Every finding on record at Bridgewater Center for Rehab & Nursing L L C

Based on observations, record review, and interviews, the facility failed to ensure a process was in place for residents to have their grievances addressed appropriately for 349 of 349 residents residing in the facility. Specifically, 12 of 12 anonymous residents present at the resident group meeting stated they did not know where to obtain grievance forms, their right to file grievances anonymously, and who the grievance officer was. The residents present at the meeting stated their views, grievances, or recommendations voiced during resident council group meetings were not acted upon and responded to with a rationale and there was no documented evidence residents' voiced concerns were investigated, and rationales or responses were provided. Findings include:The facility policy Concerns and Grievances, last reviewed 05/2026, documented the facility encouraged residents, families, and caregivers to express their concerns either anonymously or individually. Residents and/ or designated representative could make a complaint or recommendations either orally, in writing, or at the facility kiosk to Social Services, Community Life Director, Administrator, Assistant Administrator, Director of Nursing, or Assistant Director of Nursing. Concerns and grievances could also be made anonymously. Grievances were resolved or addressed within 48 hours after notification and the complainant had the right to receive written documentation related to their grievances. During a resident group meeting on 06/08/2026 at 1:58 PM, 12 of 12 anonymous residents stated there was no grievance form, a way to file a grievance anonymously, they did not know of their right to file anonymously and did not know who the grievance officer was. They had to tell either a unit manager or a social worker about their concerns. Also, 12 out of 12 anonymous residents stated the Community Life Director took notes on their concerns during the group meetings but there was no follow up and their concerns carried from meeting to meeting. Resident Council meeting minutes documented the following new business concerns:-On 01/19/2026, long call bell times, missing clothing, cleanliness of rooms, cell phone use, help with finances, ability to self-propel within the facility and the courtyard, more art supplies on the floors, and bed linen concerns.-On 02/16/2026, long call bell times, missing clothing, cleanliness of rooms, staff cell phone use, ability to self-propel within the facility and the courtyard, more art supplies on the floors, and bed linen concerns.-On 03/16/2026, long call bell times, missing clothing, cleanliness of rooms, staff cell phone use, help with finances, ability to go outside, and staff with poor attitudes.-On 04/20/2026, long call bell times, missing clothing, cleanliness of rooms, help with finances, bed linen concerns, and staff with poor attitudes.-On 05/18/2026, long call bell times, missing clothing, cleanliness of rooms, staff cell phone use, bed linen concerns, and staff with poor attitudes. There was no documented evidence the new business was investigated, or the rationales and responses were provided during subsequent resident council meetings. During observations of the main lobby and all residential units on 06/10/2026 from 9:20 AM- 10:18 AM, there was a large index card sized sign in an enclosed bulletin board approximately 5 feet from the floor near the elevator that designated the Director of Social Services as the grievance officer with a contact phone number and electronic mail address. There were no instructions on how to file an anonymous grievance, availability of grievance forms without having to ask, or a box to anonymously submit a grievance. During an interview on 06/12/2025 at 9:42 AM, Social Worker #11 stated residents needed to verbalize their complaint and they had a form they completed. They took the form to the Director of Social Work. There was no way to file anonymously because they had to come to a staff member. They knew the residents were sometimes worried about retaliation. During an interview on 06/12/2026 at 9:48 AM, the Director of Social Work stated the social worker filled out the paperwork when a resident verbally voiced a concern. After they received the paperwork, they filed the paperwork, followed up with the social workers, and gave the form to the Administrator to sign. The resident or the family was verbally updated with the resolution. They recently took over as the formal grievance officer. The Administrator was previously the grievance officer. The residents could not file anonymously because they had to ask staff for a form or voice their concerns to the social worker. The Community Life Director also had grievance forms and completed grievances for the resident council meetings. During an interview on 06/12/2026 at 9:56 AM, the Community Life Director stated they were present for all resident council meetings. Concerns were discussed during the meetings, and then they sent an electronic mail notification to the Administrator and all department heads informing them of the concerns voiced. After the electronic mail was sent, they did not get a response. The residents' complaints were the same month to month. During an interview on 06/12/2026 at 1:52 PM, the Administrator stated residents could file grievances anonymously, there were forms available at the nurses' station and they would have to ask for a blank form. There was no specific location to drop the grievance form off. Resident council concerns were sent to all department heads, and their responses were brought to the next resident council meeting. 10 New York Codes, Rules, and Regulations 415.3 (c)(1)(ii)

Based on observations, record review, and interviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for one of one main kitchen, two of seven rolling coolers (Units 2B and 5A rolling coolers), and two of four unit pantries (Units 4A and 5A pantries). Specifically, in the main kitchen prepared foods were not cooled properly, multiple single serve milk cartons were past their best by date, several food items were stored in packages on the floor or loose on the floor of the freezer, two handwashing sinks did not have access to paper towels and areas of the kitchen were unclean; The Units 2B and 5A rolling coolers did not maintain temperature for proper cold storage; the Unit 5A pantry had several areas that were unclean and the refrigerator did not maintain temperature; and the Unit 4A pantry did not have soap or paper towels dispensers or products at the sink. Findings included:The facility policy Food Storage, revised 09/2025, documented all food items were to be stored in a safe and sanitary manner to prevent contamination, maintain food quality, and comply with federal, state, and local regulations. The facility policy Food Prep Policy, revised 04/03/2025, documented staff were to wash hands thoroughly with soap and water before and after handling food, after using the restroom, and after any activity that could contaminate hands. Cool hot foods quickly to 70 degrees Fahrenheit or below within two hours then within four hours to 41 degrees Fahrenheit, use shallow containers and refrigerate promptly. Clearly label all food storage containers with contents and dates. The facility policy Hazard Analysis and Critical Control Points Cooling Process, revised 07/2025, all foods once cooked to proper internal temperature that are not being used for immediate service and must be cooled down are to be cut down to be no more than five-pound pieces. All foods must be cooled down to 70 degrees Fahrenheit within two hours. After two hours, the food must get to 41 degrees Fahrenheit within an additional four hours. If the temperature thresholds were not met, the food must be reheated back to 165 degrees Fahrenheit immediately and the process began again. All the temperatures were to be logged at the exact times noted and must be signed by the staff member involved in the cooling process. The facility policy Refrigerator Temperature Policy, revised 12/2025, documented all refrigerators used for food storage would be kept below 41 degrees Fahrenheit. Any refrigerator that cannot maintain a temperature of 41 degrees Fahrenheit and below was to be removed from service until repaired. Main Kitchen: The following observations in the main kitchen were made on 06/08/2026 from 10:38 AM to 11:02 AM:- there were 56 2% milk cartons in a crate with a best used by date of 06/03/2026;- the hot prep side sink did not have paper towels, and the dish room hand sink automatic paper towel dispenser did not work.- the walk-in freezer had polish kielbasa, a case of individually packaged frozen rolls (one roll per plastic package) six of them spilled out of the case, and one 30-pound box of lima beans were on the freezer floor. There was one open box of tilapia with the plastic bag inside unsealed exposing the fish. The floor of the walk-in freezer was sticky and had a six-inch puddle of a brown substance, and frozen broccoli and cauliflower florets on the floor.- the dry storage only had one working light and had food debris and spillage on walls and floor. The following observations in the main kitchen were made on 06/10/2026 from 10:01 AM to 11:33 AM documented:- there were no paper towels by the handwashing sinks in the hot preparation area and the dish room area- the walk-in cooler wire racks had debris on them and the floor was unclean- there were broken tiles by the handwashing sink- there was a yellow and whiteish substance in a 6-inch by 6-inch area under the microwave- the produce/juice cooler had a blackish wet sludge type substance on the floor by the milk crates- the dry storage area was unclean with discarded gloves and various food debris and spillage on the floor. There was one light out.- there were missing and broken tiles in the mop room During an observation and interview on 06/10/2026 at 10:24 AM the walk-in cooler had a pork loin dated 06/10/2026 that was 87 degrees Fahrenheit. [NAME] #66 stated the pork loins were put into the walk-in cooler at 8:30 AM at 185 degrees Fahrenheit. They took temperatures every 30 minutes and did not write the temperature down on paper and they did not check the temperature until right then. They cooked the pork until at least 165 degrees Fahrenheit and took the temperature. They put the pork loin on sheet trays and put it in the cooler. The temperatures should be documented but they did not write anything down that day. They stated they had food safety cooling training. At 11:04 AM the pork loin was 79.6 degrees Fahrenheit. During an observation and interview on 06/10/2026 at 11:13 AM, [NAME] #66 was wearing gloves, touched the garbage can and went to move the pork into the cooler. [NAME] #66 changed their gloves when asked if their gloves were changed but they did not wash their hands. During an observation on 06/10/2026 at 11:36 AM the basement dry storage room had a large black pipe on the side of the room with boxes of canned goods, ravioli, mayonnaise, granulated mashed potatoes, cereal bars, pears and beets. There was a second large black pipe with food souffle cups and paper goods underneath. The Maintenance Director stated they were either storm drains, or sewer drains. During an interview on 06/12/2026 at 12:00 PM, the Food Services Director stated food should be kept off the floor to prevent contamination. The floors were to be kept clean to prevent pest issues. Food items should not be stored under wastewater pipes. The cooks were trained in food cooling and there was a cooling