and the Department of Health if the allegation was rape. Primary Care Physician #1 stated that a psychosocial assessment should have been conducted after Resident #1 made the allegation to nursing staff. During an interview on 07/02/2026 at 9:36 AM with Social Worker #1, they stated they were the assigned social worker for Resident #1. They stated they were made aware of the incident after it occurred. They stated that since Resident #1 was alert and oriented, they would not have recommended a psychosocial assessment be completed. They stated they did not know if any interventions should be put in place following the allegation, because they lacked experience with this type of allegation. 10 NYCRR 415.4(a)(7)(b)

Based on record review and interviews during survey, the facility failed to ensure that alleged violations involving abuse, neglect, exploitation or mistreatment were reported to the Department of Health and local law enforcement no later than two hours after the allegations were made. This was identified for one resident (Resident#1) of 16 residents. Specifically, Resident#1 alleged that on 06/20/2026, Certified Nursing Assistant #1 sexually abused them while providing care. There is no documented evidence that the alleged sexual abuse was reported to local law enforcement or the New York State Department of Health as required. The facility's failure to report the incident to the New York State Department of Health posed the likelihood of harm to Resident #1 which was immediate Jeopardy and potential for harm to the other 16 residents.The findings are:The facility policy titled Abuse and Neglect, dated 04/22/2026 and reviewed June 2026, documented alleged incidents of abuse and neglect will be investigated and injuries of unknown origin will be investigated to rule out abuse, neglect, or mistreatment. The Administrator and Director of Nursing will be immediately notified of any alleged or suspected occurrence of abuse or neglect. The administrator or designee will provide a 2-hour notification to the New York State Department of Health for any alleged or suspected or confirmed case of abuse or neglect.Resident #1 was admitted to the facility with diagnosis that include obstructive and reflux uropathy (a structural or functional blockage of the urinary tract that prevents urine from flowing freely), hemiplegia (complete all partial paralysis on one side of the body) and hemiparesis (muscular weakness or partial paralysis affecting only one side of the body) following cerebral infarction(death of brain tissue caused by a prolonged lack of blood and oxygen supply) .The Minimum Data Set (a resident assessment tool) dated 05/22/2026 documented a Brief Interview for Mental Status score of 15, indicating intact cognition.A Comprehensive Care Plan titled Altered Health maintenance initiated 05/18/2026 documented the resident requires assistance with Activities of Daily Living. The Comprehensive Care Plan documented interventions that Resident #1 requires two staff members for transfers and toileting. Resident #1 also requires extensive assistance of one for dressing, bathing, grooming, and bed mobility.A facility's Accident/Incident report dated 06/20/2026 at 6:30 AM, documented Resident #1 made an allegation to Licensed Practical Nursing #1 that they were raped by Certified Nursing Assistant #1. A skin assessment was completed by Registered Nurse Supervisor #1. There is no documented evidence that the facility reported the allegation of sexual abuse to local law enforcement or the New York State Department of Health within two hours as required.During an interview on 06/25/2026 at 8:55 AM with Certified Nursing Assistant #1, they stated they provided incontinence care to Resident #1 at approximately 4:30 AM on 06/20/2026. Certified Nursing Assistant #1 stated that Resident #1 had scabs on their sacrum and complained of vaginal itching and burning and they applied A and D ointment to Resident #1's perianal area. Certified Nursing Assistant #1 stated I did not do anything more than Resident #1 asked for.During an interview on 06/25/2026 at 1:33 PM with Family Member #1, they stated they received a call from their family member (Resident #1) at approximately 7:00 AM and returned their family member's call at 9:45 AM. Resident #1 stated, You need to come here now. When Family Member #1 arrived at the facility approximately 11:00 AM, the resident was hysterically crying and stated that a staff member had raped her. Family member #1 immediately contacted law enforcement and requested that the resident be sent to the hospital.During an interview via telephone on 06/25/2026 at 2:55 PM, Resident #1 who was present with Family Member #1 at the hospital stated Certified Nursing Assistant #1 came into their room to change their brief because they were wet. Resident #1 stated Certified Nursing Assistant #1 began to apply cream to their hip and then begin to apply the cream to their anus and vaginal area. They stated they told Certified Nursing Assistant #1 that they were hurting them, and Certified Nursing Assistant #1 apologized and made a moaning sound. Resident #1 stated they felt, something enter their anus and vagina, it felt soft but was unsure if it was Certified Nursing Assistant #1's finger or penis. Resident #1 stated Certified Nursing Assistant #1 took a very long time to provide care and then they felt burning in their vaginal area after the care. Resident #1 stated they asked Certified Nursing Assistant #1 to stop, but they did not stop. Resident #1 stated when law enforcement arrived, they (law enforcement) asked them what happened. Resident #1 stated they were male law enforcement officers, and the nursing supervisor was also present who was a male, so Resident #1stated they were embarrassed and ashamed and did not want to talk about the rape with them so Resident #1stated they only reported that Certified Nursing Assistant #1 was rough with them. Resident #1 stated they are not sleeping well because of this incident and were emotionally distraught and tearful with cracks in their voice during this interview.During an interview on 06/25/2026 at 9:00AM with the Director of Nursing Services, they stated Family Member #1 called Local Law Enforcement and alleged that their family member was sexually assaulted by a staff member. Director of Nursing Services stated they did not speak to Resident #1 about the incident, but that Resident #1 reported to local law enforcement that Certified Nursing Assistant #1 was rough with them during care nothing about the alleged rape. Director of Nursing Services stated due to the change in the allegation, they did not feel that the incident rose to the threshold of reporting to the New York State Department of Health.During an interview on 06/25/2026 at 11:51 AM with the Administrator, they stated they were aware of an incident on 06/20/2026 at 9:35 AM involving Certified Nursing Assistant #1 and Resident #1. They stated Resident #1 told a nurse they were raped, but then they told the (male) Nursing Supervisor #1 it was rough handling. The Director of Nursing suspended Certified Nursing Assistant #1 because Resident #1 alleged that Certified Nursing Assistant #1 raped them. The Administrator stated they did not report the alleged rape to the New York State Department of Health because they felt that rough handling was subjective and it was the perception of the resident (resident #1).During an interview on 06/25/2026 at 2:02 PM with Primary Care Physician #1, they stated they were contacted 06/20/2026 when Resident #1 was being transferred to the hospital. Primary Care Physician #1 stated Resident #1 made an allegation they were raped. They stated that initially they were told it was rough handling. Primary Care Physician #1 stated the facility should call law enforcement and the Department of Health if Resident #1 alleged they were raped.Video surveillance was reviewed on 06/26/2026 at 9:44 AM and revealed that on 06/20/26 at 4:43 AM, Certified Nursing Assistant #1 entered Resident #1's room and exited at 5:19 AM, removing trash and linen.During an interview on 07/03/2026 at 2:33 PM with Social Worker #1, they stated they were informed about the incident on 06/22/2026 by their supervisor and were under the impression that the incident had been reported to a higher authority, but they did not ask who it was reported to. Social Worker #1 stated they should have asked and if it was not reported appropriately, they should have spoken with Resident #1 and reported the incident of alleged rape to the Department of Health. 10 NYCRR 415.4(b)(2)

Based on observations, interviews, and record review during the abbreviated survey (Intake # 3052049) the facility failed to conduct a thorough investigation of an allegation of staff to resident abuse for 1 of 1 sampled resident reviewed for abuse. Specifically, Resident #1 alleged a Certified Nursing Assistant raped them while providing incontinence care. The facility's investigative report revealed no written or recorded statement from the resident detailing the allegation, which limited the facility's ability to objectively investigate the allegation. The facility's reported that Resident #1 changed their description of the allegation and the facility reached a conclusion rather than completing a comprehensive investigation of all evidence. Based on observations, interviews, and record review during the abbreviated survey (Intake # 3052049) the facility failed to conduct a thorough investigation of an allegation of staff to resident abuse for 1 of 1 sampled resident reviewed for abuse. Specifically, Resident #1 alleged a Certified Nursing Assistant raped them while providing incontinence care. The facility's investigative report revealed no written or recorded statement from the resident detailing the allegation, which limited the facility's ability to objectively investigate the allegation. The facility's reported that Resident #1 changed their description of the allegation and the facility reached a conclusion rather than completing a comprehensive investigation of all evidence. The findings are: The facility policy titled Abuse and Neglect Policy reviewed on 06/20/2026, documented all alleged incidents of abuse and or neglect will be investigated to rule out abuse neglect or mistreatment. The administrator and director of nursing will be immediately notified of any alleged or suspected occurrence of abuse or neglect, and the administrator or designee will provide a 2-hour notification to the New York State Department of Health for any alleged, suspected or confirmed case of abuse or neglect. Abuse is defined by the willful infliction of injury, unreasonable confinement, intimidation or punishment which also result in physical harm, pain or mental anguish. Sexual abuse is defined, which includes but is not limited to sexual harassment, sexual coercion, or sexual assault. If there are reasons to suspect abuse or neglect the facility will report the ongoing investigation to the Department of Health within two hours whether the internal investigation is complete, the facility will take prompt action to protect the residents during the investigation. Resident#1 was admitted with diagnoses that include obstructive and reflux uropathy, hemiplegia and hemiparesis following cerebral infarction and had intact cognition. There was no documented evidence related to the allegations made by the Resident #1 regarding the alleged rape. Resident #1 alleges that on 06/20/2026, Certified Nursing Assistant #1 raped them while providing care. They stated that while Certified Nursing Assistant #1 was changing their incontinence brief, they felt something soft enter their vagina and anus. Resident #1 stated they were unsure if it was Certified Nursing Assistant #1's finger or penis. Resident #1 alleged Certified Nursing Assistant #1 touched and rubbed their genital and anal area and that made them feel unsafe in the facility. Video surveillance revealed that on 06/20/2026 at 4:43 AM Certified Nursing Assistant #1 entered Resident#1's room and exited at 5:19 AM removing trash and linen. The facility's Accident /Incident report dated 06/20/2026 at 6:30 AM documented Resident #1 made an allegation to Licensed Practical Nurse #1 that they were raped by Certified Nursing Assistant #1. An assessment was completed by Registered Nurse Supervisor #1 and there was redness noted in the perineal area. The Accident /Incident report documented the facility concluded that abuse did not occur because of conflicting statements provided by Resident #1. A statement signed by Licensed Practical Nurse #1 dated 06/20/2026 documented that, Resident #1 stated to them I was raped. Licensed Practical Nurse #1 asked are you sure that's a serious allegation? Resident#1 responded with agitation. I know what it feels like, I want to call my sister, she is a cop. I then said to Resident #1 Let me get a supervisor, when the supervisor arrived, we both entered the resident's room and the residence stated while he was cleaning me Certified Nursing Assistant #1 was rough with me all up in the front. A telephone statement from Registered Nurse Supervisor #1 dated 06/23/2026 documented Resident #1 accused Certified Nursing Assistant #1 of rape. Resident #1 stated that Certified Nursing Assistant #1 touched her vagina during application of cream in sacral area. Resident #1 complained that her vagina hurt and that while Certified Nursing Assistant #1 was cleaning her, he was very rough. Resident #1 complained of a burning sensation to their sacral and vaginal areas. Resident #1's skin noted to be intact, with no new skin alteration at this time. During an interview on 06/25/2026 at 8:55AM with Certified Nursing Assistant #1, they stated they provided incontinence care to Resident #1 at approximately 4:30 AM on 06/20/2026 and recalled Resident #1 had scabs on their sacrum and complained of vaginal itching and burning. Certified Nursing Assistant #1 stated they applied A and D ointment to the resident's perineal area. Certified Nursing Assistant #1 stated, I did not do anything more than they asked for. They stated that at approximately 6:30AM they were removed from shift due to an allegation made by Resident #1. During an interview on 06/25/2026 at 9:00AM with Family Member #1, they stated they received a call from Resident #1 at who stated, you need to come here now. Family member #1 arrived at the facility approximately 11:00 AM on 06/20/2026 and stated the resident was hysterically crying and stated that a staff member had raped them. Family Member #1 immediately contacted law enforcement and requested Resident #1 be sent to the hospital. During an interview on 06/25/2026 at 9:10 AM with Resident #1 they stated Certified Nursing Assistant #1 came in to change their brief because they were wet. Resident #1 stated Certified Nursing Assistant #1 began to apply cream to their hip and then began to apply the cream to their anus and then applied the cream to their vaginal area. They stated they told the Certified Nursing Assistant #1 that they were hurting them, and the Certified Nursing Assistant apologized and made a moaning sound. Resident #1 stated they felt, something enters their anus and vagina, it felt soft but was unsure if it was the Certified Nursing Assistant's finger or penis. They stated Certified Nursing Assistant #1 took a very long time to provide care and then they felt burning in their vaginal area. They stated they asked them to stop but they did not. The resident then informed Family Member #1 and when law enforcement arrived, they asked them what happened, but two male law enforcement offices came, and the (male) nursing supervisor was also present, so they felt embarrassed and ashamed, that is why they reported that the aide was rough instead of telling them they were allegedly raped. Resident #1 stated they are not sleeping well and feel afraid of returning to the facility. The resident requested to go to another healthcare facility. During an interview on 06/29/2026 at 1:55 PM with Nursing Supervisor#1 they stated they were notified by Licensed Practical Nurse #1 that Resident #1 reported that they were raped. Upon becoming aware of the allegation, they completed an assessment of the resident. Resident#1 stated that Certified Nursing Assistant #1 was applying cream during care, and the resident felt the cream went into their vagina, and they felt Certified Nursing Assistant #1's hand went into their vagina. Nursing Supervisor#1 stated they did not obtain or document any statements from Resident #1. During an interview on 06/26/2026 at 11:39AM with Director of Nursing Services they stated they were notified of the allegation in the morning on 06/20/2026 from Nursing Supervisor who told them Resident #1 made a complaint of roughness during care. The Director of Nursing Services stated the facility did obtain a statement from the Resident#1. 10 NYCRR 415.4(b)(3)

Based on observations, record review and interviews during the abbreviated Survey the facility did not ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified for (1) (Resident #1), of sixteen residents. Specifically, the facility failed to ensure that alleged violations involving sexual abuse, neglect, exploitation or mistreating are reported immediately or not later than 2 hours to the Department of Health and Local Law Enforcement after the allegations are made. Additionally, the alleged incident Caused Resident #1 psychosocial harm. The facility failed to protect Resident #1 by allowing male Nursing Supervisor#1 to perform a nursing assessment with no other staff member with them after the alleged rape allegation incident. Additionally, the facility did not provide a social worker visit or psychosocial interventions to Resident #1.Refer to F600 and F609: Scope and Severity of J.Based on observations, record review and interviews during the abbreviated Survey the facility did not ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified for (1) (Resident #1), of sixteen residents. Specifically, the facility failed to ensure that alleged violations involving sexual abuse, neglect, exploitation or mistreating are reported immediately or not later than 2 hours to the Department of Health and Local Law Enforcement after the allegations are made. Additionally, the alleged incident Caused Resident #1 psychosocial harm. The facility failed to protect Resident #1 by allowing male Nursing Supervisor#1 to perform a nursing assessment with no other staff member with them after the alleged rape allegation incident. Additionally, the facility did not provide a social worker visit or psychosocial interventions to Resident #1.Refer to F600 and F609: Scope and Severity of J.The findings are: The facility policy titled Facility Abuse and Neglect policy dated 4/22/2026 and reviewed on 06/2026 documented alleged incidents of abuse and neglect will be investigated injuries of unknown origin will be investigated to rule out abuse neglect or mistreatment. The administrator and director of nursing will be immediately notified of any alleged or suspected occurrence of abuse or neglect. The administrator or designee will provide a 2-hour notification to the New York State Department of Health for any alleged or suspected or confirmed case of abuse or neglect.Resident #1 was admitted to the facility on [DATE] with diagnosis that include obstructive and reflux uropathy(a structural or functional blockage of the urinary tract that prevents urine from flowing freely), hemiplegia(complete all partial paralysis on one side of the body) and hemiparesis(muscular weakness or partial paralysis affecting only one side of the body) following cerebral infarction(death of brain tissue caused by a prolonged lack of blood and oxygen supply) .The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15 indicating intact cognition.A facility's Accident Incident report dated 06/20/2026 at 6:30 AM documented Resident #1 made an allegation to Licensed Practical Nursing #1 that they were raped by Certified Nursing Assistant #1. Assessment was done by Registered Nurse Supervisor #1.During an interview on 06/25/2026 at 1:33 PM with Family Member #1, they stated they received a call from their family member (Resident #1) at approximately 7:00 AM and returned their family member's call at 9:45 AM. Resident #1 stated, You need to come here now. When Family Member #1 arrived at the facility approximately 11:00 AM, the resident was hysterically crying and stated that a staff member had raped her. Family member #1 immediately contacted law enforcement and requested that the resident be sent to the hospital.During an interview via telephone on 06/25/2026 at 2:55 PM Resident #1 who was present with Family Member #1. Resident #1 stated Certified Nursing Assistant #1 came into their room to change their brief because they were wet. Resident #1 stated Certified Nursing Assistant #1 began to apply cream to their hip and then begin to apply the cream to their anus and vaginal area. They stated they told Certified Nursing Assistant #1 that they were hurting them, and Certified Nursing Assistant #1 apologized and made a moaning sound. Resident #1 stated they felt, something enters their anus and vagina, it felt soft but was unsure if it was Certified Nursing Assistant #1's finger or penis. Resident #1 stated Certified Nursing Assistant#1 took a very long time to provide care and then they felt burning in their vaginal area after the care. Resident #1 stated they asked Certified Nursing Assistant #1 to stop but they did not stop. Resident #1 stated when law enforcement arrived, they (law enforcement) asked them what happened. Resident #1 stated they were male law enforcement officers, and the nursing supervisor was also present who was a male, so Resident #1stated they were embarrassed and ashamed and did not want to talk about the rape with them so Resident #1stated they only reported that Certified Nursing Assistant #1 was rough with them. Resident #1 stated they are not sleeping well because of this incident and were emotionally distraught and tearful with cracks in their voice during this interview. There was no documented evidence that the facility reported alleged violations involving abuse, neglect, exploitation or mistreating are reported immediately or not later than 2 hours to the Department of Health and Local Law Enforcement after the allegations are made. Additionally, the facility failed to ensure that resident #1s psychosocial needs were met after the allegation of rape.During an interview on 06/25/2026 at 11:51 AM with the Administrator, they stated they were aware of an incident on 06/20/2026 at 9:35 AM involving Certified Nursing Assistant #1 and Resident #1. They stated they were reported that Resident #1 informed a licensed practical nurse #1 they were raped but then changed their story and reported to the male nursing supervisor#1 the alleged incident was rough handling. The Administrator stated they did not report the alleged rape by Resident #1 to the New York State Department of Health because Resident #1 changed their story to rough handling. The Administrator stated they felt that rough handling was subjective, and the alleged rape was the perception of the resident (resident #1). The Administrator stated they did not think Resident #1 required Social Work or Psychosocial interventions.During an interview on 06/25/2026 at 2:02 PM with the Primary Care Physician they stated they were contacted 06/20/2026 when resident #1was being transferred to the hospital approximately 12:00 PM. The Primary Care Physician stated Resident #1 made an allegation they were raped but they were initially told it was rough handling. The Primary Care Physician stated the facility should call law enforcement and the Department of Health if Resident #1 alleged they were raped. 10NYCRR 415.26