policy they should follow. The breakfast cooks and prep cooks took temperatures throughout the day and should document the cooling temperatures per policy and know what time they bring the food out. If something was not cooled or cooked properly there was the potential for food borne illness. The staff should wash their hands and put on gloves any time they touched unclean surfaces and uncooked food. Housekeeping should ensure the kitchen had paper towels and there was a maintenance order in for the paper towel dispenser at the hand washing sink in the dish room. They were going to be replacing the floor in the mop room soon. They shop vac the room currently and it gets in the cracks, and they tried to keep the floor dry as pooling water could attract pests. At 12:22 PM, the Food Services Director stated milk orders came in on Monday and Thursday and it was stored in the cooler. When the stock comes in the milk should be rotated in the order of first in, first out. They have had complaints about spoiled and out-of-date milk. During an interview on 06/12/2026 at 12:51 PM the Maintenance Director stated the missing tile in the kitchen was their responsibility and they had a contractor coming to fix the floor in the kitchen mop room. Unit Pantry Refrigerators and Rolling Coolers The following observations were made on the Unit 5A pantry on 06/10/2026 from 10:16 AM to 11:14 AM:- the pantry refrigerator ambient air did not feel cool. The small thermometer on the top shelf read 60 degrees Fahrenheit. The top shelf contained eight fat-free milks, four chocolate milks, five whole milks, one 2% milk, and two sandwiches. The bottom shelf had 21 cranberry cocktails, five orange juices and two apple juices in small plastic sauce type containers, one 64-ounce bottle of cranberry juice, one 1-liter bottle of ginger ale and one resident tray on the bottom shelf. There were two 1-liter bottles of ginger ale, six 1-liter bottles of cola, and three 1-liter bottles of diet ginger ale in the door. There were 15 Ensure (nutritional supplement) in the left bottom drawer. The surveyor's thermometer read 53.5 degrees Fahrenheit after measuring the temperature for two minutes with the door shut.- individual whole milk cartons did not feel cold to the touch. The milk temperature was 60.8 degrees Fahrenheit.- the refrigerator was left closed for 11 minutes and a new milk temperature was taken and was 63 degrees Fahrenheit.- the freezer temperature was 20 degrees Fahrenheit per the in-freezer thermometer. The individual sherbert containers were frosty but soft when touched. The surveyor thermometer read 33.8 degrees Fahrenheit after three minutes in the freezer with the door shut. During an observation on 06/10/2026 at 10:47 AM, the Unit 5A rolling food cart was plugged into the wall in the solarium/dining room with the power indicator on; the outside thermometer on the cart read 52 degrees Fahrenheit. A thermometer place on the left side of the cart for 3 minutes with the door shut read 45.3 degrees Fahrenheit. A thermometer on the right side of the cart for 2 minutes with the door shut read 50.4 degrees Fahrenheit. The gasket lining on the right side of the cart was sticking out of the side of the door and was difficult to open and shut. A milk pulled from the left side of the cart had a temperature of 47.8 degrees Fahrenheit and a milk pulled from the right side was 50 degrees Fahrenheit. During an interview on 06/10/2026 at 11:25 AM, the Traveling Food Services Director stated they took the temperatures of the refrigerators on the unit that morning. They looked at the thermometers in the refrigerator and then recorded the temperatures on the log. If it was out of temperature they pulled the food out, discarded it and shut the refrigerator down until it was back in temperature. The rolling refrigerator carts temperatures were taken 3 times a day. There was no temperature recorded for the lunch meal for the rolling cooler cart that went to the 5A unit, and they were unsure of when the cart went to the unit. They were unsure if the temperature of the cart was supposed to be taken prior to going to the floor or after it was unplugged, rolled to the floor, and then plugged back in. During an interview on 06/10/2026 at 11:30 AM, the Food Service Director stated the rolling cooler carts had temperatures taken after they were brought to the floor and plugged in. They stated Food Service Supervisor #7 was responsible for taking the temperatures at lunch time for the rolling cooling cart. During an interview on 06/10/2026 at 12:19 PM, Food Service Supervisor #7 stated the rolling cooler carts had their temperatures taken prior to going to the floor. They did not know who took the temperatures for the 5A rolling cooling cart that day. The servers assigned to the unit were responsible for stocking the unit fridges. Dietary Aide #72 was responsible for stocking the Unit 5A refrigerator that day. During an interview on 06/10/2026 at 1:08 PM Dietary Aide #72 stated they stocked the 5A refrigerator that day around 7:30 AM. They checked the refrigerator temperatures when they stocked them. They did not know how long the refrigerator was out of temperature, but it was on when they came at 6:00 AM. It must have gone off after they checked it. If the refrigerator did not feel cold, they would have notified the supervisor. During an observation and interview on 06/08/2026 at 10:31 AM, the Unit 2B rolling cooler was plugged in outside the dining room. The thermometer on the outside of the rolling cooler read 56 degrees Fahrenheit. There were trays with cool items in the cart. At 12:04 PM, the rolling cooler thermometer read 46 degrees Fahrenheit. The gaskets around the right door were broken and did not seal the door. The door was clipped closed with an S hook and did not securely close. Dietary Aide #15 stated the rolling cooler was brought to the floor around 10:00 AM and the temperature should be between 34 to 36 degrees Fahrenheit. At 4:00 PM, the same Unit 2B rolling cooler was plugged in outside the dining room for the dinner meal. During an observation and interview on 06/08/2026 at 4:10 PM, the Food Service Night Supervisor #16 recorded the evening temperature. They stated the rolling cooler went up to the unit around 4:00 PM and should be between 32 to 38 degrees Fahrenheit. The coolers were plugged into the kitchen outlets after meal service and then filled with trays. The temperature was taken in the kitchen prior to the rolling cooler cart going to the floor. They were unaware the rolling cooler cart was not maintaining temperature on the unit. The facility was attempting to get new carts, and they were making do with what they had. The rolling cart temperature was taken, and it was 52 degrees Fahrenheit. During an interview on 06/12/2026 at 12:00 PM, the Food Services Director stated the servers assigned to the unit for that meal take the temperatures of the fridges and clean up any issues. They were to record the temperatures on the temperature logs. It was the same procedure for the refrigerated rolling carts. If the refrigerator was out of temperature, the staff was to let the supervisor know and a maintenance order was put in. If it was above 38 degrees Fahrenheit a work order was to be put in for as soon as possible. During an interview on 06/12/2026 at 12:51 PM, the Maintenance Director stated they were responsible for repairing the coolers on the rolling coolers. The doors were in bad shape, and they had been putting up new gaskets in the meantime to get them to close and latch. They had been broken for several weeks, and they had been trying to keep them maintaining temperature for safety until the new coolers arrived. Unclean Pantries/Pantries without access to handwashing: The Unit 5A Pantry was observed on:- 06/10/2026 at 10:34 AM, all six drawers along the bottom of the counter were sticky to the touch and were dirty with built up grime.- 06/11/2026 at 1:39 PM, the drawers in the pantry were sticky and had built up grime along the top; there was a partially eaten resident lunch tray on the counter; and the ice machine had whitish streaks under the ice dispenser nozzle and black grime build up along the back of the machine under the grate. During an interview on 06/12/2026 at 12:13 PM, Dietary Aide #73 stated they cleaned the messes they made and the steam table. They tidied up whatever they used but the whole pantry was cleaned by housekeeping. During an observation on 06/10/2026 at 9:05 AM Restorative Services Staff #51 went into the 4A kitchenette to dry their hands, left the area and stated, there are no paper towels in their either. They stated there was no soap dispenser or paper towel dispenser on the wall in the kitchenette. During an interview on 06/12/2026 at 12:00 PM, the Food Services Director stated the A building had kitchenettes which were supposed to be cleaned by housekeeping. The only things food service cleaned were the microwave, the steam table and the refrigerator. Each server had a binder on their cart they needed to sign to ensure cleaning was completed. They stated maintenance maintained the ice machines in the pantry and housekeeping cleaned them. Housekeeping also cleaned the drawers and the counters in the pantries. During an interview on 06/12/2026 12:55 PM, the Environmental Services Director stated housekeeping was responsible for restocking the paper towels in the kitchen and in the unit pantries. The paper towels and soap stock were checked daily when they cleaned the areas. Housekeeping was also responsible for cleaning the pantries and it should be done daily. There should not be any build up on the cabinets or drawers. The basic cleaning of the ice machines was the responsibility of housekeeping, but the maintenance of the machines was done by the maintenance department. Maintenance was responsible for hanging the paper towel dispensers and soap dispensers, but housekeeping should report if they were missing. 10 New York Codes Regulations Rules 483.60(i)(1)-(2)