Based on observations, interviews and reviews, the facility failed to ensure that each resident received treatment and care based on their comprehensive assessment in accordance with professional standards of practice. This was identified for one (1) (Resident #180) of one (1) resident reviewed for physical restraints. Specifically, Resident #180 with severely impaired cognition had a diagnosis of down syndrome and a facility acquired stage III pressure ulcer (a deep, full-thickness wound extending through the skin into subcutaneous fat, but not exposing muscle, tendon, or bone) to their right buttock. Resident #180 was unable to verbalize their needs and required total assistance from two (2) staff members with all aspects of care except for eating. On 03/12/2026 at 4:20 AM and 5:06 AM, Resident #180 was observed sleeping in a dark room while seated upright in a tilt-in-space wheelchair (a specialized wheelchair that tilts the user backward for redistributing pressure from the buttocks to the back to prevent pressure sores). Resident #180 was physically restrained with an upper body Posey belt (a harness-like belt that wraps the resident's trunk to keep the resident in an upright position) without a physician's order. At 6:07 AM, Resident #180 was observed to be awake and was still seated in the tilt-in-space wheelchair with the Posey belt restraint in place. Interviews with facility staff and review of the video surveillance revealed that the resident was not turned, positioned, or provided care for more than seven (7) hours. The resident's plan of care required them to be turned and positioned every two (2) to four (4) hours and their brief checked and changed every two (2) to four (4) hours. This resulted in actual harm and likelihood of serious injury, harm, impairment or death to Resident #180 that is Immediate Jeopardy. The finding is:The facility policy titled Restraints last reviewed 02/02/2026 documented the primary focus is to ensure the safety and well-being of residents while minimizing the use of restraints to the greatest extent possible. Informed consent must be obtained from the resident or their legally authorized representative before implementing any restraint. The healthcare team must provide a clear explanation of the reasons for restraint use, potential risks and benefits, and alternatives. Residents under restraint must be closely monitored, and the effectiveness of restraint interventions must be regularly evaluated. Thorough and accurate documentation is essential for all aspects of restraint use, including initial assessment, informed consent, ongoing monitoring and evaluations. The facility policy titled Activities of Daily Living last reviewed 02/02/2026 documented residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out activities of daily living independently, in accordance with the plan of care including elimination (toileting).The facility policy titled Incontinence last reviewed 02/02/2026 documented the staff and physician will summarize an individual's continence status. Incontinence care should be individualized at night to maintain comfort and skin integrity.The facility policy titled Quality of Care last reviewed 02/02/2026 documented the facility shall ensure each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the resident's comprehensive assessment, plan of care, physicians' orders, and applicable federal and state regulations. Quality of care and services are necessary to maintain or improve resident health consistent with professional standards. Avoidable decline is the deterioration resulting from failure to provide appropriate evaluation, monitoring, treatment, or interventions. Residents are monitored for changes in condition including skin conditions. Changes are evaluated promptly and interventions implemented.The undated facility policy titled Pressure Ulcer Prevention Management and Treatment Program, documented the charge nurse would update the certified nursing assistant accountability record sheet when a pressure ulcer is identified this should include: a turning and positioning schedule; out of bed schedule; toileting schedule; and adaptive/assistive devices. The incontinence care every two (2) to four (4) hours and as needed following each incontinent episode. Turning and positioning as per individual's care plan. When in a chair, if the pressure ulcer site can be relieved, the resident can sit for a limited time per an established positioning schedule. If pressure on the ulcer site can be relieved, the resident can sit for a limited time per an established positioning schedule. Use of seat cushions that redistribute pressure when applicable.Resident #180 was admitted with diagnoses that included down syndrome (genetic condition caused by an extra copy of chromosome 21 leading to intellectual disability, developmental delays, and distinct physical features and low muscle tone), pressure ulcer right buttock stage III, and bipolar disorder (chronic mental health condition characterized by intense alternating mood swings). The Quarterly Minimum Data Set (a resident assessment tool) dated 12/13/2025 documented a Brief Interview for Mental Status score was not completed as the resident was never understood and had severely impaired long and short term memory. The Minimum Data Set documented Resident #180 used a wheelchair and was dependent on two (2)staff members for all aspects of care. Resident #180 was always incontinent of bowel and bladder and was at risk for developing pressure ulcers and did not have pressure ulcers.A Comprehensive Care Plan dated 01/06/2026 and last revised 03/08/2026, documented right buttock stage III pressure ulcer, interventions included turn and position every two (2) to- four (4) hours.A Comprehensive Care Plan dated 09/10/2025 and last reviewed 12/15/2025, documented Resident #180 requires restraint alternative use secondary to inability to sit up on their own and maintain proper body alignment. Interventions included quarterly review and evaluation of use and for possible reduction. Inform family representative of benefits and risks associated with restraint use.A Comprehensive Care Plan dated 09/09/2025 and last revised 03/09/2026 documented Resident #180 has behavior symptoms to crawl out of bed onto the floor as a method of locomotion. Interventions included redirecting the resident during behavioral episodes and assessing behaviors for causative factors. A Comprehensive Care Plan dated 09/09/2025 and last revised 01/14/2026 documented Resident #180 requires assistance with Activities of Daily Living. Intervention included assistance of two (2) staff members with all aspects of care except for eating. A Restraint Alternative vs Restraint Determination assessment form dated 09/08/2025 documented Resident #180 was evaluated for a restraint alternative or restraint for the following reasons: tend to lean forward, and poor trunk control. The medical symptoms were leans forward and impulsive behavior. The device (name of device not indicated) is appropriate to maintain resident safety due to impulsive movements. The assessment form did not indicate the team's decision whether the device was a restraint alternative or a restraint. The form did not indicate the resident representative was notified. A physician's order dated 09/09/2025 documented out of bed to personal tilt-in-space wheelchair.A review of the physician's orders revealed no documented evidence of orders for the use of the Posey belt restraint, monitoring or skin check instructions related to the use of the restrictive device.A review of the medical record from 12/01/2025-03/09/2026 revealed multiple nursing progress notes indicating Resident #180 was found crawling out of bed on the floor and into the hallway. Resident #180 was redirected back to their room and was placed in their wheelchair.During an observation on 03/10/2026 at 06:51 AM, Resident #180 was observed in a dark room sitting upright on a roho cushion (a specialized cushion for pressure relief) in a tilt in space wheelchair. The resident was strapped to their wheelchair with a Posey restraint. Resident #180 was making loud incoherent random sounds. During an observation on 03/12/2026 at 04:20 AM, Resident #180 was in their room in the dark, sleeping in their wheelchair while sitting upright on a roho cushion. The resident was restrained with a Posey belt that was attached to the wheelchair with their hands secured under the Posey belt.During an observation on 03/12/2026 at 05:06 AM, Resident #180 was in their room in the dark, sleeping in their wheelchair while sitting upright on a roho cushion. The resident was restrained with a Posey belt that was attached to the wheelchair with their hands secured under the Posey belt.During an observation on 03/12/2026 at 06:07 AM, Resident #180 was sitting on a roho cushion in their wheelchair. The resident was awake. Resident #180 was able to remove their hands from under the Posey belt; however, they could not release the Posey belt on request. During an interview on 03/12/2026 at 06 :09 AM, Certified Nursing Assistant #1 (assigned to Resident #180) stated Resident #180 was usually in bed when they come in for their 11:00 PM to 07:00 AM shift; however, last night they came in at 03:00 PM and were assigned to Resident #180 for both shifts. Certified Nursing Assistant #1 stated they put Resident #180 into bed at 11:00 PM on 03/11/2026 and took the resident out of bed to the wheelchair about a half an hour ago (05:39 AM). Certified Nursing Assistant #1 they were not aware that Resident #180 was in the wheelchair at 04:20 AM and 05:06 AM and reiterated that they transferred Resident #180 into the wheelchair half an hour ago, without assistance from anyone. The surveillance video footage was reviewed on 03/12/2026, with the facility administrator and revealed that Certified Nursing Assistant #1 did not go into Resident #180's room from 10:26 PM on 03/11/2026 until 5:43 AM 03/12/2026. Certified Nursing Assistant #1 was in the resident's room for nine (9) minutes from 05:43 PM to 05:52 AM. The medication nurse, Licensed Practical Nurse # 1, was observed going into the resident's room for less than a minute at 02:55 AM and 05:30 AM. During an interview on 03/12/2026 at 09:52 AM, Licensed Practical Nurse #1 stated Resident #180 was in their wheelchair sleeping when they started their shift on 03/11/2026 at 11:00 PM. During their rounds they went into the resident's room on 03/12/2026 at 02:55 AM and Resident #180 was asleep in their wheelchair. Licensed Practical Nurse #1 stated they returned to the resident's room at 05:30 AM to administer the medications and observed Resident #180 sleeping in the wheelchair. Licensed Practical Nurse #1 stated the wheelchair Posey belt was restraining and did not know if skin checks were needed when utilizing a restraining device. During an interview on 03/12/2026 at 02:14 PM, Wound Care Registered Nurse #1 stated Resident #180 developed a stage II pressure ulcer to the coccyx, at the facility on 01/01/2026. The stage II pressure ulcer was healed on 01/13/2026. The resident developed a new unstageable pressure ulcer to their right buttock on 01/06/2026. Wound Care Registered Nurse #1 stated Resident #180 utilizes a roho cushion on their wheelchair for the prevention of pressure ulcers. Wound Care Registered Nurse #1 stated Resident #180's pressure ulcer was unavoidable because of the resident's risk factors such as incontinence, agitation, and frequent movements. Resident #180 should be turned and positioned every two (2) to four (4) hours when in bed. The Certified Nursing Assistant should shift the resident's weight and reposition every two (2) to (4) hours when the resident is seated in the wheelchair. Their brief should be checked and changed every two (2) to four (4) hours. Wound Care Registered Nurse #1 stated the existing pressure ulcer would deteriorate if the resident was left seated in the wheelchair all night long and not repositioned or changed. Wound Care Registered Nurse #1 stated the facility's electronic medical record did not allow the certified nursing assistants to document provision of turning and positioning every two (2) to four (4) hours and there was no way of knowing if the residents were turned and positioned as per the plan of care. Wound Care Registered Nurse #1 stated they believed the Director of Nursing Services was aware that the electronic medical record system was not working correctly. During a re-interview on 03/13/2026 at 9:36 AM, Licensed Practical Nurse #1 stated they did not speak to Certified Nursing Assistant #1 about Resident #180 being left in the chair all night because Certified Nursing Assistant #1 had their job, and they had their own job. Licensed Practical Nurse #1 stated they were busy as they were the only medication nurse on the 11:00 PM-7:00 AM shift for the entire unit. They regularly see Resident #180 at night sleeping in a wheelchair. Resident #180 did better in the wheelchair because when they are placed in the bed they would get out and crawl around the room and the unit. Licensed Practical Nurse #1 stated they have their own assignment to follow and are not responsible for monitoring the certified nursing assistants to see if the certified nursing assistants are providing resident care.During an interview on 03/13/2026 at 9:43 AM, the Director of Nursing Services stated the staff should have provided incontinence and toileting care and turning and positioning as per Resident #180's plan of care. Resident #180 should not have been left in their wheelchair all night long. This created a likelihood for wound deterioration and development of new wounds. The Director of Nursing Services stated that the harness-like belt is a Posey assistive device and was not considered a restraint even though the resident was unable to open the Posey assistive device on request. The Director of Nursing Services stated that the Posey assistive device did not require a physician's order. During an interview on 03/13/2026 on12:08 PM, the Administrator stated Resident #180 should not have been left in the wheelchair all night and that the staff must follow the resident's plan of care including brief change every two (2) to four (4) hours and turning and positioning every two (2) to four (4) hours. The Administrator stated they were not clinical and expected clinical staff to follow the resident's plan of care and document provision of care. During an interview on 03/13/2026 at 12:38 PM, the Medical Director stated when a resident is not provided with incontinence care and is not turned and positioned every two (2) to four (4) hours, they can develop pressure ulcers or current pressure ulcers could deteriorate and develop infection if the resident is left sitting in urine and feces. Resident #180 should have been placed in bed and not left in the wheelchair for a long time. The Medical Director stated that the nurse should have asked for an order for the Posey restraint.10 New York Codes, Rules, and Regulations 415.12