Based on observations, record review, and interviews (IQIES intake 2647397), the facility failed to ensure residents had the right to a dignified existence in a manner and an environment that promoted the maintenance or enhancement of quality of life for three of three residents (Residents #19, #41, and #72) reviewed and for 10 of 12 anonymous residents present at a resident group meeting. Specifically, Resident #19's wheelchair was unclean and in disrepair; Resident #41's ceiling dripped liquid over their bed; Resident #72's clothing was improperly labeled and was worn by another resident; and 10 anonymous residents reported their clothing was not labeled properly, was not returned to them after laundering and was distributed to other residents. Findings include: The facility policy Wheelchair Cleaning, revised 12/2025, documented all resident wheelchairs were cleaned and disinfected at least weekly and as needed to maintain a clean and sanitary condition to reduce the risk of infection transmission, promote resident comfort, and maintain a safe environment. The facility policy Homelike Environment, revised 12/2025 documented residents were provided with a safe, clean, comfortable, and homelike environment. The facility policy Laundry Services, revised 11/2025, documented resident clothing shall be labeled with the resident's identifying information upon admission and as needed. Resident laundry shall be washed, dried, folded and prepared for return in accordance with established laundering procedures and infection control practices. Personal laundry shall be processed and returned to the resident within 48 hours whenever possible. Unclean Wheelchair: Resident #19 had diagnoses including Alzheimer's disease. The 5/19/2026 Minimum Data Set assessment documented the resident had severely impaired cognition and required supervision or touching assistance with chair transfers. Resident #19 was observed in a geriatric chair (specialty wheelchair) with a broken arm rest and dried white debris drips on the chair base air on 06/08/2026 at 12:20 PM and 06/09/2026 at 8:57 AM. Dripping Ceiling: Resident #41 had diagnosis including sepsis (extreme response to an infection) and lower leg cellulitis (bacterial skin infection). The 03/10/2026 Minimum Data Set assessment documented the resident had intact cognition and required supervision for bed mobility. During an observation and interview on 06/08/2026 at 10:42 AM, Resident #41 was in bed covered with a clear trash bag. The resident stated they were protecting themselves as the ceiling leaked at times and they did not want to get wet. The ceiling had a piece of white tape that went from the window to the wall. The tape was puckered in several places and had large brown stains along the line of the tape. The 04/20/2025 work order documented Resident #41 stated there was water leaking from the ceiling. [NAME] spots were observed, however there was no leaking. No repairs were completed. The work order was completed on 04/21/2025 by Maintenance Technician #8 During an observation and interview on 06/09/2026 at 10:10 AM, Resident #41 stated several months ago the ceiling leaked. They told staff but could not remember who they notified. The staff brought them trash bags so they could cover their body and stay dry. They stated 06/08/2026 was the third time the ceiling leaked on them, staff was notified, and the leaking stopped. When there was leaking in their room, they noticed it also dripped outside their window. They stated they just want the problem fixed. The ceiling was observed with a piece of white tape that went from the window to the wall. The tape was puckered in several places and had large brown stains along the line of the tape. During an observation and interview on 06/11/2026 at 11:40 AM, Resident #41 showed Certified Nurse Aide #7 trash bags stored in their shoe on the windowsill. The resident stated they used trash bags as a tarp to protect themselves from getting wet when the ceiling leaked. They told Certified Nurse Aide #7 their ceiling leaked on 06/08/2026 and was told a toilet overflowed which meant the leaking was toilet water. The resident stated they were glad they covered themselves with a tarp because they did not want toilet water dripping on them. During an interview on 06/11/2026 at 11:33 AM, Certified Nurse Aide #7 stated the certified nurse aides were responsible for making sure wheelchairs were clean and free from food and debris. Wheelchair cleaning was assigned to the evening shift and was not documented anywhere. They did not notice Resident #19's dirty, broken chair, and if they had, they would clean the chair and call maintenance to repair the arm. When something was broken, they notified maintenance either electronically or by phone and maintenance usually came within the hour. On 06/08/2026 Resident #19 notified them their ceiling was leaking. They notified maintenance, and the issue was fixed. They were unaware the resident was covering themselves with a trash bag. During an interview on 06/12/2026 at 9:42 AM, Licensed Practical Nurse #5 stated wheelchairs, and geriatric chairs were power washed by the certified nurse aides on the night shift. Maintenance was responsible for repairs. If they observed a leaking ceiling, they would place a trash can to collect the liquid, put a towel down to ensure the floor was dry, and notify maintenance. They stated they were not aware the ceiling was leaking on Resident #41. During an interview on 06/12/2026 at 10:34 AM, Registered Nurse Unit Manager #4 stated certified nurse aides were responsible for cleaning wheelchairs. Maintenance was responsible for repairs. They previously reported the leak in Resident #41's ceiling as the leak comes and goes. When the liquid leaked directly on the resident, they recommended moving the resident during a morning meeting that both Administration and the department directors attended. They did not know the resident was covering themselves with a trash bag as a tarp and stated it was not reasonable to sleep in a bed that was wet from liquid dripping onto the bed. It was a safety concern because the floor was wet, and a wet floor sign was a tripping hazard for residents. It was not homelike to have a leaking ceiling and not dignified to live in an area of disrepair. During an interview on 06/12/2026 at 12:51 PM, the Maintenance Director stated they reviewed the work orders every day, prioritized them, and distributed the work orders to their staff. Most of the time staff repaired items in disrepair and at other times they contracted the work to a corporate approved contractor. They were notified on 06/08/2026 liquid was leaking on Resident #41 and determined the housekeeper was using too much water when they were stripping the floor in the room above. They stated they had no previous work orders for a leaking ceiling in Resident #41's room. They were notified liquid was coming through the ceiling on 06/11/2026 and again on 06/12/2026. The leak was related to an air conditioning unit in the room above. Missing Clothing: During an interview on 06/08/2026 at 12:32 PM, Resident #72 stated they lost clothing when they gave it to a certified nurse aide to be labeled. They stated their church gave them a zippered top they loved, they sent it to be labeled, it never came back to them, and they saw the top on another resident. They stated the other resident told them a certified nurse aide gave them the top. During an anonymous resident meeting on 06/08/2026 at 1:58 PM, 10 of 12 anonymous residents stated the facility took their clothes and gave them to other people. The facility labeled their clothes with another resident's name. Five of 12 residents stated they received items back from laundry that were not theirs. It was an ongoing issue. They thought some of their items were in the donation section of laundry. The 2025 Missing Items Log documented 12 reports of clothing going to laundry to be labeled and not returning. The 2026 Missing Items Log documented three reports of clothing or blankets going to laundry to be labeled and not returning. During an interview on 06/12/2026 at 12:02 PM, Certified Nurse Aide #46 stated when a resident had new clothing items that needed to be labeled, the certified nurse aide had to go downstairs, get an inventory list, fill out the sheet with the separate items and give it to the receptionist. The receptionist would then take it to laundry who would label the clothes. They liked to put the resident's room number and name inside the bag as well. If a resident reported missing clothing, they called laundry to see if they had it. During an interview on 06/12/2026 at 12:24 PM, the Assistant Director of Environmental Services stated they had a backlog of items that needed to be labeled due to the labeler breaking. All the laundry needing to be labeled came down in a bag and had a sheet attached to the bag that listed what was in the bag. After laundry was done labeling the items, they signed off on the sheet and the clothes were hung on a rack and brought back to the resident. The sheets were scanned into the computer. If something was unlabeled, the laundry staff would attempt to find out who it belonged to. If they could not determine the owner, it went into the donation area which only laundry staff had access to. During an interview on 06/12/2026 at 1:11 PM, Receptionist #48 stated they only assisted with completing the itemized clothing form for residents who received new clothing. A resident's family member or a staff member brought them the resident's clothing, and they filled out the sheet with the resident's name, room number, and list of items. They made three copies: one for the book at the front desk, one for the bag, and one was placed in an envelope that went back to the resident's room. If the items were soiled, they did not go in the bag, they just put the resident's name and room number and a note to wash the items prior to labeling. If a resident was missing items, they looked up the clothing items in the book and gave them to the activities or social work department to try and find the missing item. If the items were not found, a missing items sheet was filled out and the resident was reimbursed. They stated sometimes when they came to work there were already clothing bags at the front desk. The laundry staff worked until 4:30 PM. 10 New York Codes Regulations Rules 415.5(d)(1)(i)

Based on observations, record review, and interviews, (IQIES intake 2991234), the facility did not ensure a safe, clean, comfortable, and homelike environment for four of seven resident units (Units 2A, 3A, 4A and 5A) reviewed. Specifically, Units 2A, 3A, 4A and 5A were unclean and in disrepair. Findings include: The facility policy Homelike Environment, revised 12/2025, documented residents were provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. Unit 2A During an observation on 06/10/2026 at 10:57 AM, the floors were very sticky throughout the unit and staff shoes were heard squeaking. Unit 3B During an observations on 06/08/2026 at 4:54 PM and 06/09/2026 at 1:37 PM, room [ROOM NUMBER]'s wallpaper was peeling off the wall and the toilet paper holder was broken. The visitor in the room stated it was like that for a long time and they reported it to the facility months ago. Nothing was done to repair the wall or the toilet paper holder, and they requested a transfer to another facility because the environment was awful. Work orders documented the following issues in room [ROOM NUMBER]: -on 08/19/2025 the wallpaper was coming down over the bed, waiting on when to do it. -on 06/09/2026 the wallpaper was peeling, work was completed 06/09/2026. Unit 4A The following observations were made: -on 6/08/2026 at 11:22 AM, room [ROOM NUMBER] had spoiled and stale air odors. -on 06/08/2026 at 11:53 AM, room [ROOM NUMBER] had a strong urine odor. -on 06/08/2026 at 12:37 PM, the dining room wall outlet under the television had a live prong broken into the lower outlet. -on 06/08/2026 at 1:08 PM and 1:47 PM, 06/09/2026 at 8:16 AM, and 06/10/2026 at 8:26 AM room [ROOM NUMBER] had a sticky floor. -on 06/08/2026 at 1:53 PM, room [ROOM NUMBER] had a sticky floor. -on 06/08/2026 at 2:24 PM, room [ROOM NUMBER] had a sticky floor. -on 06/09/2026 at 8:12 AM, room [ROOM NUMBER] had a large amount of liquid on the floor in front of the bathroom. -on 06/09/2026 at 9:20 AM, room [ROOM NUMBER] had a white powdery substance and a straw on the floor under the resident's urinary catheter bag. -on 06/10/2026 at 10:43 AM, room [ROOM NUMBER] had a sticky floor. -on 06/12/2026 at 8:16 AM, room [ROOM NUMBER] had water on the floor at the base of the bed. There were wet towels on the floor and a wet floor sign near the wet towels. There was visible leaking from the ceiling. The Administrator entered the room and moved the trash can to catch the leak. During an interview on 06/11/2026 at 8:55 AM, Dietary Aide #50 stated there was no soap or paper towels in the 4A kitchenette for them to wash their hands before or after meal preparation, therefore they were unable to wash their hands. It was important to wash hands before and after meal preparation to prevent the spread of infection. They did not tell anyone about the lack of soap and paper towels in the kitchenette and should have told maintenance. Work orders documented on 12/15/2025 both sinks in the 4A pantry were clogged and about to overflow. There was no documentation about the missing soap dispenser or paper towel holder. Unit 5A The following observations were made: -on 06/08/2026 at 10:39 AM, the floor in front of the nursing station was sticky.