Based on observations, record reviews, and interviews, the facility failed to ensure that each resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for one (1) (Resident #180) of five (5) residents reviewed for Pressure Ulcers. Specifically, Resident #180 was admitted to the facility with no pressure ulcers and was assessed to be at risk for developing pressure ulcers, was incontinent of bowel and bladder, and used a Posey restraint (device to limit patient movements) in their wheelchair at night. On 01/01/2026: Developed a Stage 2 (a partial-thickness skin loss) ulcer on the coccyx (small triangular bone at the bottom of the spine). On 01/06/2026: Developed an unstageable ulcer (full-thickness tissue loss where the wound bed is fully covered by dead tissue) on the right buttock. On 01/20/2026: Right buttock wound required debridement (the medical removal of dead, damaged, or infected tissue from a wound to promote healing and prevent infection) and was classified as a Stage 3 pressure ulcer (a full thickness wound extending through the skin layers into the subcutaneous fat, resulting in deep, crater like injury). There was no documented evidence that Resident #180 had their brief checked and changed or was turned and positioned every 2-4 hours to offload the pressure areas as per their care plan. This failure, involving lack of incontinence care and care plan implementation, resulted in actual harm to Resident #180 that is not Immediate Jeopardy. The findings were:The undated facility policy titled Pressure Ulcer Prevention Management and Treatment Program, documented when a pressure ulcer is identified the certified nursing assistant accountability record sheet should include a turning and positioning schedule, out of bed schedule as per individual care plan, toileting schedule every 2-4 hours and as needed, and any adaptive/assistive devices. When in a chair, if the pressure ulcer site can be relieved, the resident can sit [in the chair] for a limited time as per the established turning and positioning schedule. The facility policy titled Quality of Care last reviewed 02/02/2026, documented avoidable decline is the deterioration resulting from failure to provide appropriate evaluation, monitoring, treatment, or interventions. Residents are monitored for changes in condition including skin conditions. Resident #180 was admitted with diagnoses that included down syndrome (genetic condition leading to intellectual disability, developmental delays, and distinct physical features and low muscle tone) and bipolar disorder (chronic mental health condition characterized by intense alternating mood swings). The Quarterly Minimum Data Set (a resident assessment tool) dated 12/13/2025, documented the resident had severely impaired long and short term memory problems. The Quarterly Minimum Data Set assessment documented Resident #180 was dependent on staff for all aspects of activities of daily living care. Resident #180 was always incontinent of bowel and bladder and was at risk for developing pressure ulcers. The resident used a wheelchair as the mobility device. The comprehensive care plan dated 09/08/2025 last revised on 12/15/2025 titled altered health maintenance-skin integrity: impaired cognition, bowel and bladder incontinence, fragile skin and skin desensitization to pain/pressure documented interventions included monitoring skin integrity every shift, providing good skin care after each episode of incontinence, changing brief every 2-4 hours, turning and positioning every 2-4 hours in bed, repositioning in out of bed seating (wheelchair) every two (2) hours, and avoiding positioning directly on trochanter (bony prominence on the upper part of the thighbone).The nursing progress note dated 01/01/2026 documented a new open area to the coccyx was noted with a Stage 2 pressure ulcer measuring 0.5 centimeter in length, 0.5 centimeter in width and 0.1 centimeter in depth. The peri wound area (area surrounding the wound bed) had slight erythema (redness). The physician order dated 01/02/2026 documented to apply Venelex ointment (topical wound treatment ) twice a day to the coccyx. Cleanse open area with normal saline, pat dry followed by Venelex ointment with dry clean dressing twice a day and as needed. A Comprehensive Care Plan dated 01/06/2026 documented the resident had a right buttock unstageable pressure injury. The comprehensive care plan was updated on 02/07/2026 and documented that the unstageable pressure ulcer to the right buttock was changed to Stage 3 pressure ulcer on 01/20/2026, and documented interventions including monitoring skin integrity daily, provide pressure reducing cushion and pressure reducing/relieving mattress, provide rest periods and turn and position every 2-4 hours. The wound care note dated 01/06/2026, written by a nurse practitioner, documented they were called to evaluate the sacrum (buttock area) for a report of skin impairment to the area. Risk factors included physical deconditioning, weakness, down syndrome, air mattress and Roho cushion (specialized cushion for pressure relief) contraindicated due to fall risk, specialty wheelchair use, incontinence, and resident being resistive with hands on care. The physical examination indicated a coccyx Stage 2 pressure injury. Treatment as ordered [01/02/2026]. The assessment included a new unstageable pressure injury to the right lower buttock with recommendations to cleanse the right buttock wound with normal saline followed by Santyl (enzymatic debriding agent) every day and as needed. Due to comorbidities and risk factors, and contraindications with offloading measures, ulcers were unavoidable. An untitled investigation report for Resident #180's pressure ulcer dated 01/07/2026, documented the pressure ulcers were a result of Resident #180's behavior of combativeness with care, and the constant need to be repositioned in the wheelchair. Resident #180 was incontinent of bowel and bladder, and staff had difficulty performing wound care secondary to the resident's behaviors. The wound care note dated 01/13/2026 documented coccyx pressure ulcer healed. Conservative sharp debridement was completed for the right lower buttock unstageable wound at the bedside. The resident tolerated the procedure well. Recommendations to continue Santyl and dry clean dressing once daily and as needed. Wound care note dated 01/20/2026 documented the right lower buttock pressure injury was assessed to be a Stage 3 pressure ulcer. Recommendations were to continue Santyl, and dry clean dressing daily and as needed. A review of the medical record from 12/01/2025 - 03/09/2026 indicated multiple nursing progress notes documenting that Resident #180 was found crawling out of bed on the floor and into the hallway. Resident #180 was redirected back to their room and was placed in their wheelchair.The Certified Nursing Assistant Accountability instructions dated 09/08/2025 (resident care instruction provided to certified nursing assistants) documented Resident #180 required two (2) person assistance for bed mobility, dressing, grooming, bathing, and transferring. It further documented Resident #180 was to have their brief changed every 2-4 hours and as needed, and to be turned and positioned every 2-4 hours, female Certified Nursing Assistants only. There was no documented evidence that the resident was turned and positioned every 2-4 hours or that the brief check and change was performed every 2-4 hours. During an observation on 03/10/2026 at 6:51 AM, Resident #180 was observed in a dark room sitting upright on a Roho cushion in a tilt-in-space wheelchair. The resident was strapped to their wheelchair with a Posey restraint. Resident #180 was making loud incoherent random sounds. During an observation on 03/12/2026 at 4:20 AM, Resident #180 was in their room in the dark, sleeping in their wheelchair while sitting upright on a Roho cushion. The resident was restrained with a Posey belt that was attached to the wheelchair with their hands secured under the Posey belt.During an observation on 03/12/2026 at 5:06 AM, Resident #180 was in their room in the dark, sleeping in their wheelchair while sitting upright on a Roho cushion. The resident was restrained with a Posey belt that was attached to the wheelchair with their hands secured under the Posey belt.During an observation on 03/12/2026 at 6:07 AM, Resident #180 was sitting on a Roho cushion in their wheelchair. The resident was awake. Resident #180 was able to remove their hands from under the Posey belt; however, they could not release the Posey belt upon request. During an interview on 03/12/2026 at 6 :09 AM, the assigned Certified Nursing Assistant #1 stated Resident #180 was usually in bed when they come in for their 11:00 PM to 7:00 AM shift; however, last night they came in at 3:00 PM and were assigned to Resident #180 for both shifts. Certified Nursing Assistant #1 stated they put Resident #180 into bed at 11:00 PM on 03/11/2026 and took the resident out of bed to the wheelchair about a half an hour ago (5:39 AM). Certified Nursing Assistant #1 stated they were not aware that Resident #180 was in the wheelchair at 4:20 AM and 5:06 AM and reiterated that they transferred Resident #180 into the wheelchair half an hour ago without assistance from anyone. The video surveillance footage was reviewed with the facility administrator on 03/12/2026 and revealed that Certified Nursing Assistant #1 did not go into Resident #180's room from 10:26 PM on 03/11/2026 until 5:43 AM 03/12/2026. Certified Nursing Assistant #1 was in the resident's room on 03/12/2026 for nine (9) minutes from 5:43 AM to 05:52 AM. The medication nurse, Licensed Practical Nurse #1, was observed going into the resident's room for less than one (1) minute on 03/12/2026 at 2:55 AM and 5:30 AM. During an interview on 03/12/2026 at 9:52 AM, Licensed Practical Nurse #1 stated Resident #180 was in their wheelchair sleeping when they started their shift on 03/11/2026 at 11:00 PM. On 03/12/2026, they went into Resident #180's room at 2:55 AM and the resident was asleep in their wheelchair. Licensed Practical Nurse #1 stated they returned to the resident's room at 5:30 AM to administer the medications and again observed Resident #180 sleeping in the wheelchair. During an interview on 03/12/2026 at 2:14 PM, Wound Care Registered Nurse #1 stated the resident uses a Roho cushion on their wheelchair for prevention of pressure ulcer development. The plan of care requires turning/positioning in bed and shifting weight/repositioning in the wheelchair every 2-4 hours. Incontinence care (brief changes) is also required every 2-4 hours. Wound Care Registered Nurse #1 deemed the ulcers were unavoidable due to risk factors, including incontinence, agitation, and frequent movements. The nurse noted that leaving the resident in the wheelchair all night without repositioning or changing would cause the pressure ulcer to deteriorate. Wound Care Registered Nurse #1 stated that the electronic medical record system did not allow certified nursing assistants to document turning and positioning, making it impossible to verify if the plan of care was followed. Wound Care Registered Nurse #1 believed the Director of Nursing Services was aware that the electronic medical record system was not functioning correctly. During a re-interview on 03/13/2026 at 9:36 AM, Licensed Practical Nurse #1 stated they did not speak to Certified Nursing Assistant #1 about Resident #180 being left in the wheelchair all night because Certified Nursing Assistant #1 had their job, and they had their own job. Licensed Practical Nurse #1 stated they were busy as they were the only medication nurse on the 11:00 PM - 7:00 AM shift for the entire unit. They regularly see Resident #180 at night sleeping in a wheelchair. Resident #180 did better in the wheelchair because when they are placed in the bed they would get out and crawl around the room and the unit. Licensed Practical Nurse #1 stated they have their own assignment to follow and are not responsible for monitoring the certified nursing assistants to see if the certified nursing assistants are providing resident care. During an interview on 03/13/2026 at 9:43 AM, the Director of Nursing Services stated the staff should have provided incontinence and toileting care and turning and positioning as per Resident #180's plan of care. Resident #180 should not have been left in their wheelchair all night long. This situation created a likelihood for the deterioration of the existing wound and development of new wounds. The Director of Nursing Services stated the electronic medical record system does not allow the certified nursing assistants to document provision of turning and positioning and toileting every 2-4 hours. The Director of Nursing Services stated they did not know how long the electronic medical record system has not been working properly; however, the Information Technology staff is working to resolve the issue. The Director of Nursing Services stated at this time there was no evidence to show that the staff was providing turning and positioning and toileting care to the residents. During an interview on 03/13/2026 at 12:08 PM, The Administrator stated the staff must follow the resident's plan of care including brief change every 2-4 hours and turning and positioning every 2-4 hours. The Administrator stated they were not clinical and expected clinical staff to follow the resident's plan of care and document provision of care. During an interview on 03/13/2026 at 12:38 PM, the Medical Director stated that when a resident is not provided with incontinence care and is not turned and positioned every 2-4 hours, they can develop pressure ulcers or the current pressure ulcers could deteriorate and develop infection if the resident is left sitting in urine and feces. Resident #180 should have been placed in bed and not left in the wheelchair for a long time. 10 New York Codes, Rules, and Regulations 415.12(c)(1)

Based on observation, record review, and interviews, the facility failed to develop a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet each resident's medical and nursing needs that are identified in the comprehensive assessment. This was identified for one (1) of two (2) residents reviewed for skin conditions. Specifically, Resident #12 had a physician's order for contact precautions due to extended-spectrum -lactamase infection (antibiotic resistant bacteria) in the coccyx wound and enhanced barrier precautions for the wounds on both heels. There was no comprehensive care plan developed with interventions to address the resident's enhanced barrier precaution and contact precautions status.The finding is:The facility comprehensive care plan policy last reviewed on 2/2/2026 documented a comprehensive person-centered care plan including measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive person-centered care plan is developed within seven days of the completion of the required assessment such admission, annual or significant change in status, and no more than 21 days after admission. The assessments of residents are ongoing, and care plans are revised as information about the residents and resident conditions change. The interdisciplinary team reviews and updates the care plan.Resident #12 was admitted to the facility with diagnosis including acute embolism and thrombosis (a blood clot forms in the deep veins) of right lower extremity, non-pressure chronic ulcer of the right foot, and extended spectrum beta lactamase infection of the skin and subcutaneous tissue. The Quarterly Minimum Data Set, dated [DATE] documented a Brief Interview of Mental Status score of 11, indicating the resident had moderate cognitive impairment. The Minimum Data Set assessment documented the resident had one (1) stage 3 pressure ulcer as well as three (3) venous and arterial ulcers. The minimum data set did not indicate the resident was on any transmission-based precautions.The current physician's order dated documented contact precautions for extended-spectrum -lactamase infection of the coccyx wound and enhanced barrier precautions secondary to wounds on both heels. During an observation on 03/10/2026 at 6:56 AM, a contact precautions signage was placed outside Resident #12's room door. A green dot was noted next to Resident#12's name which indicated resident was also on enhance barrier precautions, as per the facility infection control policy.A review of Resident #12's medical record revealed there was no comprehensive care plan with interventions to address the enhanced barrier precaution and contact precautions status.During an interview on 03/15/2026 at 10:07 AM, the Wound Care Nurse stated the resident was on contact precautions and enhanced barrier precautions as per the physician's orders and the infection control care plan should have been initiated and continued until the contact precautions and enhanced barrier precautions were resolved.During an interview on 03/15/2026 at 10:42 AM, the Director of Nursing Services stated the infection control care plan should have been initiated to address Resident #12's enhanced barrier precaution and contact precaution status.10 NYCRR 415.11(c)(1)

Based on observations, interviews, and record review the facility failed to ensure that each resident was treated with respect and dignity and in a manner and in an environment that promotes maintenance or enhancement of their quality of life. This was identified for one (1) (Resident #104) of two (2) residents reviewed for Dignity. Specifically, during multiple observations, Resident #104 was observed in their room with a urinary catheter drainage bag that was not covered. The urinary catheter drainage bag was half-filled with urine and was visible from the hallway. The finding is:The facility's policy titled, Dignity last revised on 02/02/2026 documented that residents shall be treated with Dignity and respect at all times. Treated with Dignity means the resident will be assisted in maintaining and enhancing their self-esteem and self-worth. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed, including keeping the urinary catheter bags covered.Resident #104 was admitted with diagnoses including neuromuscular dysfunction of the bladder (loss of bladder control caused by nerve damage), hemiplegia and hemiparesis (one sided body impairment), and urinary retention (inability to fully or partially empty the bladder). The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #104 was rarely and never understood and had severe cognitive impairment. Resident #104 had an indwelling catheter (a flexible tube inserted into the bladder to drain urine, held in place by a water filled balloon).A Comprehensive Care Plan (CCP) titled, Altered Health Maintenance: Foley Catheter dated 09/23/2024 and revised on 02/09/2026 documented interventions including, ensuring that the Foley (urinary) drainage bag is not touching the floor, observe for decrease urinary output or leakage, and empty the Foley drainage bag every shift.A Physician Order dated 11/23/2025 documented Foley catheter,16 French (specific outer diameter of the tube), 10 milliliters balloon for diagnosis of neurogenic bladder (loss of bladder control caused by nerve damage).A Physician Order dated 12/31/2025 documented Foley catheter care every shift.During an observation on 03/09/2026 at 11:05 AM, Resident #104 was in bed with a Foley catheter drainage bag that was not covered and was visible from the hallway. The Foley catheter drainage bag was half filled with yellow colored urine.During an observation on 03/09/2026 at 12:41 PM, Resident #104 was eating their lunch in bed. Resident #104 had a Foley catheter drainage bag that was not covered and was visible from the hallway. The Foley catheter drainage bag was half filled with yellow colored urine.During an observation on 03/13/2026 at 9:00 AM, Resident #104 was in bed with a Foley catheter drainage bag lying on Resident #104's landing mat (soft, thick, foldable mat designed to cushion a landing, fall or mishap) and was visible from the hallway. The Foley catheter drainage bag was half filled with yellow colored urine. The Foley catheter drainage bag was not covered with a privacy cover.During an interview on 03/09/2026 at 12:45 PM, Certified Nursing Assistant #4 stated that they did not notice that Resident #104's Foley catheter drainage bag was not covered with a privacy bag. Certified Nursing Assistant #4 stated they were busy providing care to other residents and forgot to put the privacy cover for Resident #104's Foley catheter drainage bag.During an interview on 03/11/2026 at 8:01 AM, Licensed Practical Nurse #5, Medication Nurse, stated that the Certified Nursing Assistants are responsible for placing the privacy covers for the Foley catheter. Licensed Practical Nurse #5 stated they were not sure if there was a privacy cover for Resident #104's Foley catheter drainage bag when they went into administer Resident #104's medications on 03/09/2026.During an interview on 03/13/2026 at 9:13 AM, Certified Nursing Assistant #5 stated that they did not notice that Resident #104's Foley catheter drainage bag did not have a privacy cover when they (Certified Nursing Assistant #5) had provided care for Resident #104 early in the morning. Certified Nursing Assistant #5 stated they were busy doing care with other residents and did not check if Resident #104's Foley catheter drainage bag was covered with a privacy cover.During an interview on 03/16/2026 at 10:17 AM, the Director of Nursing Services stated that Resident #104's Foley catheter drainage bag should have been covered with a privacy bag. The Director of Nursing Services stated that they expect their staff to ensure that all residents are cared for in a dignified manner.10 NYCRR 415.5(a)