-on 06/08/2026 at 12:32 PM, room [ROOM NUMBER] had a sticky floor.-on 06/08/2026 at 11:18 AM, room [ROOM NUMBER] had heavily scuffed floors, a dried brown liquid spill on the floor, a tan dried smear to the left when entering the room, and the entrance floor was sticky-on 06/10/2026 at 9:21 AM, the floor in front of the nursing station was sticky, the floor in front of the elevator had crumbs and several dime sized spots of black/dark brown debris-on 06/10/2026 at 9:31 AM, housekeeping used a long-handled scraper on the floor at the beginning of the upper hall across from nursing station to remove some of the stuck-on debris and did not sweep it up, mopped the area and the debris spread across the floor.-on 06/10/2026 at 9:37 AM, there were dried liquid drops in an arc in front of room [ROOM NUMBER] after the area was mopped. -on 06/10/2026 at 10:34 AM, drawers along bottom of the counter in the pantry were sticky to the touch, all six of them were visibly dirty with built up grime.-on 06/11/2026 at 1:11 PM, there was half dollar sized hole in the flooring in the middle of the hallway across from the soiled utility room.-on 06/11/2026 at 4:09 PM, room [ROOM NUMBER] had crumbs and debris under and around the bed. -on 06/11/2026 at 4:10 PM, room [ROOM NUMBER] had several grey track marks to and from the bed.-on 06/11/2026 at 4:11 PM, the area around the entrance to nursing station had visible black spots, stuck on debris, and the floor was sticky. The front of the nursing station had black stuck on debris spots and food crumbs. -on 06/11/2026 at 4:51 PM, there was a bucket in the ceiling under the sprinkler system. The ceiling was dripping, and the Director of Nursing and Maintenance were observing the area. -on 06/12/2026 at 8:07 AM, room [ROOM NUMBER]'s ceiling along the wall tiles were bubbled up in several spots-on 06/12/2026 at 8:08 AM, there was a large water stain on the ceiling tile at the entrance to the North Hall. During an interview on 6/11/2026 at 11:33 AM, Certified Nurse Aide #7 stated housekeeping was responsible for cleaning resident rooms, mopping, sweeping, and emptying trash. When they noted an odor in a resident room or sticky floors, they notified housekeeping. The floors were very sticky, and residents did not like it because their feet stuck to the floor and at times, they lost their balance. Sticky floors were a safety concern; it was not homelike or dignified. Maintenance was responsible for fixing things that needed repair like air conditioning, toilets, and beds. When maintenance was required, they put a work order in the electronic system and maintenance usually addressed the issue within the hour. The dining room was very hot on 06/10/2026 and maintenance was on the unit addressing the air conditioning unit. They stated the air conditioner was in the wrong mode, however it was still hot in the dining room hours after they left. During an interview on 06/12/2026 at 9:42 AM, Licensed Practical Nurse #5 stated housekeeping was responsible for cleaning resident rooms including sweeping and mopping. The floors were always sticky and tacky because of the chemical they used to clean the floors. It was important to keep the rooms clean and floors not sticky because it was the residents' home. Maintenance was responsible for building upkeep and general repairs. If they noticed something that required a repair, they completed a work order and maintenance responded within 30 to 40 minutes. Maintenance fixed things such as leaks, spots on walls and ceilings, and beds. It was important for the building to be in good working order, so the rooms were homelike. During an interview on 06/12/2026 at 10:34 AM, Registered Nurse Unit Manager #4 stated they were responsible for oversite of the unit. They noticed sticky floors and reported the issue to the Director of Environmental Services who stated it was related to humidity. When they noticed the rooms had odors, they called housekeeping so the room could be refreshed. When they arrived on the unit on 06/12/2026 the Director of Nursing told them about a leak in room [ROOM NUMBER]. There was a wet floor sign in the room, and the room was a safety concern because of the wet floor, and the wet floor sign could cause a resident to slip or trip. During an interview on 06/12/2026 at 11:32 AM, Housekeeper #60 stated they were responsible for cleaning mirrors, sinks, toilets, sweeping, mopping, and wiping down walls. They had a list with every room number on it and documented when they needed things like a soap dispenser and turned the sheet into their supervisor. The floors were sticky, and they believed it was the floor cleaner the facility used. When they noted bad odors in resident rooms they used the airlift air freshener. Maintenance was responsible for installing soap dispensers and paper towel holders. During an interview on 06/12/2026 at 12:51 PM, Maintenance Director #3 stated they were responsible for property maintenance, general upkeep of resident rooms, grounds, trash pick-up, driveway maintenance, and building maintenance. Most work orders were entered into the work order system and others were called in directly. Every day they reviewed the work orders, prioritized them, and distributed the work orders to their staff. Most of the time facility staff repaired items in disrepair and other times they contracted the work to a corporate approved contractor. They were notified that liquid was coming through the ceiling in room [ROOM NUMBER] on 06/11/2026 and again on 06/12/2026. The leak was related to an air conditioning unit in the room above. They cleaned the condensation and cleared out the line and believed the problem was corrected. When it continued to leak on 06/12/2026, they replaced the unit. They completed environmental rounds every day and looked at ceilings, walls, floors, and air temperatures. In addition to the environmental rounds, they had a daily safety meeting. All staff should report areas of concern as maintenance could miss things on their daily environmental rounds. 10 New York Codes Regulations and Rules 415.29(j)(1)

Based on observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for three of seven medication carts (Unit 4A, Unit 4B, and Unit 5A). Specifically, the Unit 4A medication cart contained eye drops and inhalers that were not dated when opened, a blister pack of medications expired 06/05/2026, one insulin pen without a pharmacy label and one insulin pen that was not dated when opened; the Unit 4B medication cart contained an insulin pen that was not dated when opened; and the Unit 5A medication cart had unlabeled medication in a cup, a blister pack of medication that expired 01/15/2026, and an inhaler with two different open dates on it. Findings include: The facility policy Medication Storage Parameters, revised 12/2025, documented medications were stored in accordance with the manufacturer and to maintain internal and external products physically separated from each other to prevent contamination. Advair Diskus expired one month after removal from pouch; all insulin products should be dated when opened and discarded 28 days after opening; Salmeterol (bronchodilator) date when removed from foil pouch and discard after 6 weeks Unit 4A North CartDuring an observation and interview on 06/10/2026 at 12:04 PM, the 4A North medication cart contained Lumigan 0.01% ophthalmic solution that was not dated when opened. The dispense date was 10/19/2025. Licensed Practical Nurse # 57 stated the resident received the eye drops the evening prior and eye drops had to be dated when they were opened. The Albuterol inhalers (bronchodilator) for Resident #32 and Resident #109 were not dated when opened and had a pharmacy label documenting dispose of medication 12 months after removal from pouch. There was a resident blister pack for lisinopril (blood pressure medication) that expired 06/05/2026. A lispro insulin pen was dated 05/02/2026 and the nurse stated it expired after 28 days, and the insulin was only administered at night and since there was not another pen in the cart it was used the previous evening. There was an admelog insulin pen without a pharmacy label. Licensed Practical Nurse #57 stated no medication should be administered without a pharmacy label because you would not know which resident the medication belonged to. It was even more important with insulin because you would not want to transfer one resident's blood to another resident because they could get a blood borne infection. They stated there was a grey bag in the medication room where expired medications should be placed and sent back to the pharmacy. When Licensed Practical Nurse #57 was putting expired medications in the grey pharmacy bag, Registered Nurse Unit Manager #4 stated they just had a nurse check the medication carts for expired medications and proper labeling of medications the previous day. Unit 4B non vent medication cartDuring an observation and interview on 06/10/2026 at 12:47 PM, Licensed Practical Nurse #56 stated insulin was dated when opened and expired in 28 or 56 days depending on the insulin. The medication cart contained a Lantus insulin pen that did not have an open date on it. Licensed Practical Nurse #56 stated the pen was used because there was insulin missing and the resident received insulin at night. They stated it was important to label medications when opened because expired medications were not as effective. Unit 5ADuring an observation on 06/10/2026 at 3:30 PM, the unit 5A medication cart contained an open unlabeled yellow oblong pill in a medication cup. During an observation and interview on 06/10/2026 at 3:36 PM, Licensed Practical Nurse #12 stated the medication in the medication cup was gabapentin for a resident that was at an activity. There was a medication card for ondansetron (anti-nausea) 4 milligram for Resident #332 that expired 01/15/2026. Licensed Practical Nurse #12 stated they were not sure how often the medication carts were checked; but every shift should check for expired medications. The expired ondansetron should not be in the medication cart. The Fluticasone-salmeterol inhaler had two dates on it 05/06/2026 and 05/26/2026 with a pharmacy label that documented discard one month after opening. Licensed Practical Nurse #12 was not sure why there were two dates on the inhaler and stated it was confusing. Mycophenolate mofetil was administered to Resident #252 on 06/10/2026 from a box that documented an expiration date of March 2026. Licensed Practical Nurse #12 stated they did not check the expiration date prior to administration and should have. During an interview on 06/12/2026 at 10:34 AM, Registered Nurse Unit Manager #4 stated all nurses who administered medications should make sure the medication had a pharmacy label and an open date to ensure it was safe for administration. All multidose medications such as eye drops, inhalers, nasal sprays, and insulins had to be dated when opened. Insulin expired 28 days after opening, inhalers expired 30 days after opening, and eye drops had different expiration dates, however most expired within 30 days. It was important to discard medication when they expired because the medications were not as effective after that date. 10 New York Codes Rules Regulation 415.18(d)