Based on observation, record review, and interviews, the facility failed to ensure that each resident had secure and confidential medical records. This was identified for one (1) (Resident #27) of five (5) residents reviewed for the Medication Administration Task. Specifically, Licensed Practical Nurse #1 left Resident #27's electronic record open in the hallway with the personal and medical information visible to other staff, residents, and visitors.The finding is:Resident #27 was admitted with diagnoses that included fracture of the finger in the right hand, cerebral infarction (lack of blood supply to the brain tissue causing tissue death), chronic obstructive pulmonary disease (long-term lung disease that makes breathing difficult). The admission Minimum Data Set assessment dated [DATE], documented a Brief Interview for Mental Status score was not completed as Resident #27 was rarely or never understood.During a medication pass observation on 03/10/2026 at 6:33 AM, Licensed Practical Nurse #1 went into Resident 27's room to administer medications to the resident and left the computer screen open and visible to other staff, residents, and visitors in the hallway. During an interview on 03/10/2026 at 6:33 AM, Licensed Practical Nurse #1 stated the resident's personal and medical information should be protected and the computer screen should have been closed.During an interview on 03/15/2026 at 7:20 AM, the Director of Nursing Services stated to protect the resident personal and medical information, the computer screen needs to be minimized or closed when not in use.10 NYCRR 415.3(e)(1)

Based on observations, record review and interviews, the facility failed to ensure that each resident was free from physical restraints that was used for the purpose of discipline or convivence; and that the restraint was used to treat the residents' medical conditions with ongoing re-evaluation of the need for the physical restraint. This was identified for one (1) (Resident #180) of one (1) resident reviewed for restraints. Specifically, Resident #180 had diagnoses including down syndrome with severely impaired cognition and a facility acquired stage 3 pressure ulcer to their right buttock. Resident #180 was physically restrained with an upper body Posey belt (a harness-like belt that wraps the resident's trunk to keep the resident in an upright position) with no documented evidence of a physician's order, the medical necessity, care instructions for nursing staff, or ongoing monitoring and re-evaluation of the need for the physical restraint. Additionally, there was no documented evidence that a consent to use the restraint was obtained and the resident representatives were informed of the risks and benefits of the restraint being used for Resident #180.Cross Reference: F684 Quality of CareThe finding is:The facility policy titled Restraints last reviewed 02/02/2026 documented the primary focus is to ensure the safety and well-being of residents while minimizing the use of restraints to the greatest extent possible. Informed consent must be obtained from the resident or their legally authorized representative before implementing any restraint. The healthcare team must provide a clear explanation of the reasons for restraint use, potential risks and benefits, and alternatives. Residents under restraint must be closely monitored, and the effectiveness of restraint interventions must be regularly evaluated. Thorough and accurate documentation is essential for all aspects of restraint use, including initial assessment, informed consent, ongoing monitoring and evaluations. Resident #180 was admitted with diagnoses that included down syndrome (genetic condition caused by an extra copy of chromosome 21 leading to intellectual disability, developmental delays, and distinct physical features and low muscle tone), pressure ulcer right buttock stage III, and bipolar disorder (chronic mental health condition characterized by intense alternating mood swings). The Quarterly Minimum Data Set (a resident assessment tool) dated 12/13/2025 documented a Brief Interview for Mental Status score was not completed as the resident was never understood and had severely impaired long and short term memory. The Minimum Data Set documented Resident #180 used a wheelchair and was dependent on two (2) staff members for all aspects of care. The Quarterly Minimum Data Set assessment documented Resident #180 had no restraints in and out of bed.A Comprehensive Care Plan dated 09/10/2025 and last reviewed 12/15/2025, documented Resident #180 requires restraint alternative use secondary to inability to sit up on their own and maintain proper body alignment. Interventions included quarterly review and evaluation of use and for possible reduction. Inform family representative of benefits and risks associated with restraint use.A Restraint Alternative vs Restraint Determination assessment form dated 09/08/2025 documented Resident #180 was evaluated for a restraint alternative or restraint for the following reasons: tend to lean forward, and poor trunk control. The medical symptoms were leans forward and impulsive behavior. The device (name of device not indicated) is appropriate to maintain resident safety due to impulsive movements. The assessment form did not indicate the team's decision whether the device was a restraint alternative or a restraint. The form did not indicate the resident representative was notified. A physician's order dated 09/09/2025 documented out of bed to personal tilt-in-space wheelchair.A review of the physician's orders revealed no documented evidence of orders for the use of the Posey belt restraint, monitoring or skin check instructions related to the use of the restrictive device.A review of the medical record from 12/01/2025-03/09/2026 revealed multiple nursing progress notes indicating Resident #180 was found crawling out of bed on the floor and into the hallway. Resident #180 was redirected back to their room and was placed in their wheelchair.During an observation on 03/10/2026 at 06:51 AM, Resident #180 was observed in a dark room sitting upright on a roho cushion (a specialized cushion for pressure relief) in a tilt in space wheelchair. The resident was strapped to their wheelchair with a Posey restraint. Resident #180 was making loud incoherent random sounds. During an observation on 03/12/2026 at 04:20 AM, Resident #180 was in their room in the dark, sleeping in their wheelchair while sitting upright on a roho cushion. The resident was restrained with a Posey belt that was attached to the wheelchair with their hands secured under the Posey belt.During an observation on 03/12/2026 at 05:06 AM, Resident #180 was in their room in the dark, sleeping in their wheelchair while sitting upright on a roho cushion. The resident was restrained with a Posey belt that was attached to the wheelchair with their hands secured under the Posey belt.During an observation on 03/12/2026 at 06:07 AM, Resident #180 was sitting on a roho cushion in their wheelchair. The resident was awake. Resident #180 was able to remove their hands from under the Posey belt; however, they could not release the Posey belt on request. During an interview on 03/12/2026 at 06 :09 AM, Certified Nursing Assistant #1 (assigned to Resident #180) stated Resident #180 was usually in bed when they come in for their 11:00 PM to 07:00 AM shift; however, last night they came in at 03:00 PM and were assigned to Resident #180 for both shifts. Certified Nursing Assistant #1 stated they put Resident #180 into bed at 11:00 PM on 03/11/2026 and took the resident out of bed to the wheelchair about a half an hour ago (05:39 AM). Certified Nursing Assistant #1 they were not aware that Resident #180 was in the wheelchair at 04:20 AM and 05:06 AM and reiterated that they transferred Resident #180 into the wheelchair half an hour ago, without assistance from anyone. During an interview on 03/12/2026 at 09:52 AM, Licensed Practical Nurse #1 stated Resident #180 was in their wheelchair sleeping when they started their shift on 03/11/2026 at 11:00 PM. During their rounds they went into the resident's room on 03/12/2026 at 02:55 AM and Resident #180 was asleep in their wheelchair. Licensed Practical Nurse #1 stated they returned to the resident's room at 05:30 AM to administer the medications and observed Resident #180 sleeping in the wheelchair. Licensed Practical Nurse #1 stated the wheelchair Posey belt was restraining and did not know if skin checks were needed when utilizing a restraining device. During a re-interview on 03/13/2026 at 9:36 AM, Licensed Practical Nurse #1 stated they did not speak to Certified Nursing Assistant #1 about Resident #180 being left in the chair all night because Certified Nursing Assistant #1 had their job, and they had their own job. Licensed Practical Nurse #1 stated they were busy as they were the only medication nurse on the 11:00 PM-7:00 AM shift for the entire unit. They regularly see Resident #180 at night sleeping in a wheelchair. Resident #180 did better in the wheelchair because when they are placed in the bed they would get out and crawl around the room and the unit. Licensed Practical Nurse #1 stated they have their own assignment to follow and are not responsible for monitoring the certified nursing assistants to see if the certified nursing assistants are providing resident care.During an interview on 03/13/2026 at 9:43 AM, the Director of Nursing Services stated harness-like belt is a Posey assistive device and was not considered a restraint even though Resident #180 was unable to open the Posey assistive device on request. The Director of Nursing Services stated that the Posey assistive device did not require a physician's order. During an interview on 03/13/2026 on12:08 PM, the Administrator stated they were not clinical and expected clinical staff to follow the resident's plan of care and document provision of care. During an interview on 03/13/2026 at 12:38 PM, the Medical Director stated the nurse should have asked for an order for the Posey restraint for Resident #180.10 NYCRR 415.4(a)(2-7)

Based on observation, record review, and interviews, the facility did not ensure that each resident's environment remained free of accident hazards. This was identified for one (1) (Resident #28) of four (4) residents reviewed for Accidents. Specifically, an unsecured oxygen E-Cylinder tank (a portable, high-capacity metal cylinder used to store compressed medical grade oxygen) was observed on Resident 21's bed side. The E-Cylinder tank was not secured in a holder or a metal rack.The finding is: The facility's policy, titled Oxygen Cylinder Storage last revised on 02/02/2026, documented that the facility will store, handle, and maintain oxygen cylinders in a safe manner. Oxygen cylinders should be stored to prevent tipping, damage, contamination, or fire hazards and should be readily accessible for resident care needs while ensuring staff and resident safety. Oxygen cylinders must be secured using racks, chains, straps, or approved carts. Cylinders must never be stored loosely on the floor. Cylinders must be protected from falling, tipping, or physical damage. Cylinders stored in Nursing units must be secured in approved holders or carts. Resident #28 was admitted with diagnoses including shortness of breath, aphasia (language disorder caused by brain damage resulting inability to speak, understand, read and write) and traumatic brain injury (caused by external force). The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #28 was rarely and never understood. Resident #28 had severe cognitive impairment. A review of Resident #28's electronic medical record revealed that Resident #28 did not have a physician's order for the use of oxygen. A Comprehensive Care Plan (CCP) titled, Altered Health Maintenance: Resident noted with acute or potential condition, upper respiratory infection, sore throat, dry and moist protective cough dated 12/04/2025 last revised on 12/30/2025 documented interventions including antibiotic therapy, oxygen as needed, and bedrest as needed. During an observation on 03/09/2026 at 11:13 AM, Resident #28 was in bed sleeping. A free-standing E-cylinder oxygen tank was on the left side of Resident #28's bed. The E-tank oxygen gauge (a device that measures the pressure of oxygen in a tank to determine the remaining volume) arrow was pointed in the middle dial, indicating the amount of oxygen present in the tank. The E-Cylinder tank was not secured in a holder, rolling safety stand, or a metal rack. During an interview on 03/09/2026 at 11:24 AM, Licensed Practical Nurse #7, Medication Nurse, stated that Resident #28 uses oxygen therapy as needed. Licensed Practical Nurse #7 stated they did not see the free-standing E-Cylinder tank when they gave medications to Resident #28 in the morning. Licensed Practical Nurse #7 stated that the E-Cylinder tank should be secured with a rolling safety stand or a metal rack. During an interview on 03/09/2026 at 2:10PM, Certified Nursing Assistant #6 stated that they did not see the free-standing E-Cylinder tank in Resident #28's room when they provided morning care to Resident #28. Certified Nursing Assistant #6 stated that the E-Cylinder tank should have been secured on a rolling safety stand. During an interview on 03/09/2026 at 2:38PM, Licensed Practical Nurse #8, Charge Nurse, stated that Resident #28 should not have any free-standing E-Cylinder tank in their room. Licensed Practical Nurse #8 stated that there are plenty of rolling safety stand in the unit to secure the E-Cylinder tank. Licensed Practical Nurse #8 stated they did not know that Resident #28 was on oxygen therapy. During an interview on 03/16/2026 at 10:12 AM, the Director of Nursing Services stated that staff should use a rolling safety stand when securing an E-Cylinder tank. The Director of Nursing Services stated that a free-standing E-Cylinder tank is unsafe and can cause injury. The Director of Nursing Services stated that all staff members are responsible for checking each resident room for any hazards including unsecured oxygen tanks. 10 NYCRR 415.12(h)(1)

Based on observations, record review, and interviews, the facility failed to ensure that residents who have an indwelling catheter received the appropriate care and services to prevent urinary tract infections to the extent possible. This was identified for one (1) (Resident # 40) of four (4) residents reviewed for Urinary Catheter. Specifically, Resident #40 was admitted to the facility with a chronic long-term Foley catheter. On 03/09/2026, Resident #40 was observed with the Foley catheter drainage bag stored above their waistline causing potential for urinary retention and the urine to flow back into the bladder.The finding is: The facility policy and procedure for Foley Catheter dated 2/2/2026 documented that the purpose of this procedure is to prevent infection of the resident's urinary tract. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Resident #40 was admitted with the diagnosis of benign prostatic hyperplasia without lower urinary tract symptoms The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The resident required substantial/maximal assistance for toilet use. The resident was non-ambulatory and had an indwelling catheter. The urinary incontinence and indwelling catheter comprehensive care plan dated 03/06/2026 documented indwelling catheter in place for urinary retention, with increased risk for urinary tract infection secondary to Foley catheter and history of urinary tract infection, increased risk for dehydration with urinary tract infection. Interventions included to ensure the Foley drainage bag is not touching floor, conduct ongoing assessment for urinary tract infection, change Foley catheter per physician orders, empty drainage bag every shift and assure that the drainage bag is clean, covered, and positioned below the indwelling catheter. The physician's orders dated 03/09/2026 documented Foley catheter 18 French (size) With 30 cubic centimeter balloon (used to hold catheter In place) due to urinary retention related to diagnoses of obstructive uropathy and neurogenic bladder; change Foley catheter every four (4) weeks; flush Foley catheter every shift with 30-50 cubic centimeter normal saline as needed and provide Foley catheter care every shift. During an observation on 03/09/2026 at 10:15 AM, Resident # 40 was in their room seated in their wheelchair. The resident's Foley catheter drainage bag that was connected to the resident's Foley catheter was stored above the resident's waist level, on the resident's wheelchair arm pad. During an observation with the Licensed Practical Nurse #3 on 03/09/2026 at 11:15 AM, Resident #40 was observed with their Foley catheter drainage bag stored above the resident's waist level. Licensed Practical Nurse #3 stated they did not realize that the Foley drainage bag was not stored properly and that the bag should be below the resident's waist level. During an interview on 03/09/2026 at 11:17 AM, Registered Nurse #1 stated that the foley drainage bag should not be placed above the resident's waistline. Registered Nurse #1 stated if the urinary drainage bag is placed above the Foley catheter and the bladder, the urine would not drain properly and could cause an infection and urinary retention. During an interview on 03/12/2026 at 12:10 PM, the Director of Nursing Services stated the urinary drainage bag should be placed below the urinary catheter site so the urine could drain effectively. If the drainage bag is above the waistline, this can cause urinary retention and infections. During an interview on 03/17/26 at 11:45 AM, the Medical Director stated the urinary drainage bag should not be placed above the resident's bladder level for effective urinary drainage. If the bag is above the bladder, the urine would not be able to drain. This can cause urinary retention and infections. 10 NYCRR 415.12(d)(1)