Based on observations and interviews (IQIES intakes 2991229 and 3008641) the facility failed to ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for two of two test trays (06/08/2026 lunch tray and 06/09/2026 breakfast tray) sampled, and for 10 of 12 anonymous residents present at the Resident Council meeting. Specifically, the 06/08/2026 breakfast tray and the 06/09/2026 lunch tray had hot foods served below 130 degrees Fahrenheit, cold foods served above 49 degrees Fahrenheit and were not palatable; and 10 anonymous residents stated the hot food was cold and flavorless, milk was often served spoiled, lettuce was often brown, and the facility often ran out of food and cups.Findings include: The facility policy Food Temperature at Point of Service, revised 01/2026, documented hot food would be held and served at 135 degrees Fahrenheit or higher and cold food would be held and served at 41 degrees Fahrenheit or lower to prevent foodborne illness. During an observation on 6/8/2026 at 10:31 AM, the 2-door mobile refrigerator was plugged in outside the dining room of floor 2B in the hallway. The thermometer on the outside of the unit read 56 degrees Fahrenheit. The door gaskets were torn, and some were partially outside the door and did not create a seal. The door was clipped closed with two S-hooks and did not securely close the unit. The lunch trays were sitting inside the cart with milk beverages on the trays. The milk cartons felt warm. During an observation and interview on 06/08/2026 at 12:04 PM, Dietary Aide #15 stated they were assigned to serve lunch on 2B. The 2-door mobile refrigerator temperature was 46 degrees Fahrenheit. They stated they brought the mobile refrigerator with trays to the floor around 10:00 AM. The refrigerator temperature should have been between 34-36 degrees Fahrenheit. They could not locate an internal thermometer. During an observation on 06/08/2026 at 12:34 PM, Resident #379's lunch meal was tested as the first tray served, and a replacement meal was ordered. Food temperatures were measured and verified by Certified Nurse Aide #20 as follows: creamy Maryland chicken w/ mushroom was 128.7 degrees Fahrenheit, mandarin oranges were 58.1 degrees Fahrenheit, milk was 55.8 degrees Fahrenheit, and water was 72 degrees Fahrenheit. The beverages all tasted warm. During a resident council meeting on 06/08/2026 at 1:58 PM ten anonymous residents stated the food was often cold, meals were not on time, milk was sour, iceberg lettuce was brown, and the facility frequently ran out of food. The weekends seemed to be worse. Over this past weekend they ran out of cups for drinks. During an observation and interview on 06/08/2026 at 4:00 PM the 2-door mobile refrigerator from lunch was observed plugged in on 2B outside the dining room. The log sheet on the side of the cart documented 37 degrees Fahrenheit by Food Service Supervisor #16. At 4:10 PM, Food Service Supervisor #16 stated the cooler came up from the kitchen around 4:00 PM and the temperature should be 32-38 degrees Fahrenheit. It was plugged in downstairs and only unplugged to bring it upstairs, then immediately plugged in again. The temperature was recorded before bringing the unit upstairs. They found the internal thermometer on the back wall of the refrigerator, and it read 52 degrees Fahrenheit. They did not know the unit temperature was out of safe range. They were trying to obtain new equipment but made do with what they had until new refrigerators could be obtained. During an observation on 06/09/2026 at 8:20 AM, Resident #9's breakfast meal was tested, and a replacement meal was ordered. Food temperatures were measured and verified by Certified Nurse Aide #19 and were as follows: scrambled eggs were 120.9 degrees Fahrenheit, milk was 50 degrees Fahrenheit, yogurt was 49.5 degrees Fahrenheit and oatmeal was 172.4 degrees Fahrenheit and burned surveyor mouth. During an interview on 6/12/26 at 9:00 AM, Certified Nurse Aide #17 stated the residents often complained that the hot food was cold, they were missing items on their tray, and the food did not look or taste appealing. During an interview on 6/12/2026 at 9:17 AM, Charge Nurse #18 stated the residents complained the flavor of the food was bad, they did not get many options, and the presentation was bad. When they really liked something, it was pulled off the menu because it was too expensive. During an interview on 06/12/2026 at 12:00 PM, Food Service Director #25 stated the dietary aide assigned to the unit was responsible for taking and recording temperatures for the refrigerators and rolling carts on the units. When a refrigerator was out of temperature (above 39 degrees Fahrenheit) the dietary aide should notify their supervisor and place a work order with maintenance. When a refrigerator or freezer was not working properly there was potential for residents to be exposed to food borne illness. They completed test trays and expected temperatures of cold items including milk to be 140 degrees Fahrenheit and hot entrees to be served at 140 degrees Fahrenheit or higher. Residents complained about cold food which was attributed to the time it took certified nurse aides to pass the trays. Milk arrived at the facility on Mondays and Thursdays and was stored in a cooler. When it arrived, it should be put in the cooler immediately and rotate first in first out. Recently residents complained about spoiled milk and out of date milk. They determined there was a condenser coil in the milk cooler that was not working properly, and it was repaired. 10 New York Codes, Rules, and Regulations 415.14(d)(1)(2)

Based on observations, record review, and interviews (iQIES intake #2997455 and 3008641), 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 for two of eight residents (Resident #13 and Resident #376) reviewed and two of two staff (Housekeeper #64 and Certified Nurse Aide #61) observed. Specifically, Resident #13 was on contact precautions for clostridioides difficile (a highly infectious bacteria that causes diarrhea) and Certified Nurse Aide #61 walked into the resident's room to retrieve a meal tray without wearing a gown or gloves or washing their hands with soap and water; Resident #376 did not have a contact precaution sign on their door with clostridioides difficile results pending; and Housekeeper #64 cleaned the floors of all rooms, including contact precaution for clostridioides difficile, with a quaternary sanitizer (broad spectrum sanitizer ineffective against clostridioides difficile) instead of chlorine-based bleach.Findings include: The facility procedure Cleaning Patient Rooms identified with Clostridium Difficile documented the housekeeper would use sodium hypochlorite (chlorine-based sanitizer) disinfectant to clean the room, including the floors.The purple Contact Precautions sign documented all staff must wear a gown and gloves before entering the room and must wash their hands with soap and water when exiting the room. Hand sanitizer was not allowed.1)Resident #13 had diagnoses including recurring clostridioides difficile. The 05/13/2026 Minimum Data Set (assessment tool) documented frequent bowel incontinence and staff supervision was provided with toileting. Resident #13's care card documented contact precautions for clostridioides difficile. During an observation and interview on 06/10/2026 at 8:56 AM, Certified Nurse Aide #61 walked into Resident #13's room without donning a gown or gloves. They exited the room carrying the resident's breakfast tray then, used hand sanitizer, and proceeded to enter the next resident's room. Certified Nurse Aide #61 stated they knew what precautions were required by looking at the sign on the door. They reviewed the purple contact precaution sign hanging on the resident's door and stated they only had to wear a gown and gloves when doing direct care, and they were not required to be worn when taking the meal tray out of the room. They stated hand sanitizer was effective after leaving the room. During an interview on 06/10/2026 at 9:01 AM, Registered Nurse #62 stated contact precautions required staff to wear a gown and gloves any time they entered the room and handwashing with soap and water was required when leaving the room. During an interview on 06/10/2026 at 9:06 AM, Registered Nurse #18 stated contact precautions required staff to wear a gown and gloves any time they entered the room and required handwashing with soap and water when leaving the room. Resident #13 also required their room to be cleaned with bleach. The in-service coordinator recently provided annual infection control training on the topic to all staff. During an interview on 06/12/2026 at 9:07 AM, Housekeeper #64 stated they used a quaternary sanitizer on the sinks in all resident rooms, even rooms with contact precaution for clostridioides difficile. When they mopped the floors in all resident rooms, regardless of precautions, they used individual mop pads and a quaternary sanitizer. During an interview on 06/12/26 at 9:41AM the Director of Housekeeping stated staff should clean contact precaution rooms with bleach and mop the floors with a quaternary sanitizer. During an interview on 06/12/2026 at 10:39 AM, Infection Preventionist #39 stated if a resident was on contact precautions for clostridioides difficile the room needed to be cleaned with bleach, including the floors. A quaternary sanitizer would not kill clostridioides difficile. There was a checklist environmental services referenced when cleaning a resident's room who had clostridioides difficile. 2)Resident #376 had diagnoses including osteomyelitis (bone infection), urinary tract infection, and diarrhea. The 06/04/2026 Minimum Data Set assessment documented the resident was cognitively intact, was frequently incontinent of bowel, was taking an antibiotic, and received intravenous medications.The comprehensive care plan initiated 05/29/2026 documented the resident was a risk for alteration in bowel related to antibiotic use. Interventions included monitoring for loose stools, and any changes were reported to the physician. The 6/11/2026 at 1:15 PM Physician #40 order documented the resident had a laboratory order for stool specimen for clostridioides difficile for diarrhea.The 06/11/2026 at 1:15 PM, Registered Nurse Unit Manager #30 progress note documented there was a new order for stool culture and sensitivity for clostridioides difficile.Resident #376's room was observed without contact precaution signage outside their room door on 06/11/2026 at 2:13 PM and 4:53 PM, and on 06/12/2026 at 8:39 PM. During an interview on 06/12/2026 at 8:58 AM, Certified Nurse Aide #35 stated they knew what personal protective equipment to wear based on the sign outside the door. During an interview on 06/12/2025 at 9:05 AM, Licensed Practical Nurse #41 stated the proper personal protective equipment worn was determined by the sign outside the resident's room. The signs were placed by the Infection Preventionist. They verified the order for the clostridioides difficile specimen for Resident #376, but they did not enter it. Precautions for clostridioides difficile should probably be started as soon as there was an order to rule it out because the precautions were beyond just the enhanced barrier precautions.During an interview on 06/12/2026 at 9:30 AM, Registered Nurse Unit Manager #30 stated staff knew what personal protective equipment to wear in a resident room based on the sign outside their room. Clostridioides difficile required contact precautions with the purple sign and the sign was different than the enhanced barrier precaution sign. Contact precautions should be initiated as soon as the laboratory order was obtained. Typically, the Infection Preventionist put up the signs. They did not call the Infection Preventionist when they got the order for stool for clostridioides difficile, however, they could have put up the sign themselves and did not. During an interview on 06/12/2026 at 11:55 AM, the Infection Preventionist stated they were responsible for initiating and maintaining isolation precautions. The sign informed all staff and visitors what personal protective equipment was required prior to entering the room. Clostridioides difficile had its own sign because it required different cleaning and was highly contagious. To prevent it's spread, a gown and gloves and hand washing were required every time the room was entered. Those precautions should be initiated as soon as a specimen was ordered for clostridioides difficile. 10 New York Codes, Rules and Regulations 415.19(a)(b)

Based on observations and interviews, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for one of one main kitchen walk-in freezers. Specifically, the main kitchen walk-in freezer was malfunctioning and did not have an out of service sign posted to prevent staff from using it for food storage.Findings include:The facility policy Food Storage, last reviewed 09/2025, documented freezer temperatures would be monitored and documented daily. Any temperature concerns would be reported immediately and a work order submitted according to facility procedures.The facility policy Equipment Repair and Maintenance Reporting, last reviewed 01/2026, documented all dietary staff were responsible for reporting equipment malfunctions, damage, or safety concerns immediately. Equipment issues would be entered into the work order system as soon as they were identified and equipment that presented a safety risk would be removed from service until repaired.During an observation and interview on 06/10/2026 at 10:10 AM, the walk-in freezer in the main kitchen was 52 degrees Fahrenheit. The freezer contained one box of frozen tilapia (fish). There was no signage posted outside the freezer indicating it malfunctioned. Food Service Director #25 stated the freezer went down so no food was supposed to be inside the freezer. When equipment was out of order, they were supposed to put up a sign. The freezer temperatures were high over the weekend, so they were monitoring them, and they were currently using a refrigeration truck in the parking lot that was delivered on 06/09/2026.10 New York Codes, Rules, and Regulations 415.5(e)(1)(2)

Based on observations, interviews, and record review the facility failed to ensure the interdisciplinary team determined a resident's ability to safely administer their own medications, if clinically appropriate, for one of one resident (Resident #361) reviewed. Specifically, Resident #361 had two budesonide-formoterol fumarate dihydrate aerosol inhalers (used for opening airway) in their room and there was no documented evidence of an assessment or a physician order for the resident to safely self-administer medications.Findings include: The facility policy Self-Administering of Medication, revised 11/2025, documented each resident's ability to self-administer medications will be assessed upon admission, with significant changes as defined by the Minimum Data Set and at annual resident care plan reviewed by using the self-administration of medication assessment tool. Every resident has the right to self-administer if assessed as capable by the Interdisciplinary Care Team and upon receipt of a physician's order to self-medicate. If resident is considered appropriate for self-administration of medication a locked drawer/container will be issued to the resident, and the medications administration record will be labeled to identify the resident as self-medicating. Resident #361 had diagnoses including dementia, schizophrenia (severe mental illness), and obstructive lung disease. The 5/15/2026 Minimum Data Set assessment documented the resident had moderate cognitive impairment and required partial/moderate assistance for personal hygiene. During observations on 06/08/2026 at 11:39 AM, 06/09/2026 at 1:16 PM, and 06/10/2026 at 9:01 AM a clear zipped pouch containing two budesonide-formoterol fumarate inhalers was observed at the end of the resident's bed. The June 2026 Medication Administration Record documented budesonide-formoterol fumerate dihyd aerosol two puffs by mouth twice daily at 11:00 AM and 10:00 PM, for shortness of breath, rinse mouth with water and clean mouthpiece. The medication was documented as administered on 06/09/2026 at 11:00 AM and 10:00 PM and on 06/10/2026 at 11:00 AM (the Medication Administration Record did not identify what nurse administered the medication). There was no documented evidence of a medication self-administration assessment or a physician order for self-medication or a comprehensive care plan related to self-administration or storage of medication in the resident's room. During an interview on 06/12/2026 at 9:47 AM Licensed Practical Nurse #12 stated a resident needed an order to have an inhaler at their bedside, and it was indicated in the medication administration record. They stated a resident would usually do a training if they were able to self-administer medication and it would be documented in their chart. They stated they had the inhaler prescribed to Resident #361 in their medication cart and there was no order in the medication administration record for Resident #361 to self-administer medications. They stated they saw Resident #361's inhalers at the end of their bed and they should not be in their room if they do not have an order to self-administer. During an interview on 06/12/2026 at 10:06 AM Registered Nurse Unit Manager #23 stated that there was a self-administering of medications assessment that was updated every 90 days. During the assessment, they witnessed a resident correctly self-administer medications then they would get a physician order. They stated there would be a self-administration of medications paper in the medication administration record. Resident #361 was not assessed for self-administration of medications, and they found two inhalers at their bedside in a clear purse. They stated they did not know how long the inhalers were there.10 New York Codes, Rules and Regulations 415.23(f)(1)(vi)

Based on record review and interviews, the facility failed to ensure all investigations were thoroughly investigated to rule out abuse, neglect and mistreatment for one of one resident (Resident #298) reviewed. Specifically, Resident #298 sustained an injury of unknown origin, a right hip fracture, and a thorough investigation was not completed to rule out abuse, neglect, or mistreatment and the incident was not reported to the New York State Department of Health as required.Findings include:The facility policy Accident/Incidents Reporting, Investigating and Implementing Corrective Action, revised 03/2026, documented the facility would promptly investigate any accident or incident and initiate measures to prevent recurrence. Any incident or accident resulting in serious bodily injury would be reported immediately to the Director of Nursing who, in turn, would report to the Administrator. The Administrator or designee would be responsible for reporting the incident or accident to the appropriate agencies or authorities, according to local, state and federal regulations and statutes.Resident #298 had diagnoses including Alzheimer's disease and right femur (thigh bone) fracture. The 03/22/2026 Minimum Data Set assessment documented the resident had severely impaired cognition, had no behaviors, did not reject care, had one fall without injury since admission/reentry, was independent with bed mobility, sit to stand bed/chair transfers and walking 10 feet, and required supervision/touching assistance with walking 50 feet with two turns.The 03/24/2026 comprehensive care plan documented the resident was a potential victim of abuse related to cognitive disabilities. Interventions included redirecting away from persons of concern, monitoring socialization, observing and intervening with resident removing clothing, observing whereabouts of resident and intervening as needed to redirect, assess for behavior used as communication for symptoms of pain. The resident was at risk for falls related to unsteady gait, confusion, and impaired judgement. Interventions included wear proper non-skid footwear, educate resident and family on mobility and transfer, call bell and frequently used items within reach, and ensure use of cane, walker, or quad cane.The 04/23/2026 facility Investigative Summary documented:- on 04/18/2026 at approximately 10:00 AM, Registered Nurse Unit Manager #23 was called to the unit and notified Resident #298 was grimacing, resistant to care, and unable to stand on their right leg. Registered Nurse Unit Manager #23 assessed the resident and notified the physician on call. Orders were obtained to send the resident to the hospital for evaluation. The Director of Nursing and Administrator were notified. The resident was admitted to the hospital with a displaced femoral neck fracture and surgical intervention was completed during admission.-Staff interviews included staff on duty during the day shift. Certified Nurse Aide #53 went into the resident's room to provide care. When the resident was unable to get out of bed independently and was showing signs of pain, Licensed Practical Nurse #52 notified the supervisor. -Staff interviews included staff on duty during the overnight shift. Certified Nurse Aide #54 and Licensed Practical Nurse #55 stated the resident had no problems or falls during the shift and had no pain.-Based on interviews conducted as part of the facility's internal investigation, the facility determined the resident's injury was an unfortunate and unforeseen incident which was not reportable to the New York State Department of Health. The facility believed the resident had experienced an unwitnessed fall and was able to get up without assistance. The resident was known to self-transfer in their room and had a diagnosis of osteoporosis (weak bones). Staff interviews were conducted, and abuse was ruled out. The care plan was reviewed and was found to have been followed appropriately. There was no documented evidence how the facility determined abuse, neglect, or mistreatment was ruled out During an interview on 06/10/2026 at 4:07 PM, Licensed Practical Nurse #52 stated they were notified by the certified nurse aide that Resident #298 was not walking, which was different from their baseline. The resident was sent to the hospital and had a fracture, but they had never heard what the outcome was.During an interview on 06/11/2026 at 12:20 PM, Registered Nurse Unit Manager #23 stated they were called to the unit to do an assessment on Resident #298 because the resident was unable to stand and that was a change in condition. They notified the provider, and the resident was sent to the hospital for X-rays and ended up having a fracture. They were unsure if the resident had a fall. It was a fracture of unknown origin, so an investigation was completed by the Director of NursingDuring an interview on 06/12/2026 at 1:10 PM, the Director of Nursing stated they were notified of injuries of unknown origin. They or a registered nurse supervisor would obtain 72 hours' worth of staff statements, and an incident report was completed. They reviewed the report, reviewed for any care plan violations, and then ruled out abuse, neglect and mistreatment. The investigation was reviewed with the Administrator, and they determined if it was a reportable incident. Resident #298 was not moving like themselves and was normally independent. The resident and staff were unable to tell them what had happened. The investigation was started on 04/18/2026 and was completed on 04/20/2026. They had ruled out abuse and any care plan violations and determined it was not reportable because the resident was independent before the incident, had a history of osteoporosis, so they thought it was a pathological fracture (a broken bone that occurred from an underlying disease or condition that had weakened the bone).10 New York Codes, Rules and Regulations 415.4