Based on record review and staff interviews during a recertification survey, the facility failed to ensure the provision of care and services necessary to maintain acceptable parameters of hydration status. This was identified for one (1) (Resident #277) of eight (8) residents reviewed for nutrition and for one (1) (Resident #14) of one (1) resident reviewed for Dialysis. Specifically. The facility did not monitor and document the fluid intake for Resident #277 and Resident #14 who had a physician ordered 1200 milliliter (mL) fluid restriction. As a result, the facility staff were unable to determine whether the residents' prescribed fluid restriction orders were followed, placing the residents at risk for fluid imbalance.The findings are: A facility policy and procedure titled Fluid Restriction, dated 02/02/2026, documented fluid restrictions will be followed as per Physician's orders and follows the procedures: the amount of fluid allowed in a 24-hour period will be specified in a physician's order and sent to dietary [department] via electronic medical record system. The dietary department and nursing department will determine how much fluid will be provided at meals and medication passes. No water will be provided at the bedside unless calculated into the daily total fluid restriction. -Resident #277 was admitted on [DATE] with diagnoses including dehydration, acute kidney injury on chronic kidney disease, and acute heart failure. The admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 15, indicating the resident had intact cognition. Resident #277 did not exhibit any behaviors or refusal of care/treatment, was independent for feeding, and had no signs or symptoms of dehydration. A Physician's order dated 03/05/2026, documented Diet: No Added Salt with a 1200 milliliter fluid restriction with special instructions to use 60 milliliters of fluid per medication pass. The order did not specify the reason for the fluid restriction. A dietary progress note dated 03/06/2026 documented Resident #277 had a physician's diet order of no added salt and a 1200 milliliter fluid restriction. Resident #277's appetite was good, with approximately 75 percent of meals with fluids intake. A nursing progress note dated 03/06/2026 documented Resident #277 had good appetite, and fluids were encouraged and tolerated. The note did not specify the amount of fluid consumed by the resident in numerical form to determine a total of 1200 cubic centimeter of fluid intake. A medical progress note dated 03/07/2026 documented Resident #277 has diagnoses of heart failure and acute and chronic renal failure. The plan included monitoring renal function, continue medication of Lasix (diuretic) 20 milligrams daily, monitor fluid status and weights, and a 1200 milliliter fluid restriction. A comprehensive care plan titled Nutritional Status, effective 03/06/2026, documented Resident #277 required a therapeutic diet, with goals to consume food and fluids as tolerated. Interventions included providing adequate proteins, calories, and fluids to meet estimated needs, monitoring laboratory values, documenting and reporting dietary noncompliance, encouraging and monitoring meal intake; monitoring weight; and providing the diet as ordered. A comprehensive care plan titled Risk for dehydration secondary to diuretic therapy and a 1200 milliliter fluid restriction per 24 hours; a goal that resident will consume fluids as tolerated 840 milliliters from dietary, 180 milliliters from medications, and 180 milliliters from recreation. Interventions included monitoring output, monitoring labs, and encouraging intake as appropriate. A review of the electronic medical record Medication Administration Record from 03/05/2026 to 03/16/2026 and meal intake record 03/06/2026 to 03/16/2026 indicated no evidence that the fluid intake was recorded to quantify the amount of fluid consumed by the resident in numerical form to ascertain 1200 cubic centimeter of fluid intake by the resident. During an interview on March 12, 2026, at 4:23 PM, the Registered Dietitian stated that fluid amounts provided on the meal trays are listed in the dietary computer system and that the nursing staff was verbally instructed to use 60 milliliters of fluid for medication administration for each shift. The Registered Dietitian confirmed that the resident's total daily fluid intake is not documented. During an interview on 03/17/2026 at 11:54 AM, the Director of Recreation stated that recreation staff review diet restrictions before activities and communicate with nursing regarding fluid allowances. They further stated that there is no place for staff to document the amount of fluid provided or consumed by the resident. During an interview on 03/17/2026 at 12:06 PM, Certified Nursing Assistant #10 stated they document food and fluid intake on the resident's profile in the electronic medical record. They do not give Resident #277 extra fluids during the day. Certified Nursing Assistant #10 reviewed the meal intake record and confirmed that there was no fluid intake documented, only a percentage for the meal. During an interview on 03/17/2026 at 12:10 PM, Licensed Practical Nurse #15 stated they rely on the physician orders to identify fluid restrictions, but do not document fluid consumption in the medication administration record. Licensed Practical Nurse #15 stated they write a daily note indicating the resident is on a restriction; however, they do not document actual amount of fluid consumed by the resident. -Resident #14 was admitted with diagnoses that included end stage renal disease, arteriovenous fistula, and diabetes mellitus. The annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score was 8, which indicated moderately impaired cognition. The resident received dialysis. A Comprehensive Care Plan for dehydration dated 2/25/2021 and last updated 01/23/2026 documented the resident was at risk for dehydration due to dementia, dependent on staff for fluid, potential for electrolyte imbalance, and fluid restriction 1200 milliliters/24 hours. Interventions included dietary consultation as needed, encourage fluid and food intake as appropriate, monitor for change in output and to monitor for signs and symptoms of dehydration such as poor skin turgor, dry mouth, thirst, and change in mental status. A Comprehensive Care Plan for Stage 4 renal failure dated 2/25/21 and updated 01/23/2026 documented the resident was at risk for excess fluid retention and to monitor the resident's weight as per the physician's order. A current physician's order documented to maintain fluid restriction of 1200 cubic centimeters a day, every shift in total. A Certified Nursing Assistant fluid intake record for Resident #14 dated from 02/17/2026 to 03/17/2026 revealed inconsistent entries for the fluid intake consumed by the resident. The examples included but were not limited to 02/17/2026, 02/18/2026, 02/19/2026, 02/21/2026, 02/22/2026, 02/23/2026, 02/25/2026, 02/27/2026, 02/28/2026, 03/02/2026, 03/03/2026, 03/04/2026, 03/07/2026, 03/08/2026, 03/09/2026, 03/11/2026, 03/12/2026, 03/13/2026, 03/15/2026, 03/16/2026 and 03/17/2026 there were missing entries for the resident's fluid intake on the meal consumption records for various meals. A review of the medication administration record for the month of march indicated no record of the resident fluid intake for all medication administration. A review of the nursing progress notes for the month of March 2026 there were no entries related to the amount of fluid consumed. During an interview on 03/17/2026 at 10:21 AM, Licensed Practical Nurse #13, the unit manager, stated that the resident was on 1200 cubic centimeter fluid restriction and that the certified nursing assistants were responsibility for recording the resident's fluid intake for each meal on the electronic Meal Consumption Record. Licensed Practical Nurse #13 stated that nursing is allotted 360 cubic centimeters of the 1200 cubic centimeters fluid daily, for medication pass. Licensed Practical Nurse #13 stated that the fluids given by the nurses during medication pass were not documented. Licensed Practical Nurse #13 stated that they were responsible for monitoring the certified nursing assistants to ensure the resident's fluid intake was being documented on the Meal Consumption Record. During an interview on 3/17/26 at 10:24 AM, Licensed Practical Nurse #14 stated that the residents receive 240 cubic centimeters of fluid with their morning and the afternoon medication administration pass. Licensed Practical Nurse #14 stated that they do not document the amount of fluid they administer with medication as the Dietitian had already calculated the amount of fluid the nurses were to administer with their medications administration pass. During an interview on 03/17/2026 at 10:42 AM, the Dietitian stated the resident was on a 1200 cubic centimeters fluid restriction. The Dietitian stated dietary was responsible for 860 centimeters of fluid and nursing was responsible for 340 centimeters of fluid for all medication administration pass. The Dietitian stated the 860 cubic centimeters fluid amount includes all liquids served on the resident's meal tray and nursing staff are responsible for monitoring and documenting the fluid intake. During an interview with the Medical Director on 3/17/26 at 1:01 PM, the Medical Director stated that when a resident is on fluid restriction their expectation is that the intake should be monitored and documented to ensure that the resident is receiving the prescribed amount of fluid to prevent fluid over loaded, that the staff knows what the resident intake is, and that the order is followed. The Medical Director stated residents with a diagnosis of congestive heart failure and end stage renal failure are at risk for fluid overload when their fluid intake is not carefully monitored. The Medical Director further stated that the residents plan of care should be followed as written. During an interview on 03/17/2026 at 1:14 PM, the Director of Nursing Services stated that the certified nursing assistants should document the amount of fluid the resident received with each meal for all residents on fluid restriction. The Director of Nursing stated for residents on fluid restrictions, the fluids administered by the nurses during medication administration pass, should be documented on the Medication Administration Record; however, the facility electronic medical record system was not set up for the nurses to record the fluid amount. The Director of Nursing Services stated that going forward dietary will set up the system where the fluids given by the nurse are documented on the Medication Administration Record. The Director of Nursing Services stated that the nurse manager should be monitoring the Meal Consumption Record and the Medication Administration Record for completion and accuracy. The Director of Nursing stated that the unit nurse manager should ensure that the nursing staff document the actual amount of fluid consumed by the resident, during meals and medication administration, in numerical form instead of the percentage to calculate a total of 1200 fluid restriction is followed. The Director of Nursing Services further stated not monitoring the fluid intake could lead to potential for fluid overload for residents on fluid restriction. 10 NYCRR 415.12 (i) (1)

Based on observation, record review and interviews, the facility did not ensure medications were properly stored in medication carts. This was identified for one (1) (Unit 3 southwest medication cart) of eight (8) medication carts reviewed during the medication storage task and Medication Administration task. Specifically, an unlocked and unsupervised medication cart was observed on unit 3 southwest in the hallway. There was no nursing staff present in the vicinity of the medication cart.The finding is:The facility policy titled Storage of Medications last reviewed 02/02/2026, documented the medication nurse on duty is responsible for the security of the carts contents. The cart must be locked and secure at all times when not in use.The facility policy titled Medication Administration, last reviewed 02/02/2026 documented to keep all mediations under lock and key.During a medication pass observation on 03/10/2026 at 6:33 AM, Licensed Practical Nurse #1 went into Resident 27's room to administer their medications. Licensed Practical Nurse #1 left the unlocked medication cart unsecured and out of their view, in the hallway.During an interview on 03/10/2026 at 6:33 AM, Licensed Practical Nurse #1 stated they forgot to lock the cart and that the medication cart should be locked when they go into a resident's room and the cart is out of their view.During an interview on 03/15/2026 at 7:20 AM, the Director of Nursing Services stated they expect the nursing staff to lock the medication cart after removing medications from the cart, it should always be locked when not in use.483.45(g)(h)(1)(2)

Based on observations, record reviews, and interviews, the facility did not ensure that food was prepared, distributed, and served in accordance with professional standards for food service safety. This was identified for one (1) (Resident #74) of four (4) residents reviewed for Tube Feeding. Specifically, Resident #74's tube feeding formula and the water bags were unlabeled and did not indicate the resident's name, the date, or the time the tube feeding was initiated.The finding is:The facility policy titled Gastronomy Feedings last reviewed 02/02/2026, had no documentation for labeling the feeding with the resident's name date and start time. The policy documented disposable equipment is to be changed every 24 hours or as necessary. The Feeding is to be disposed within 24 hours of feeding administration.Resident #74 was admitted with diagnoses that included traumatic subdural hemorrhage (blood collects between the brain and its outer most covering after a head injury), nondisplaced fracture of first cervical vertebra (spine), and Anoxic brain damage (when oxygen is cutoff to the brain leading to brain cell death). The Quarterly Minimum Data Set assessment dated [DATE], documented Resident #74 had a Brief Interview for Mental Status score of 99, indicating the resident could not complete the interview and had severe cognitive impairment. The Quarterly Minimum Data Set assessment documented Resident #74 had a gastronomy tube for nutrition.The Comprehensive Care Plan titled Tube Feed dated 12/13/2024, documented provide tube feed regimen as ordered by the Physician.The Comprehensive Care Plan titled Risk for Dehydration dated 12/13/2024, documented interventions that included providing hydration fluids via gastronomy tube to meet hydration needs.A physician's order dated 10/06/2025, documented Jevity 1.5 formula, via feeding pump, at a rate of 75 cubic centimeters per hour, to run thirteen (13) hours or until volume completes, total volume 1000 cubic centimeters. 760 cubic centimeters of water in formula, 50 cubic centimeters of water before starting feeding and at the end of feeding, and an auto flush of 95 cubic centimeters every hour until total feeding completes. Total auto flush volume is 1235 cubic centimeters, total water 2095 cubic centimeters. Total volume 2335 cubic centimeters. Start feeding at 4:00 PM daily and run till completed.A review of the Medication Administration Record for March 2026 was documented by each shift on 03/09/2026. There was no documented evidence that the gastrostomy feeding was started at 4:00 PM.On 03/09/2026 at 11:04 AM, Resident #74 was observed in bed. The resident's representative was at the bedside. A tube feeding of Jevity 1.5 was observed hanging and running, it was un-labeled, no name, date or time hung was documented on the bottle of Jevity 1.5.During an interview on 03/09/2026 at11:30 AM, the assigned 7:00 AM-3:00 PM shift Licensed Practical Nurse #10 observed the tube feeding currently running for Resident #74 and stated the gastrostomy feeding formula bottle was not labeled with resident's name with date and time the formula was hung. Licensed Practical Nurse #10 stated Resident #74's feeding starts at 4:00 PM every day and should run approximately 13 hours or until it is finished. Licensed Practical Nurse #10 stated the nurse who hung the feeding should have labeled the bottle, with the name of the resident, the time and date it was hung and the volume to infuse hourly and the total volume to infuse. They were unsure as to why the feeding currently hanging was not labeled, they stated they should have noticed this when they were in the room to give the resident medications, and water flushes as ordered. During an interview on 03/13/2026 at 2:30 PM, Licensed Practical Nurse #11, the medication nurse who initiated the feeding on 3/8/2026 at 4:00 PM, stated the tube feeding bottle should be labeled with the rate, the resident's name, time the bottle was hung, and the date. They were unsure why they did not label the feeding on 03/08/2026 it was an oversite.During an interview on 03/15/2026 at 7:18 AM, the Director of Nursing Services stated the tube feeding bottle should be labeled with the resident's name, time hung, and date. They expect the nurses who are on the following shifts to check to see if the tube feeding formula bottle is labeled and running as ordered.10 NYCRR 415.14(h)

Based on observation, record review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This was identified for one (1) (Resident #12) of two (2) residents reviewed for skin conditions. Specifically, Resident #12 had a physician's order for Enhanced Barrier Precautions and Contact Precautions. Certified Nurse Assistant #3 was wearing two pairs of gloves, did not have a protective gown on, and their surgical mask was observed under their mouth.The finding is:The facility's Infection Control policy last reviewed on 8/2025 documented that any resident suspected or diagnosed as having communicable diseases shall be placed in the appropriate type of isolation precautions. For contact precautions, gowns are indicated if soiling is likely and if contact with the resident or handling of items in the room are expected. Wear Gloves when entering the room. Change after contact with infective material. Gloves are to be removed and discarded before leaving the room. All healthcare workers, visitors and residents will follow established precautions as well as any special instructions that become necessary.The Enhanced Barrier Precaution Policy dated 8/2025 documented to implement enhanced barrier precaution during high contact resident care activities for those residents who are within multidrug resistant organisms unless otherwise ordered by the primary medical doctor. An example of high contact resident care activities including dressing, bathing, showering, changing linens, changing briefs or assisting with toileting. The facility will implement enhanced barrier precautions to include any resident including chronic wounds and venous status ulcers. Gowns and gloves are needed when providing high contact resident care activities.Resident #12 was admitted to the facility with diagnoses including acute embolism and thrombosis (a blood clot forms in the deep veins) of unspecified deep veins of right lower extremity, non-pressure chronic ulcer of the right foot, and extended spectrum beta lactamase infection of the skin and subcutaneous tissue. The Quarterly Minimum Data Set, dated [DATE] documented the resident had a Brief Interview of Mental Status of 11, indicating the resident had moderate cognitive impairment. The Minimum Data Set assessment documented the resident had one (1) stage 3 pressure ulcer as well as three (3) venous and arterial ulcers. The resident was always incontinent with bowel and bladder and required assistant with toileting.The current physician's order dated documented contact precautions for extended-spectrum -lactamase infection of the coccyx wound and enhanced barrier precautions secondary to wounds on both heels. During an observation on 03/10/2026 at 6:56 AM, a contact precautions signage was placed outside Resident #12's room door. A green dot was noted next to Resident#12's name which indicated resident was also on enhance barrier precautions, as per the facility infection control policy. Certified Nurse Assistant #3 was observed providing incontinence care for Resident #12. Certified Nurse Assistant #3 was wearing two pairs of gloves, did not have a protective gown on, and their surgical mask was observed under their mouth.During an interview on 03/10/2026 at 7:07 AM, Certified Nurse assistant #3 stated they believed Resident #12's roommate was on contact precautions. Certified Nurse Assistant #3 stated they never followed contact precautions for Resident #12 because they knew Resident #12 was not on contact precautions. Certified Nurse Assistant #3 stated they did not need to ask the nurse who was on contact precautions in the room. Certified Nurse Assistant #3 further stated that if the signage was posted on the right side of the wall, then that would indicate Resident #12 was on contact precautions. Certified Nurse Assistant #3 stated that they utilized contact precaution for the resident on the left side of the room because the contact precaution sign was posted on the left side of the door. Certified Nurse Assistant#3 stated they did not know what the green dot indicator on the contact precaution signage meant and that the contact precautions were not listed on the Certified Nurse Assistant assignments sheets. Certified Nurse Assistant #3 stated they used double gloves to protect themselves and the surgical face masks felt better below their mouth.A review of Resident #12's roommate indicated that the resident did not have any transmission-based precautions ordered by a Physician.The daily certified nurse assistant assignment sheets for the unit did not indicate any transmission-based precautions for Resident #12.The nurse assistant instructions for Resident #12 documented the resident was on contact precautions and enhanced barrier precautions.During an interview on 03/12/2026 at 06:30 AM, Licensed Practical Nurse #1 stated they were aware that Resident#12 was on contact precautions; however, the signage was posted on the wrong side of the door. Licensed Practical Nurse #1 stated they were aware the signage placement was incorrect and did not get a chance to place the signage on the correct side. Licensed Practical Nurse #1 stated Resident #12 required contact precautions and enhanced barrier precautions due to an infection in their wounds.During an interview on 03/12/2026 at 06:49 AM, Licensed practical Nurse #9 stated they knew which residents were on infection control precautions because there were physician orders for the precautions. Licensed Practical Nurse #9 stated that by looking at the precaution signage posted by the door, staff would not know which resident in the room was on contact precautions. Licensed Practical Nurse #9 stated that facility does not place the precaution signage to correspond with the specific resident in the room. Licensed Practical Nurse #9 stated that nurse assistants are informed which residents are on contact precautions through verbal report at the beginning of the shift from licensed practical nurses. Licensed Practical Nurse #9 stated at the start of each shift there is a brief meeting to inform staff of residents on precautions. Licensed Practical Nurse #9 further stated a green dot next to the resident's name indicates the resident is on enhance barrier precautions.During an interview on 03/13/2026 at 09:38 AM, Licensed Practical Nurse #4 (Infection Prevention Nurse) stated irrespective of the side where the signage is posted on the door, the staff should ask the nurse which resident is on transmission-based precautions. Licensed Practical Nurse #4 stated Certified Nursing Assistant #3 should have put on a gown and the mask while providing care to Resident #12. The mask should not be worn below the mouth.During an interview on 03/15/2026 at 07:13 AM, the Director of Nursing stated it was not acceptable that the staff was unable to identify the precaution residents in the rooms. The Director of Nursing stated it is important to utilize the appropriate Personal Protective Equipment to prevent the spread of infectious organisms.10 NYCRR 415.19(a) (1-3)