Based on observations, record review, and interviews, the facility failed to implement the comprehensive care plan for one of one resident (Resident #16) reviewed. Specifically, Resident #16's comprehensive care plan documented the resident required supervision with the potential for dependent care with eating and the resident was observed feeding themself without staff supervision. Findings include:The facility policy Activities of Daily Living, revised 06/2025, documented the resident's care plan and certified nursing aides care cards would document the level of assistance required for care. The certified nurse aide would document the completed level of care in the electronic medical record daily. Resident #16 had diagnoses including dysphagia (difficulty swallowing). The 03/02/2026 Minimum Data Set (assessment tool) documented the resident was dependent with eating. The comprehensive care plan initiated 12/19/2025 and revised 05/27/2026, documented the resident was supervised at each meal and fed if needed. The certified nurse aide care card documented Resident #16 was dependent with eating. During an observation on 06/08/2026 at 1:30 PM, Resident #16 was in bed with their lunch tray to the side on a tray table, unopened and untouched. There were no staff present in the room or the general area. Nothing was opened or consumed on the tray and the silverware was still sitting on the napkin. During an observation on 06/09/2026 from 1:00 PM through 2:10 PM, Resident #16 was served lunch at 1:13 PM on a tray table while sitting in the hall. The meal tray was set-up, and the meat was cut by an unidentified staff who left the resident without assisting them and returned at 2:01 PM to retrieve their tray. The resident consumed approximately 50% of their lunch. No staff approached the resident during the meal to offer encouragement or assistance. During an interview on 06/12/2026 at 9:00 AM, Certified Nurse Aide #17 stated they knew how much assistance a resident needed at meals by checking the care plan. Dependent with care meant two staff needed to care for the resident and if they refused care, they should notify the charge nurse and try to reapproach the resident later. Resident #16 did not eat orally the last time they worked with them. During an interview on 06/12/2026 at 9:17 AM, Registered Nurse #18 stated staff knew how much care a resident needed by looking at the profile card. Dependent with care meant they needed assistance with everything. If a resident refused care, they should reapproach a couple times then try a different caregiver. Staff should tell the charge nurse, and they would document the issue. Resident #16 was known to refuse care, but they were unsure if meal intake and refusal of assistance were current issues. If the care plan documented dependent with eating, staff should assist the resident through the meal. During an interview on 06/12/2026 at 12:10 PM, Assistant Director of Rehabilitation #63 stated occupational therapy determined what level of feeding ability a resident required on admission. Dependent with eating meant the resident did not participate at all. Resident #16 was care planned for one-to-one assistance at meals. Resident #16 was not eating orally during the last occupational therapy assessment in December 2025. They should not have been given a tray and left alone with it. 10 NYCRR 415.11(c)(2)(iii)

Based on observations, record review, and interviews, (IQIES 2991229), the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for three of three residents (Residents #10, #72, and #376) reviewed. Specifically, Resident #72 had a self-reported skin impairment they requested only the wound team or the provider to assess, their request was not communicated to the provider or the wound team, and the skin impairment was not assessed timely; Resident #10 had a wound dressing applied without an order; and Resident #376 had a central line (a venous catheter used to give medicine, fluids, or obtain blood samples) and there was no physician order for its use and or directions for monitoring of the site. Findings include: The facility policy Change in Resident Status, revised 12/2025, documented the supervisor, unit manager or staff nurse would notify the physician of any change in status and document in the medical record along with any physician directives. Change in status includes pressure areas, open areas, and failure to follow physician's orders. The facility policy Central Line Dressing Change, revised 09/2025, documented the staff was to change the dressing at the site of a peripherally inserted central catheter/central line to allow for assessment of the insertion site and prevent infection. Central Line dressings were changed 24 hours after placement of line, then weekly and as needed if dressing has been compromised per the physician's order. The facility policy Flushing Peripherally Inserted Central Catheter/Central Line, revised 02/2026, documented licensed staff were to flush the peripherally inserted central catheter/central line safely per the medical provider's order. The staff were to assess insertion site for signs of infiltration (fluid leaking into surrounding tissue), phlebitis (inflammation of a vein) or infection, complete the flushing per the order, and document in the electronic medical record. 1) Resident #72 had diagnoses including abnormally dry skin, diabetes with nerve damage, and chronic pain syndrome. The 04/12/2026 Minimum Data Set documented the resident had intact short-term and long-term memory, was independent with their daily decisions, required set up or was independent for all activities of daily living, was at risk for developing pressure ulcers, and had two arterial ulcers with applications of non-surgical dressings and medications/ointments. The 04/13/2026 comprehensive care plan documented the resident had venous ulcers and inflammation of the right lower extremity, the resident wished to do their own wound care, was safely able to perform their own treatment, did not allow wound assessment by the wound care team and refused their shower. Interventions included skin assessments on admission, every three months, and as needed; keep skin clean and dry; notify the nurse of any redness or breakdown; weekly skin evaluations by the registered nurse; and perform treatment per order. During an interview on 06/08/2026 at 12:32 PM, Resident #72 stated they had sores on their buttocks that were there for a week and no one had told the doctor. Nursing progress notes documented: -on 06/07/2026 by Licensed Practical Nurse #12 the resident complained of an open area on their buttocks. The resident refused to let staff observe the area but would allow wound care or the provider to view the open area the next day. The resident was educated that they could not treat something the resident would not allow to be viewed, and their complaint would be communicated to the oncoming staff to inform the provider on Monday 06/08/2026. -on 06/08/2026 by Licensed Practical Nurse #13 the resident voiced concerns regarding an open area on their buttocks. The supervisor was notified and came to the unit to assess the reported area. The resident refused assessment by the supervisor despite education on the importance of evaluation. No further complaint was voiced at that time, and they would continue to monitor. -on 06/09/2026 by Licensed Practical Nurse #14 the resident was observed crying and voiced concerns of pain in the buttocks. The writer offered to assess the area and the resident refused. The resident was educated on the importance of offloading weight and encouraged to lie down in bed to take pressure off the buttocks; the resident declined. The 5 North 24-hour report documented: -on 06/07/2026 Resident #72 complained of an open area on their buttocks. The instructions include monitoring the complaint, view if possible, and update Nurse Practitioner #21 on Monday 06/08/2026. The day shift documented there was a complaint of an open area and the resident was refusing to allow any staff to view the open area on buttocks. The resident only wanted to speak to wound care or the nurse practitioner tomorrow, not the floor staff. The resident was educated the staff could not treat the area if they did not know what was there. The evening shift documented still refusing -on 06/08/2026 Resident #72 complained of an open area on their buttocks. The instructions included to monitor. There was nothing documented in the day shift column and evening shift documented the resident refused to let the supervisor assess the area. -on 06/09/2026 Resident #72 had a complaint of an open area on their buttocks. The instructions documented to monitor. The day shift and night shift columns documented there were no changes. The evening shift column documented there was a complaint of an open area on their buttocks. The resident refused to let nursing staff assess. There was no documented evidence the wound care team or the medical provider were notified regarding the resident's request for them to assess the open area on the resident's buttocks from 06/07/2026 to 06/11/2026. The 06/12/2026 at 12:37 PM Wound Care Registered Nurse #22 progress note documented the resident had a left gluteal (buttock) cyst (a lump often filled with fluid or pus) that was unable to be measured. The wound had full thickness with 100% slough (moist dead tissue) with reddened surrounding skin. The resident had severe pain. During an interview on 06/12/2026 at 9:46 AM, Licensed Practical Nurse #12 stated if a resident self-reported an open area they would look at the area, document it, call the provider and let the unit manager or supervisor know about it. If the resident refused to allow them to look at the area, they should educate the resident and report it to another nurse so they could try and observe the area and notify the provider. They did not inform the provider about Resident #72's self-reported open area as it was the weekend. They did not report it to the supervisor either because even when there was a provider in the building the resident refused to let them look at their body. During an interview on 06/12/2026 at 10:15 AM, Registered Nurse Unit Manager #23 stated the medication nurses should contact them or a supervisor if a resident reported an open area. If a resident only wanted the open area assessed by the wound care team or the provider, the wound care team or the provider should be informed. They were aware Resident #72 was self-reporting an open area and was refusing to let the nurses look at it. They did not know if the wound care team or the provider were updated as there were no progress notes to reflect it. During an interview on 06/12/2026 at 10:26 AM, Wound Care Registered Nurse #22 stated they were typically notified of new open areas by phone or voicemail. They stated if the resident wanted their open area only observed by wound care or the provider, they should have been informed so it could be looked at. They believed they were informed in morning report on Monday 06/08/2026 of Resident #72's potential open area but they forgot about it and did not assess the wound. A potential open area should not go five days without being assessed. During an interview on 06/12/2026 at 11:32 AM, Nurse Practitioner #21 stated if a resident was self-reporting an open area, they should be notified. If a resident only wanted the area seen by wound care or the provider, both should be notified so the area could be assessed. They were notified of Resident #72's potential open area today, 06/12/2026. A potential open area should not go five days without being assessed. The open area appeared to be a cyst that opened and was approximately 2 x 2 centimeters. It was difficult to see, and the resident was in severe pain. They refused any facility treatment and was being sent to the hospital for evaluation. 