Based on observations, record review, and interviews during the Recertification Survey initiated on 9/4/2024 and completed on 9/11/2024, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. This was identified for two (Resident #214 and Resident #546) of four residents reviewed for Transmission-Based Precaution (TBP). Specifically, Resident #214 had a physician's order for contact precaution for Methicillin-Resistant Staphylococcus Aureus (MRSA-bacterium that is resistant to some antibiotics) in the sputum (mucus). 1) On 9/4/2024, Physical Therapist #1 was observed entering Resident #214's room without wearing appropriate Personal Protective Equipment and pushed the resident's wheelchair to transport Resident #214 from their room to the Rehabilitation Room. Physical therapist #1 did not perform hand hygiene after transporting Resident #214. 2) On 9/5/2024 during the medication pass observation, Licensed Practical Nurse #7 was observed declogging (removing blockage or obstruction) Resident #214's Gastrostomy Tube (GT-feeding tube). After the procedure, Licensed Practical Nurse #7 did not change their gloves, did not perform hand hygiene, and administered Resident #214's eye drops to both eyes. 3) Resident #546 was admitted to the facility from the hospital with recommendations to be placed on contact precautions due to an infection to both heel wounds. There was no physician's order for contact precautions until 9/4/2024, six days after the resident was admitted . On 9/4/2024, Licensed Practical Nurse #4 was observed entering the resident's room without performing hand hygiene and without wearing proper Personal Protective Equipment. The finding is: The facility's policy and procedure titled Precautions Infection Control, last revised on 8/2023 documented that the facility will use Transmission-Based Isolation Precautions which include Contact Precautions consisting of wearing gloves when entering the room. Gloves are to be removed and discarded before leaving the room. Gowns are indicated if soiling is likely or if contact with the resident or handling of items in the room is expected. Perform hand hygiene. After confirmation of isolation precautions, the Infection Preventionist or designee will post the appropriate isolation precaution sign and provide an isolation station. The resident must remain in their room and all services be brought to the resident (e.g. rehabilitation, activities, dining, etc.). The facility's policy and procedure titled, Medication Administration, last revised on 8/2023 documented before administering eye medication, wash hands and apply clean disposable gloves. Use a separate tissue for each eye and allow 5 to 15 minutes to elapse before administering the second medication. Dispose of gloves and wash hands after administering eye drops or ointment. Resident #214 was admitted with diagnoses including Acute and Chronic Respiratory Failure, Type 2 Diabetes Mellitus, and Non-Traumatic Intracerebral Hemorrhage (brain bleed). An Admission Minimum Data Set (MDS) assessment dated [DATE] documented no Brief Interview for Mental Status (BIMS) score as Resident #214 had severely impaired cognitive skills for daily decision making. The Minimum Data Set (MDS) assessment documented the resident was on special treatment for isolation or quarantine for active infectious diseases including Methicillin-Resistant Staphylococcus Aureus and had a feeding tube. A Comprehensive Care Plan (CCP) dated 8/3/2024 titled Contact Precautions, documented interventions that included to place the contact precaution signage on the door indicating to put on Personal Protective Equipments including a Gown and gloves during high contact with the affected source (the resident). A physician's order dated 8/5/2024 and renewed on 8/13/2024 documented Contact Precautions in place related to Methicillin-Resistant Staphylococcus Aureus in the sputum. A physician's order dated 8/5/2024 documented Hydroxypropyl Methycell Ophthalmic solution, one drop to both eyes every 8 hours. 1) During an observation on 9/4/2024 at 10:55 AM, Resident #214 was sitting in their recliner when Physical Therapist #1 entered the room without wearing any Personal Protective Equipment (PPE) and proceeded to wheel Resident #214 to the Rehabilitation Room. The Physical Therapist did not perform any hand hygiene after they wheeled the resident to the Rehabilitation Room. Physical Therapist #1 then started working on their computer. A signage posted outside Resident #214's door read Contact Precautions. The signage included instructions for the Personal Protective Equipment (PPE) gloves and gowns. Hand hygiene. Limit transport of residents to medically necessary purposes. Ensure that infected or colonized areas of the resident's body are contained and covered. Use disposable noncritical patient-care equipment or implement patient-dedicated use of such equipment. Physical Therapist #1 was interviewed on 9/4/2024 at 11:00 AM and stated they did not know the resident was on contact precautions and read the sign outside the resident's door. Physical Therapist #1 stated they thought that Personal Protective Equipment (PPE) was for high-contact care only. Physical Therapist #1 stated they transported Resident #214 for their scheduled Rehabilitation Therapy session, and they did not think to wear a gown, or gloves prior to transporting the resident. Physical Therapist#1 stated that Resident #214 wore a mask during Rehabilitation Therapy sessions and the staff that worked with Resident #214 would always wear a gown and gloves. Physical Therapist #1 stated they should have read and followed the Personal Protective Equipment (PPE) requirements including hand hygiene. The Infection Preventionist was interviewed on 9/4/2024 at 4:38 PM and stated the contact isolation sign was posted outside Resident #214's room for guidance to staff and visitors. The Infection Preventionist stated they expected all staff and visitors to follow the required Personal Protective Equipment indicated on the signage. The Infection Preventionist stated Physical Therapist #1 should have used the required PPE (Personal Protective Equipment) and should have washed their hands after they brought the resident to the Rehabilitation Room. The Director of Nursing Service was interviewed on 9/10/2024 at 12:17 PM and stated Physical Therapist #1 should have followed the correct Personal Protective Equipment (PPE) and performed hand hygiene. 2) During the medication administration observation on 9/5/2024 at 8:28 AM, Licensed Practical Nurse #7 (Medication Nurse) was observed entering Resident #214's room wearing a gown, a mask, and gloves. Licensed Practical Nurse #7 unclogged the Gastrostomy Tube (GT) by squeezing and rolling the tube with their thumb and forefinger numerous times. Licensed Practical Nurse #7 did not change the gloves and did not wash their hands after the procedure and then administered eye drops to the resident's eyes using the same gloves. Licensed Practical Nurse #7 was interviewed on 9/5/2024 at 8:35 AM and stated they should have changed their gloves and performed hand hygiene after they unclogged the Gastrostomy Tube (GT), and before they administered the eye drops. Licensed Practical Nurse #7 stated they were nervous during the medication observation and forgot to change their gloves and wash their hands. The Infection Preventionist was interviewed on 9/9/2024 at 9:39 AM and stated that Licensed Practical Nurse #7 should have changed their gloves and performed hand hygiene before administering the eye drops. The Director of Nursing Service was interviewed on 9/9/2024 at 10:43 AM and stated Licensed Practical Nurse #7 should have changed their gloves and performed hand hygiene before administering the eye drops. 50423 3) Resident #546 was admitted with diagnoses including Encephalopathy, Acute Kidney Failure, and Moderate Protein-Calorie Malnutrition. There were no Minimum Data Set assessments completed because Resident #546 was recently admitted . A Social Work Progress Note dated 8/29/2024 documented a Brief Interview for a Mental Status score of 6, indicating the resident had severe cognitive impairment. A Comprehensive Care Plan for Right and Left Lateral Heel (Trauma) dated 8/28/2024 and revised on 9/4/2024 documented interventions including but not limited to contact precautions, administering treatment as per physician's order, and following measures to prevent contamination of the wound such as hand hygiene. A nursing progress note dated 8/28/2024 documented Resident #546 was on contact precautions from the hospital due to rare Enterobacter Cloacae complex (a group of infectious bacteria) and moderate Staphylococcus Aureus to the wounds on bilateral heels. A physician's order dated 9/4/2024 documented the implementation of contact precautions. During an observation on 9/4/2024 at 2:13 PM, Resident #546 was observed sitting in their wheelchair in the unit hallway, outside of their room. A sign was observed posted outside of Resident #546's door which documented to perform hand hygiene and apply gloves and gown before entering the room. Licensed Practical Nurse #4 (the nurse manager) pushed the resident's wheelchair to transport the resident into their room. Licensed Practical Nurse #4 did not perform hand hygiene prior to entering or when exiting the resident's room. Additionally, Licensed Practical Nurse #4 did not put on gloves or a gown prior to entering the resident's room. Licensed Practical Nurse #4 was interviewed immediately following the observation and they stated they did not have to wear gloves and gown when entering the resident's room unless there was direct contact with the resident. Licensed Practical Nurse #4 stated the infectious areas of the resident's body were covered. Licensed Practical Nurse #4 was re-interviewed on 9/5/2024 at 10:50 AM and stated they should have put on gloves and a gown and washed their hands prior to entering Resident #546's room. It is expected that they perform hand hygiene prior to entering and upon exiting a resident's room who was on contact precautions. Licensed Practical Nurse #4 further stated the physician's order for contact precautions for Resident #546 should have been in place since admission and it was an oversight. The Infection Preventionist was interviewed on 9/9/2024 at 9:47 AM and stated Licensed Practical Nurse #4 should have put on appropriate Personal Protective Equipment for contact precautions prior to entering Resident #546's room and should have performed hand hygiene prior to entering the room and exiting the room. The Infection Preventionist stated there should have been a physician's order for contact precautions in place from admission. The Director of Nursing Services was interviewed on 9/10/2024 at 2:37 PM and stated Licensed Practical Nurse #4 should have put on appropriate Personal Protective Equipment before entering Resident #546's room and should have performed hand hygiene before entering the room and exiting the room. The Infection Preventionist stated there should have been a physician's order for contact precautions in place from admission. 10 NYCRR 415.19(a)(1-3) 10 NYCRR 415.19(b)(4)

Based on observations, record review, and interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 00346145) initiated on 9/4/2024 and completed on 9/11/2024 the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident #544) of two residents reviewed for hospitalization s, one (Resident #10) of four residents reviewed for skin conditions, and one (Resident #193) of five residents reviewed for tube feeding. Specifically, 1) Resident #544 was admitted to the facility with an abdominal surgical incision and treatment recommendations from the hospital and was also seen by the facility's wound care consultant with recommendations to treat the abdominal surgical site. The facility did not follow the hospital or the wound care consultant's recommendation and no physician's orders were obtained to treat the surgical wound. Additionally, there was no documented evidence that treatment of the abdominal surgical site wound was administered. 2) Resident #10, with a history of a Vascular Ulcer to the second left toe, was observed on 9/04/2024 with a gauze dressing in between the left great toe and second toe. There was no physician's order for the treatment of the second left toe. 3) Resident # 193, had a gastronomy (feeding) tube which was no longer being utilized as the resident was eating their meals by mouth. There was no physician's order to monitor or flush the gastronomy tube for patency. The findings are: 1) Resident #544 was admitted with diagnoses including Malignant Neoplasm (a type of abnormal and excessive growth of tissue) of the uterus, Surgical wound, and Moderate Protein-Calorie Malnutrition. The Admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 11, indicating the resident had moderate cognitive impairment. The Minimum Date Set assessment documented the resident received surgical wound care during the assessment period. A hospital discharge summary dated 6/13/2024 documented instructions for wound care as follows: dressing change twice daily or as needed. Apply dry gauze to the midline (surgical) incision and secure with tape. A Patient Review Instrument (PRI) completed on 6/13/2024 documented treatment of dressing changes twice daily to the surgical wound. The physician's orders were reviewed from date 6/13/2024 to 6/25/2024. There were no physician's orders indicating treatment administration to the abdominal surgical incision. The comprehensive care plan titled Resident has an Infection Related to Abdominal Surgical Site dated 6/17/2024 and revised on 6/27/2024, documented interventions including but not limited to administer wound care as per physician's order, implement infection control protocol as needed, and medical management of the underlying condition. A wound care consultation progress note, written by Nurse Practitioner #1, dated 6/18/2024 documented Resident #544 had an abdominal surgical incision that measured 15 centimeters in length with 18 staples. There were three areas of dehiscence (separation of a wound's edges) with moderate serous exudate (drainage from a wound). The progress note documented a recommended treatment of Calcium Alginate (a treatment typically used for draining wounds). The medical record lacked documented evidence of a treatment order for Calcium Alginate to the abdominal surgical wound as recommended by the wound care consultant. The nursing progress note dated 6/20/2024 documented Resident #544 was sent to the hospital on 6/20/2024 for evaluation of the open surgical incision site. The nursing progress note dated 6/21/2024 documented Resident #544 returned from the hospital to the facility on [DATE] and was returned back to the hospital again on 6/21/2024. The nursing progress note dated 6/22/2024 documented Resident #544 returned to the facility on [DATE] with instructions for wound care: daily wound care with Bacitracin (an antibiotic ointment), dry gauze, and tape. The Resident may wear an abdominal binder while out of bed. The nursing progress note dated 6/24/2024 written by Licensed Practical Nurse #17 documented that treatment to the abdomen was administered by the floor nurse. A wound care consultation progress note dated 6/25/2024, written by Nurse Practitioner #1, documented the following wound care treatment for Resident #544's abdominal incision site: normal saline cleanse followed by Xeroform (an occlusive dressing used for wound care) to the wound bed then Calcium alginate, and cover with a dry, clean, dressing daily and as needed. The medical record from 6/1/2024 to 6/26/2024 lacked documented evidence of a physician's orders related to the treatment to the surgical incision site. The Treatment Administration Record from 6/1/2024 to 6/26/2024 did not indicate documentation related to the treatment administration to the surgical incision site. Licensed Practical Nurse #17, the nurse manager, was interviewed on 9/11/2024 at 8:03 AM and stated there should be a physician's order for any wound care treatment and that treatment should be documented in the Treatment Administration Record by the administering nurse. Registered Nurse #3, the wound care nurse and nursing supervisor, was interviewed on 9/11/2024 at 8:41 AM and stated any wound care treatment recommended by the hospital or wound care consult should have been reconciled and documented in the Treatment Administration Record. Registered Nurse #3 stated if the wound care treatment was not administered to a resident, the wound could deteriorate or become infected. Registered Nurse #3 was re-interviewed on 9/11/2024 at 10:37 AM and stated when a resident is admitted they review the Patient Review Instrument (PRI) and hospital discharge paperwork. Registered Nurse #3 stated they were responsible for reconciling and transcribing orders when Resident #544 was admitted . Registered Nurse #3 stated the resident should have had an order for wound care treatment as recommended by the hospital upon admission and readmission. Registered Nurse #3 further stated they did not know Resident #544 did not have an active physician's order for wound care treatment in the medical record, this was an oversight. Nurse Practitioner #1 was interviewed on 9/11/2024 at 1:42 PM and stated they provided wound care consultation for Resident #544 on 6/18/2024 and 6/25/2024 and recommended treatment for the abdominal surgical incision site. Nurse Practitioner #1 stated nursing staff is responsible for obtaining the physician's order. Nurse Practitioner #1 stated any open wound, including Resident #544's surgical incision wound, should have an order in place for wound treatment. The Director of Nursing Services was interviewed on 9/11/2024 at 1:42 PM and stated there should have been an order for the wound care treatment for Resident #544's surgical incision site. Nurses are responsible for contacting the Physician for wound care treatment orders. The Director of Nursing Services stated if a wound care treatment is being administered to a resident, it should be based on the physician's orders. Resident #544 did not have a physician's order and the treatment was not administered to their abdominal surgical site and this was an oversight. 48827 2) The facility's Undated policy titled Pressure Ulcer Management and Treatment Program documented the Certified Nursing Assistants are responsible for daily reporting of changes in the resident's skin integrity. The Wound Care Clinician and the interdisciplinary team will meet after the identification of a wound within seventy-two hours to assess the need for additional interventions and treatments. In addition, each wound/ulcer will be evaluated weekly. Resident #10 was admitted with diagnoses including Acute Respiratory Failure, Non-Pressure Chronic Ulcer of part of the left foot, and Depression. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating the resident had intact cognition. The Minimum Data Set assessment documented the resident is at risk of developing pressure ulcers/injuries. A wound care note dated 3/12/2024 documented that the resident had a resolved Vascular Ulcer on the second left toe and was at high risk for recurrence. The Comprehensive Care Plan titled Skin Integrity last revised on 7/31/2024 documented interventions that included applying bilateral heel booties when in bed. A nursing progress note dated 9/1/2024, written by Licensed Practical Nurse #14, documented Resident #10 complained of itching and pain to their left toes. Licensed Practical Nurse #14 cleansed the left foot with soap and water and requested a physician's consult. A review of the physician communication book revealed a note written by Licensed Practical Nurse #14 on 9/01/2024 indicating Resident #10 complained of itching and pain to the left foot and toes. In this communication book, the Physician responded that the resident was seen and no new orders were provided. The Physician did not date their note. The Physician's signature was illegible. There was no corresponding physician's progress note related to an assessment or evaluation of the left foot and toes on 9/1/2024. Resident #10 was observed in bed on 9/4/2024 at 11:55 AM. The resident had a piece of gauze between the resident's left big toe and left second toe. Resident #10 was interviewed on 9/4/2024 at 11:55 AM and stated the nurses do not look at their toes every day. Resident #10 stated they scraped their toe a few weeks ago and it has not healed and the nurse had put the gauze between their toes. Resident#10 was observed in bed watching television on 9/6/2024 at 12:50 PM. The resident had a band-aid on their left second toe. Resident #10 stated their band-aid was changed a few days ago by a nurse. Licensed Practical Nurse #14 was interviewed on 9/9/2024 at 8:41 AM and stated they notified the Physician that the resident complained of discomfort and they observed a scab on the left second toe by documenting in the physician's communication book. Licensed Practical Nurse #14 stated the resident had a previous breakdown on a toe on the left foot but they could not recall which toe. Licensed Practical Nurse #14 stated they did not alert the unit manager, or apply a dressing to the site. Resident #10 was observed sitting in their bed watching television on 9/9/24 at 8:45 AM. The resident had a band-aid on their left second toe. A review of the medical record revealed that there was no physician's order for the gauze dressing or band-aid or any treatment to the resident's left second toe. A review of the Treatment Administration Record indicated no treatment administration to the resident's left second toe. The progress note written by the Wound Care Nurse dated 9/09/2024 documented the resident had a re-opened vascular wound to the left second toe measuring 1 centimeter by 1.2 centimeters. The wound was observed with 100% red tissue, scant drainage, and slight erythema (redness of the surrounding skin). The Comprehensive Care Plan titled Left second toe (VASCULAR ULCER) dated 9/09/2024 documented interventions that included monitoring skin integrity daily and bilateral heel booties when in bed. Licensed Practical Nurse #5, the Unit Manager, was interviewed on 9/9/2024 at 8:50 AM and stated they were not aware of the wound on the resident's left second toe. Licensed Practical Nurse #5 stated the treatments should not be applied without a physician's order. Licensed Practical Nurse #5 stated Licensed Practical Nurse #14 should have notified the wound care nurse or the Unit Manager regarding the scab on the resident's second toe so the resident could be assessed. Physician #1 was interviewed on 9/10/2024 at 8:32 AM and stated they were not made aware of a concern regarding Resident #10's toes. Physician #1 stated medical progress notes should have been written to address the condition of Resident #10's left toes. Physician #1 stated the Nursing staff should have called the wound care nurse to assess and decide if treatment was needed. Physician #1 stated the nurses should not have just put a band-aid on without alerting the wound care nurse or the Physician. Registered Nurse #3, the Wound Care Nurse, was interviewed on 9/10/2024 at 10:31 AM and stated they should have been notified of Resident #10's wounds. The Wound Care Nurse stated if a wound is not treated correctly, it can deteriorate. The Director of Nursing Services was interviewed on 9/10/2024 at 2:29 PM and stated the nursing staff should have called the Physician to obtain a treatment order and should have referred the resident to the wound care nurse for further evaluation. 3) The facility's policy titled Gastronomy Feedings revised 6/2022 documented instill water as ordered and cleanse the skin around the gastronomy tube. Resident #193 was admitted with diagnoses including Acute Respiratory Failure, Type 2 Diabetes Mellitus, and Dementia. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 99, indicating the resident was unable to complete the interview due to severely impaired cognition. The Minimum Data Set assessment documented the resident had a gastronomy tube. The physician's order dated 7/30/2024 documented to discontinue the tube feeding. A review of the medical record revealed there was no physician's order to flush Resident #193's Gastronomy Tube. A physician's order dated 8/5/2024 documented that Resident #193 received a regular ground meal diet by mouth. Certified Nursing Assistant #3 was interviewed on 9/6/2024 at 2:12 PM and stated Resident #193 still has a gastronomy tube but it is not used. Resident #193 receives a meal tray three times a day and eats their meals by mouth. Licensed Practical Nurse #4, the Unit Nurse Manager, was interviewed on 9/9/2024 at 11:45 AM and stated there should be a Physician's order to flush the gastronomy tube. Licensed Practical Nurse #3 was interviewed on 9/9/2024 at 11:54 AM and stated the resident did not use the gastronomy tube as of 8/05/2024. Licensed Practical Nurse #3 stated they did not flush the resident's gastronomy tube because there was no order and they did not contact the Physician to obtain an order to flush the feeding tube. The Chief Dietician was interviewed on 9/10/2024 at 8:07 AM and stated the gastronomy tube feeding order for Resident #193 was discontinued on 7/30/2024. The Chief Dietician stated the Dieticians were responsible for placing the physician's order to flush the gastronomy tube to keep the tube patent and it was an oversight. Physician #1 was interviewed on 9/10/2024 at 8:36 AM and stated they if the gastrostomy tube is not flushed the tube may become clogged and would have to be removed and replaced. The Director of Nursing Services was interviewed on 9/10/2024 at 2:27 PM and stated there should be an order to flush the gastronomy tube to maintain patency. The nurses need to monitor the gastronomy tube and should have alerted the nurse manager or the Dietician that there was no order in place to flush the resident's gastronomy tube. 10 NYCRR 415.12

Based on observations, record review, and interviews during the Recertification Survey initiated on 9/4/2024 and completed on 9/11/2024, the facility did not ensure that each resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This was identified for one (Resident #2) of three residents reviewed for Pressure Ulcers. Specifically, Resident #2 had a Stage 4 pressure ulcer and an unstageable pressure ulcer to their back. Resident #2 had a care plan intervention and recommendations for an air mattress. During several observations, the adjustable weight setting for the air mattress was not set accurately. The finding is: The facility's undated policy titled Pressure Ulcer Prevention, Management, and Treatment Program documented to initiate preventive measures and promote wound healing. The nurse assigned to administer the pressure ulcer treatment will administer specific treatment and sign for having administered such treatment on the treatment record. The facility's Low Air Loss Mattress Operator's Manual under Operating Instructions documented: determine the resident's weight and set the control knob to that weight setting on the control unit. Resident #2 was admitted with diagnoses including Traumatic Brain Injury, Respiratory Failure, and Depression. The 6/29/2024 Quarterly Minimum Data Set assessment documented no Brief Interview for Mental Status score as the resident had severely impaired cognition for daily decision-making. The Minimum Data Set assessment documented the resident had two unstageable pressure ulcers. A Comprehensive Care Plan effective 6/19/2024 documented the resident has a right Inferior (lower) Back Unstageable Pressure Injury with an intervention to use an air mattress. A Comprehensive Care Plan effective 6/19/2024 documented the resident has a right Superior (upper) Back Unstageable Pressure Injury with an intervention to use an air mattress. A physician's order dated 8/1/2024 documented for a nurse to check the air mattress for proper placement, setting (based on weight), and functioning every shift twice a day: 7:00 PM-7:00 AM, 7:00 AM-7:00 PM. A wound consultant note dated 9/3/2024 documented an intervention for an air mattress. The wound consult documented that the resident's current weight as of 9/3/2024 was 156.2 pounds. The resident had an unstageable right superior back wound. The wound was debrided (removal of damaged tissues) of a thick cap of necrotic (dead) tissue. The wound measured three centimeters in length and two centimeters in width. The right inferior back Stage 4 pressure measured four centimeters in length, four centimeters in width, and two centimeters in depth. The resident's weight in the electronic medical record as of 9/3/2024 was 156.2 pounds. On 9/9/2024 at 11:50 AM, Resident #2 was observed sitting in the gerichair adjacent to their bed. The air mattress weight setting was set at 265 pounds. On 9/10/2024 at 9:14 AM, Resident #2 was observed lying in bed. The air mattress weight setting was set at 265 pounds. A review of the Treatment Administration Record for September 2024 revealed the resident's air mattress was checked for proper placement, setting (based on weight), and functioning as indicated by the nurses' signatures on 9/9/2024 for the 7:00 AM-7:00 PM shift, and on 9/9/2024-9/10/2024 for the 7:00 PM-7:00 AM shift. Registered Nurse #3, the wound care nurse, was interviewed on 9/10/2024 at 11:40 AM. Registered Nurse #3 observed Resident #2's air mattress and confirmed that the weight setting was set at 265 pounds. Registered Nurse #3 stated the weight setting on the air mattress should be consistent with the resident's weight of 156 pounds. Registered Nurse #3 stated they observed the resident earlier in the morning during wound rounds but did not check the weight setting on the mattress. Registered Nurse #3 stated, I think that if the weight setting on the mattress is set higher than the resident's weight, it could cause discomfort to the resident. Registered Nurse #3 stated they were not sure if an inaccurate weight setting affected wound healing. Nurse Practitioner #1, the wound care consultant, was interviewed on 9/10/2024 at 12:32 PM and stated the weight setting on the air mattress is supposed to be consistent with the resident's weight to properly redistribute the weight to assist with wound healing. The Director of Nursing Services was interviewed on 9/10/2024 at 1:09 PM and stated the weight setting on the air mattress should be consistent with the resident's weight. The Director of Nursing Services stated if the weight setting on the air mattress is not consistent with the resident's weight, this could affect wound healing or prolong the healing process. Registered Nurse #2 was interviewed on 09/11/2024 at 10:34 AM and stated they signed the Treatment Administration Record on 9/9/2024 during the 7:00 AM-7:00 PM shift to indicate that they checked the air mattress for proper placement, setting (based on weight), and functioning. Registered Nurse #2 stated when they checked the mattress weight setting on 9/9/2024, the weight setting was accurate according to the resident's actual weight. 10 NYCRR 415.12(c)(1)

Based on observation, record review, and interviews during the Recertification Survey initiated on 9/4/2024 and completed on 9/11/2024, the facility did not ensure the resident environment remained as free of accident hazards as possible. This was identified for one (Resident #208) of four residents reviewed for Accidents. Specifically, on 9/4/2024, Resident #208 had an aerosol container of Lysol spray on their bedside table. Facility staff were aware of the aerosol spray container but did not remove it. The finding is: The facility's policy titled Environmental Hazard, dated 8/2023, documented aerosols (air fresheners, deodorants, hair sprays, disinfectants) are prohibited for use inside of the facility. The Occupational Safety and Health Administration Safety Data Sheet, titled Professional Lysol Disinfectant Spray - All Scents, dated 9/21/2020, documented the Lysol was a flammable aerosol; contains gas under pressure; may explode if heated; and causes eye irritation. In a fire or if heated, a pressure increase will occur and the container may burst, with the risk of a subsequent explosion. Gas may accumulate in low or confined areas or travel a considerable distance to a source of ignition and flash back, causing fire or explosion. Resident #208 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, and Anxiety Disorder. The 7/20/2024 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 12, indicating the resident had moderately impaired cognition. A physician's order dated 8/9/2024 documented to administer oxygen therapy at 3 liters per minute via a nasal cannula continuously for Chronic Obstructive Pulmonary Disease. On 9/4/2024 at 11:35 AM, an aerosol spray container of Lysol Disinfectant Spray was observed on Resident #208's bedside table. The resident was lying in bed and was receiving oxygen via a nasal cannula. The resident stated their family brought in the Lysol spray and the aides used it to spray the room. On 9/4/2024 at 11:40 AM, the Lysol spray was brought to the attention of Registered Nurse #1 (charge nurse). Registered Nurse #1 stated they were not aware of the Lysol aerosol spray being present in Resident #208's room. Registered Nurse #1 stated did not know if the Lysol aerosol spray was allowed to be kept in the resident's room. On 9/4/2024 at 11:45 AM, Registered Nurse #1 returned to Resident #208's room, removed the Lysol aerosol spray from the room and told the resident that the aerosol sprays were not permitted. Certified Nursing Assistant #1 was interviewed on 9/4/2024 at 12:22 PM and stated they had seen the aerosol spray in Resident #208's room but did not use it because the staff are not allowed to use aerosol sprays. Certified Nursing Assistant #1 stated they did not tell anyone about the spray because they assumed the resident had approval to have the spray. Resident #208 was interviewed on 9/5/2024 at 8:52 AM and stated their family brought the aerosol spray and the resident has been using it for a couple of months. Resident #208 stated the staff saw the Lysol spray as it was kept on the bedside table in plain view. Licensed Practical Nurse #1, the unit nurse manager, was interviewed on 9/6/2024 at 10:55 AM. Licensed Practical Nurse #1 stated aerosol sprays were not allowed in resident rooms. Social workers need to speak to Resident #208's family about not bringing in the aerosol spray for the resident. The Director of Nursing Services was interviewed on 9/9/2024 at 9:24 AM and stated aerosol sprays were not permitted in the facility because these sprays are flammable. The Director of Nursing Services stated the aerosol spray should have been removed from the resident's room when the staff first noticed it. 10 NYCRR 415.12(h)(1)

Based on observation, record review, and interviews during the Recertification and Abbreviated Survey (Complaint # NY00287059) initiated on 1/5/2023 and completed on 1/13/2023 the facility did not ensure that each resident received adequate supervision to prevent accidents. This was identified for one (Resident #310) of three residents reviewed for Accidents. Specifically, Resident #310 had a history of multiple falls and was identified at risk for falls. Resident #310 was to be placed in a high visibility observational area when out of bed as per the resident's plan of care. On 11/24/2021 Resident #310 was left unsupervised when Certified Nursing Assistant (CNA) #5 did not follow their assignment to monitor the Northeast TV lounge that was designated by the facility as a high visibility area. Resident #310 ambulated down the hallway to their room and fell sustaining a fracture to the right hip. This resulted in actual harm for Resident #310 that is not Immediate Jeopardy. The finding is: The facility's policy, titled Safety and Supervision of Residents, effective 4/2020 and last reviewed 12/12/22, documented that monitoring the effectiveness of interventions shall include ensuring that interventions are implemented correctly and consistently. Resident #310 was admitted with diagnoses including Age-related Osteoporosis without current pathological fracture, Osteoarthritis of the knee, and Unspecified Dementia with behavioral disturbance. The 10/1/2021 Significant Change Minimum Data Set (MDS) assessment documented the resident had a Brief Interview for Mental Status (BIMS) score of 7, indicating the resident had severe cognitive impairment. The MDS documented the resident required extensive assistance of two staff members for transfers and did not walk in their room or the corridor. Resident #310 was not stable and was only able to stabilize with staff assistance from a seated to a standing position. The resident had bilateral lower extremity range of motion limitations. The resident had falls within the last month and falls with a fracture within the last 2-6 months. A falls risk assessment dated [DATE] documented a fall risk score of 19 indicating the resident was At Risk for falls. The falls risk assessment documented a score of 10 or higher indicated the resident was At Risk for falls. The Comprehensive Care Plan (CCP) developed for at risk for falls dated 6/7/2021 documented the resident was at risk for falls secondary to Osteoarthritis, Psychotropic Drugs, Dementia, History of Falls, and Impaired Balance. The CCP included interventions effective 6/8/2021 to Encourage the resident to remain in area of high visibility. The resident had 11 unwitnessed falls (6/8/2021, 6/26/2021, 7/12/2021, 8/27/2021, 9/8/2021, 10/5/2021, 10/7/2021, 10/18/2021, 10/20/2021, 10/21/2021 and 11/2/2021) prior to the 11/24/2021 fall. Of the 11 falls two occurred in the resident's bathroom, eight occurred in the resident's room and one occurred in the TV lounge area. An observation was conducted on the third floor, North Unit on 1/13/2023 at 11:00 AM. There were three common television areas observed on the unit. There were two nursing stations on the unit and there was a TV lounge adjacent to each nursing station. A third television area was observed in the unit dining room which was situated across from both nursing stations. The Nursing Progress note, written by Registered Nurse (RN) #1, dated 11/24/2021 documented that they were called to the unit to assess Resident #310 at around 9:15 AM. Upon entering the resident's room, the resident was observed on the floor in a lying position next to the bathroom door with a pillow under their head. The resident's right leg was externally rotated with a bulge (swelling) to the right hip. Staff was present in the room. The resident was transferred to the hospital and admitted with a diagnosis of a right femoral fracture. The Accident/Incident investigation report relating to the fall on 11/24/2021 documented that Resident #310 was last toileted by CNA #6, who worked on the 11:00 PM-7:00 AM shift, at 6:30 AM and then placed in the 3rd floor Northeast television lounge, a high observation area. CNA #6 documented in their statement that there were CNAs present in the high observation area (the Northeast TV lounge) at 7:00 AM when CNA #6 completed their shift at 7 AM. At 9:00 AM, CNA #5, who worked on the 7:00 AM to 3:00 PM shift, was scheduled to monitor the high observation area. CNA #5 documented in a written statement, My charge nurse told me it was my time in the dining room, but no one was in there yet. A written statement provided by the unit Licensed Practical Nurse (LPN) #4 documented that upon passing the TV lounge, LPN #4 noticed Resident #310 was not in the Northeast TV area where Resident #310's wheelchair was found with the wheels in a locked position. LPN #4 immediately went to Resident #310's room and found Resident #310 on the floor. LPN #4 called the unit manager who was LPN #3. LPN #4 documented Resident #310 was able to get up from their wheelchair and make the short walk from the 3 Northeast TV lounge to the resident's room, where the resident fell , unwitnessed. The facility's Accident/Incident investigation conclusion, completed on 11/26/2021, documented that the unit manager (LPN #3) failed to ensure assignments were being carried out. The investigation documented that the unit manager (LPN #3) was unclear when directing the workforce, which left a gap in resident monitoring. The gap left in resident monitoring, allowed Resident #310 to get up, ambulate without assistance, and fall sustaining a fracture. The facility concluded that staff failed to maintain the high observation area. The CNA assignment sheet dated 11/24/2021 documented that CNA #5 was assigned to cover the TV Area from 9:00 AM-9:30 AM. There was no documented evidence the CNA assignment sheet specified which of the three TV areas CNA #5 was assigned to monitor as the high observation area. During an interview with CNA #5 on 1/11/2023 at 1:39 PM, they stated that they were aware they were scheduled to cover the high observation area on the day of Resident #310's fall. CNA #5 stated that they went to the TV area located in the unit dining room at 9:00 AM but nobody was there at that time, so they left the dining room and tended to another resident. During an interview with LPN #3 on 1/11/2023 at 2:36 PM, they stated they expected CNA #5 to cover the high observation area, in the TV lounge rooms, based on the assignment distributed on that day. LPN #3 stated that there are two TV lounge areas and a unit dining room on the unit. LPN#3 stated that the high observation coverage area designation was usually determined by the unit manager based on the availability of staff. Sometimes the high visibility observation area was the TV lounge areas and sometimes the high visibility observation area was the unit dining room. LPN #3 stated that CNA#5 was written up for not being in the high visibility area at their scheduled time. The LPN stated they were also written up because the Director of Nursing Services (DNS) expected them to monitor the residents in the high visibility areas. The LPN stated that it was unreasonable to expect them to be monitoring the high visibility areas and interacting with physicians from their office at the same time. During an interview with LPN #2 on 1/11/2023 at 3:04 PM, they stated they worked on the 3:00 PM-11:00 PM shift. They said that the designation of the high visibility area is based on how many residents need supervision and the unit staffing on that day. The LPN stated that the unit dining room is routinely used as the high observation area; however, the two TV lounge areas are sometimes used as well. During an interview with CNA #1 on 1/11/2023 at 3:06 PM, they stated they worked the 3:00 PM-11:00 PM shift. The CNA stated the unit supervisor alerts the CNAs of the coverage assignments for the high visibility area at the beginning of the shift and the assignments are documented on an assignment sheet. During an interview with the DNS on 1/11/2023 at 3:25 PM, they stated that the facility utilizes one of the two TV lounge rooms on the unit as the designated high observation areas. The DNS said that Resident #310 was left unsupervised and should have been supervised. The resident transferred themselves out of their wheelchair and walked to their room, fell , and fractured their hip because they were not supervised. The DNS stated that the staff members did not ensure the supervision schedule was followed which resulted in the resident's fall and injury. During an interview with the Administrator on 1/13/2023 at 3:21 PM, they stated that the two TV lounge areas were designated as the high observation areas. The Administrator stated that staff should adhere to the schedules for high observation area coverage and should be monitoring the high observation areas as scheduled to promote resident safety. During an interview with the Medical Director on 1/13/23 at 4:45 PM, they stated that the staff should follow schedules for monitoring as written in an effort to prevent accidents. 10NYCRR415.12(h)(1)

Based on staff interviews and record review during an abbreviated survey the facility did not ensure that each resident requiring special services received proper treatment and [MEDICAL CONDITION] (an artificial opening into the windpipe to allow breathing) care and key staff were not trained in bathing a resident with a [MEDICAL CONDITION]. Specifically, one (Resident #1) of five residents reviewed for special needs was showered by staff with an unprotected [MEDICAL CONDITION]. The resident went into respiratory arrest and a large amount of water was suctioned from her [MEDICAL CONDITION]. This resulted in actual harm that is not Immediate Jeopardy. Complaint Number: NY 622 The finding is: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (an assessment tool) dated [DATE] documented that Resident #1 has no speech clarity and modified independence in cognition. The resident requires [MEDICAL CONDITION] care and physical help for bathing. There was no documented evidence of a policy or procedure regarding activities of daily living (ADL) care for residents with tracheostomies. There was no documented evidence of staff training regarding ADL care for residents with tracheostomies. The Comprehensive Care Plan (CCP) dated [DATE] and updated [DATE] documented Resident #1's risk for alteration in respiratory status and respiratory insufficiency secondary to [MEDICAL CONDITION]. The CCP dated [DATE] and updated [DATE] documented that Resident #1 requires total assistance of one person for bathing. The CCP lacked documented evidence of interventions for bathing/showering the resident with a [MEDICAL CONDITION]. The CCP dated [DATE] and updated [DATE] documented Resident #1's altered respiratory status and to maintain patent airway with [MEDICAL CONDITION]. The [MEDICAL CONDITION] Consultation dated [DATE] documented Resident #1's toleration for ventilator nocturnally. The CCP dated [DATE] documented Resident #1's risk for aspiration due to [MEDICAL CONDITION]. The Speech Therapy Treatment Trach/Vent-Discharge Summary dated [DATE] documented that Resident #1's [MEDICAL CONDITION] and swallowing function is NPO (nothing by mouth). The CNA (Certified Nursing Assistant) Accountability Record for [DATE] documented Resident #1's bathing schedule with total assistance in the shower. There was no documented evidence of instructions on bathing/showering the resident with a [MEDICAL CONDITION]. The Nursing Progress Notes (NPN) dated [DATE] for the 7:00 AM to 3:00 PM nursing shift documented that Resident #1 was tolerating [MEDICAL CONDITION] HME (heat and moisture exchangers) with room air; no acute respiratory distress. The Respiratory Progress Notes (RPN) dated [DATE] at 1835 (6:35 PM) documented that Resident #1 respiratory arrested during shower. The resident was bagged on 100% oxygen; Code Blue was called. The resident regained consciousness and was placed on vent awaiting EMS (emergency medical services) to arrive and transport to ACF (acute care facility). The NPN dated [DATE] at 1840 (6:40 PM) documented that the nurse's aide called out for help due to Resident #1's respiratory arresting during shower. A Code Blue was called and the resident immediately bagged and suctioned by respiratory therapist. Resident regained consciousness promptly and was placed on mechanical ventilation. EMS arrived, monitored resident and placed IV (intravenous access). Resident was transported to the hospital. The Ventilator Flow Sheet for [DATE] documented that Resident #1 respiratory arrested during shower; was bagged on 100% with ambu. The resident was suctioned; large quantity of H2O (water) came [MEDICAL CONDITION] oral pharynx; palpable pulse throughout. The resident was agonally (gasping) breathing, assisted during Code Blue and later placed on LTV (ventilator); EMS at bedside for transport to ACF. The Hospital Emergency Department Aftercare Instructions dated [DATE] documented [DIAGNOSES REDACTED]. The RPN dated [DATE] documented that the resident was received from EMS and placed on vent; stable, color is pink, no sign of respiratory distress. The NPN dated [DATE] for the 7:00 AM to 3:00 PM nursing shift documented that Resident #1 remains on vent today due to respiratory distress during the ,[DATE] shift (on [DATE]). An interview was conducted with the assigned 3:00 PM to 11:00 PM CNA #1 on [DATE] at 3:25 PM. CNA #1 stated that, on [DATE] sometime after 6:00 PM, she was told by the respiratory therapist that she could take Resident #1 to the shower. CNA #1 and CNA #10 transferred Resident #1 to a shower chair and brought the resident to the shower room. CNA #10 left the room while CNA #1 showered the resident. CNA #1 stated that, when she finished showering Resident #1, she started towel-drying the resident at which time CNA #10 returned. CNA #1 looked at the resident's face, which was blue and CNA #10 yelled out the door for help. The nurse and respiratory therapist came right away. CNA #1 stated that she showered Resident #1 like she would shower any resident. She was never told not to get water in the area of Resident #1'[MEDICAL CONDITION] protect [MEDICAL CONDITION] a shower. She stated, "That's up to respiratory. I'm not supposed to do anything about [MEDICAL CONDITION] most times people (residents) have oxygen which covers it (trach) in the shower." CNA #1 further stated that she was never trained to do anything different in showering a resident with a trach. An interview was conducted with the Respiratory Therapist (RT) on [DATE] at 1:54 PM. The RT stated that, on [DATE] before 6:30 PM, she was in another resident's room when she heard a call out for help. The RT responded to the shower room at the same time as the nurse. The RT stated that, when she looked through the shower room doorway, Resident #1 was obviously blue and unresponsive. The RT stated that Resident #1'[MEDICAL CONDITION] not covered. The RT started ambu-bagging and suctioned the resident. The RT stated that she suctioned a large quantity of water through [MEDICAL CONDITION] oral pharynx. The resident remained with a pulse and started to turn pink; she placed the resident on a vent until 911 arrived. The RT stated that she did give the okay for the aides to shower Resident #1 but did not cover or tell the aides to cover the trach. The RT then stated that she is not aware of any protocol for showering a resident with a trach; "You'd have to check with the Director of Respiratory." An interview was conducted with the 3:00 PM to 11:00 PM Registered Nurse Supervisor (RNS) on [DATE] at 3:11 PM. The RNS stated that, on [DATE] just before 6:30 PM, he was on the third floor and responded to a Code Blue on Unit 1 South. The RNS stated that the respiratory therapist and nurse were there; the resident had already regained consciousness; CPR (cardiopulmonary resuscitation) was not needed and 911 had already been called. The Administrator was present on the unit. The RNS stated that he spoke with RT #1, who told the RNS that she had suctioned a lot of water from Resident #1's trach; the RNS stated that RT #1 told him it happened in the shower. The RNS stated that, at the time, he thought it was strange because a resident'[MEDICAL CONDITION] have a cap before showering. The RNS then stated, "But I don't know what happened because I wasn't there. I didn't think of it as much of an issue then." The RNS further stated that "whenever a resident with [MEDICAL CONDITION] being showered, [MEDICAL CONDITION] be capped so water doesn't get in (the trach) but that would have to be provided by RT (respiratory therapy)." The RNS stated he doesn't know what the aides are taught about showering a resident with a trach; "That would be RT too." An interview was conducted with the Director of Respiratory Care (DRC) on [DATE] at 3:46 PM. The DRC stated that a resident'[MEDICAL CONDITION] be covered during a shower. The DRC stated, "The aides have never really been taught this directly. It's more common sense since there's a hole." The DRC further stated, "Respiratory is really the one to say a resident needs to have it (trach) covered. We haven't taught the aides about that." An interview was conducted with the 3:00 PM to 11:00 PM Registered Nurse (RN) on [DATE] at 4:18 PM. The RN stated that, on [DATE] a little before 6:30 PM, she was in another room and heard a yell for help. She ran and saw an aide standing in the doorway of the shower room. The resident was in the shower area looking blue and in respiratory arrest. The RN stated that RT #1 was there and started bagging and suctioning the resident; the resident had a pulse. The RN stated that RT #1 suctioned a lot of water from the resident'[MEDICAL CONDITION] the resident started turning a more normal pink color. The resident was then placed on a vent waiting for 911, which the RN had already called. The RN stated that she never thought to question why water was in Resident #1's trach. The RN stated that nursing doesn't direct the aides regarding showering residents with trachs; "If they're (aides) are going to give a shower, they have to ask RT." She further stated, "I don't know what aides are taught (regarding showering a resident with a trach)." An interview was conducted with the In-Service Director/Assistant Director of Nursing (ISD) on [DATE] at 1:15 PM. The ISD stated that there is an eight hour training for a CNA before the CNA starts on Unit 1 South. The CNA is paired with another CNA already working on Unit 1 South and Respiratory trains the new CNA. The ISD stated that CNAs should always protect [MEDICAL CONDITION]'s airway during bathing by using a wash cloth, if necessary, and Respiratory trains the CNA on this. The ISD stated that she maintains the CNA Competency that is completed after the training; "Respiratory does the training. I keep the records." The ISD then presented the CNA Competencies and stated that ADL care is not included on the Competency. An interview was conducted with the Registered Nurse Manager (RNM) for Unit 1 South on [DATE] at 1:51 PM. The RNM stated that she oversees the unit, which has a vent/trach side and a rehab side; there is no dedicated direct care staff on the vent/trach side because they share the unit. The RNM stated that the aides should be trained not to get [MEDICAL CONDITION] wet during bathing; "Respiratory does the training." During a subsequent interview with the DRC on [DATE] at 2:16 PM the DRC stated that all new aides to the Unit 1 South receive an eight hour training whereby they are buddied -up with another CNA. DRC stated that she takes about half an hour to an hour of that time to go over equipment, vent alarms, tubing & humidification, and how to determine the need to call for help, including alarms going off too much, difficulty breathing and if a resident is in any distress. The DRC stated that, as a lesson plan, she uses the CNA Competency used by the ISD; the Competency does not include ADL care. The DRC stated, "I don't really go over showering a resident with a trach. It just seemed common sense not to get water in that area. But, I guess I'm going to have to start going over it." She further stated, "I don't know of a policy for showering or ADLs with a trach." During a subsequent interview with the ISD on [DATE] at 2:44 PM the ISD stated that she thought Respiratory educated staff on how to shower a resident with [MEDICAL CONDITION] they (Respiratory) do not. During an interview with the DRC and the Director of Nursing (DON) on [DATE] at 3:11 PM the DON stated that the DRC must have misspoken regarding training of ADL care for residents with trachs. The DRC stated that she does train aides on how to shower a resident with [MEDICAL CONDITION], when asked how, she explained that she does not actually go into the shower but the seasoned aide is training (the new aide in duties of the unit). The DON and DRC stated that there is no proof of training and there is no policy on bathing or ADL care of residents with trachs. An interview was conducted with CNA #10 on [DATE] at 3:27 PM. CNA #10 stated that, on [DATE], she took Resident #1 to the shower room with CNA #1 but then left to care for another resident for a few minutes. When CNA #10 returned to the shower room, CNA #1 was towel-drying the resident and CNA #1 saw the resident looking blue. CNA #10 opened the door and called for help; the respiratory therapist and nurse came. CNA #10 stated that she has not been trained to give a shower to a resident with [MEDICAL CONDITION] respiratory should make sure everything is okay for a resident to be showered before the shower. She stated, "If a resident can't bend their head then respiratory should have done something like put a collar or something. I presume I can just wash." An interview was conducted with the Medical Director (MD) on [DATE] at 11:11 AM. The MD stated that she was not involved with the incident involving Resident #1 but was notified afterwards. She does not know of any investigation at this time but is aware water was suctioned from the resident's trach. The MD stated that a resident'[MEDICAL CONDITION] to be covered during bathing because the potential for water in the respiratory tract if [MEDICAL CONDITION] not covered can be very damaging to the resident. She further stated that she is not aware any policy or procedure regarding ADL care for residents with trachs; "we don't always have a policy unless something happens." During a subsequent interview with the DON on [DATE] at 11:29 AM the DON stated that she was unaware of the circumstances surrounding Resident #1's incident in the shower on [DATE]; nothing was reported to her regarding water being suctioned from the resident's trach. There is no investigation and no staff training since the incident. The DON further stated that there is no policy or procedure regarding showering/bathing or ADL care of a resident with a trach. An interview was conducted with the Administrator on [DATE] at 11:38 AM. The Administrator stated that he responded to a Code Blue for Resident #1 on [DATE] around 6:30 PM. The resident had been brought back to her room. RN #1 was at the bedside and said the resident had a pulse. The Administrator stated that he did not see any sense of urgency and the next day told the DRC to look into the occurrence but the DRC did not follow-up with his request. The Administrator stated he is not aware of anything inappropriate having occurred. During a subsequent interview with RT #1 on [DATE] at 3:30 PM RT #1 reiterated that she suctioned a large quantity of water through Resident #1'[MEDICAL CONDITION] [DATE]. She further stated that it is very possible that the water caused the resident's respiratory distress. 415.12 (k)(5)(4)