2) Resident #10 had diagnoses including poor circulation and diabetes. The 03/31/2026 Minimum Data Set documented the resident had intact cognition, had no behaviors, required moderate assistance or was dependent for all activities of daily living, was at risk for pressure ulcers, had moisture associated skin damage and had non-surgical dressings applied. The 05/28/2026 Comprehensive Care Plan documented the resident was at risk for impaired skin integrity related to diabetes, medication, and their skin being desensitized to pain or pressure. Interventions included weekly skin checks, use risk assessment tools to monitor risk factors, keep skin clean and dry, alert the provider and wound team of any redness or open areas, and to observe the skin when providing care. Observations of Resident #10 were made: -on 06/08/2026 at 1:14 PM their left leg was open to air with clear and reddish colored fluid weeping in spots. -on 06/09/2026 at 12:52 PM sitting in their wheelchair with a blue absorbent dressing wrapped in gauze on their left leg. -on 06/10/2026 at 9:36 AM was sitting in their wheelchair with long pants on. The resident stated their leg was still wrapped and was sore. There were visible lines through the resident's pant leg from the dressing. -on 06/11/2026 1:18 PM sitting in their wheelchair with shorts on. The blue absorbent pad was visible from right below the left knee to the mid to lower calf/upper ankle area. The gauze wrap had slipped down and bunched up. The resident stated the dressing was applied on Monday (06/08/2026) by a nurse but they could not remember who. The dressing was not changed since then. At 4:13 PM, the resident's blue absorbent pad was visible from right below the left knee to the mid to lower calf where the gauze wrap was bunched up. There were no documented evidence of a physician orders to apply a dressing to the resident's left leg. There were no documented nursing progress notes from 06/08/2026 to 06/11/2026 regarding the fluid weeping front the resident's leg or the dressing applied to the resident's leg. During an interview on 06/11/2026 at 4:18 PM, Registered Nurse Unit Manager #23 stated Resident #10's wound dressing order fell off due to an automatic discontinue on 06/05/2026. The resident did not have an order to apply Optilock (blue absorbent dressing) since 06/01/2026. The nurses were supposed to be looking at the resident's leg daily. They were unaware the resident stated the dressing had not been changed since Monday. They had seen the resident's dressing and thought there were orders in place. During an observation on 06/11/2026 at 4:57 PM, Registered Unit Manager #23 obtained new orders from Nurse Practitioner #37 to remove the old dressing, cleanse with soap and water, apply moisturizing cream and wrap with gauze wrap. They removed the old dressing using normal saline to the adhered gauze wrap. The Optilock (blue absorbent dressing) was slightly sticking to the skin but came off. The resident had one dime sized area on the upper inner calf. The skin was flaky around the bottom of the calf and there were areas of darkened pinkish-brown, and beefy areas of skin exposed. There was a pink and red raised indentation halfway around the lower calf/right above ankle indent on the inside to middle of the left leg. During a phone interview on 06/12/2026 at 9:09 AM Licensed Practical Nurse #13 stated if a resident had a treatment it would be on the Medication Administration Record or Treatment Administration Record in the electronic medical record. If a resident needed a dressing done but did not have an order for one, they called the registered nurse supervisor so they could come up and assess the resident then call the provider to obtain an order. A dressing should not be done without a physician's order. Resident #10 had a dressing on their left leg on Tuesday evening, and wanted it off. The resident stated it was itching, and they were digging at their skin and crying. They took the dressing off and put a different dressing on the resident because the resident's leg was weeping. They put the Optilock dressing on the resident and wrapped it in an ace bandage so it would not come off. They did not know if the resident had an order for the dressing. They let the supervisor know but did not remember which supervisor it was. They did not write a progress note or let the provider know and they should have. 3) Resident #376 had diagnoses including osteomyelitis (bone infection). The 06/04/2026 Minimum Data Set assessment documented the resident was cognitively intact, received antibiotics, and received intravenous medications. The 05/29/2026 physician order documented the resident was to receive ceftriaxone sodium (intravenous antibiotic) two grams every day at 10:00 AM for osteomyelitis through a peripherally inserted central catheter. The registered nurse was to change the dressing; extension set and cap every week and measure the length of the external catheter on Mondays. Flushed the line with 10 milliliters of normal saline before use. There was no documented evidence of an order to monitor the peripherally inserted central catheter site. There was no documented evidence of the initial measurements of the length of the catheter. The comprehensive care plan initiated 05/29/2026 documented the resident received intravenous antibiotic therapy through a peripherally inserted central catheter. Interventions included the site was monitored for infection every shift and as needed. The dressing was changed every 72 hours and as needed by a registered nurse. The 05/29/2026 at 6:54 PM, Registered Nurse #32 progress note documented the resident had a peripherally inserted central line to their left upper extremity. The dressing was clean and intact. Measurements were extension of 16 centimeters; and arm circumference was 33 centimeters. They left a message for the Infection Preventionist that the dressing would need to be changed weekly. The June 2026 Treatment Administration Record documented the peripherally inserted central line dressing was changed on 06/01/2026 and 06/08/2026 by the Infection Preventionist. There was no documented evidence the length of the external catheter was measured as ordered. During an observation and interview on 06/08/2026 at 11:41 AM, Resident #376 had a dual lumen peripherally inserted central catheter in their left upper arm. The dressing was intact and dated 06/01/2026. The resident stated the dressing was changed last at the hospital before they were admitted to the facility (the resident was admitted to the facility on [DATE]). During an interview on 06/11/2026 at 10:32 AM, Licensed Practical Nurse #33 stated a registered nurse monitored Resident #376's peripherally inserted central catheter site, and there was an order to change the dressing, monitor the site, and measure the length. During an interview on 06/11/2025 at 10:43 AM, Registered Nurse Unit Manager #30 stated they monitored Resident #376's peripherally inserted central catheter site for pain and swelling daily when they administered the antibiotic. They were not sure if there was an order for it or if it was documented anywhere. The Infection Preventionist changed the dressing once a week and took measurements at that time. During an interview on 06/11/2026 at 11:07 AM, the Infection Preventionist stated they changed the dressings for all central lines in the facility. If the length of the tubing looked off, they measured it. It was not documented anywhere that the site was assessed or monitored. During a follow up interview on 06/12/2026 at 11:22 AM, they stated they were not sure if a peripherally inserted lines required an order specifically for the line. They should document measurements of the line in the electronic record, but they were not perfect. They did not have access to the hospital records to see what the length was supposed to be so they would only know if it was pulled out by the look of it. Resident #376's dressing was dated for 06/09/2026 because that was when they changed the dressing and they forgot to put a late note in. They changed all the central lines for the facility on Mondays so if there were any that they did not get to, they just changed them as soon as possible. 10 New York Codes, Rules, and Regulations 415.12

Based on observations, record review, and interviews, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion for one of two residents (Resident #18) reviewed. Specifically, Resident #18's right-hand palm guard (used to prevent contractures and protect the skin) was not applied as ordered.Findings include: The facility policy Adaptive Devices revised 02/2025, documented a physical or occupational therapy screen was completed to assess the resident's range of motion status. If a resident had decreased range of motion or contractures, interventions would be recommended which were specific and appropriate for the resident's needs. The residents would have a plan of care developed to address the adaptive devices as per physician's recommendation and adaptive devices would be documented on the certified nurse aide care card.Resident #18 had diagnoses including stroke and arthritis. The 02/26/2026 Minimum Data Set assessment documented the resident had severe cognitive impairment, did not reject care, had upper and lower extremity impairment on one side, was dependent on staff for all activities of daily living, and did not receive physical or occupational therapy.The 02/29/2026 comprehensive care plan documented the resident had contractures (restricted movement) to the right hand and arm. Interventions included position resident every 2 hours as needed, positioning devices, and monitor for changes.The comprehensive care plan updated 05/21/2026, documented the resident had impaired activities of daily living performance related to decreased muscle strength, cognitive impairment, and restricted movement and stiffness. The resident was dependent on all activities of daily living. Interventions included right palm guard to be worn at all times except for skin checks and hygiene each shift.The 02/20/2026 Occupational Therapist #24 evaluation and treatment plan documented the resident had a history of a right upper extremity contracture from a stroke and was able to tolerate a palm guard that was already in place so there was no need for skilled services at that time.The 02/23/2026 physician order documented right palm guard to be worn at all times except for skin checks and hygiene each shift. There was no documented evidence the physician order for the right palm guard was included on the 06/2026 treatment administration record. Resident #18 was observed with their right wrist bent downward, and fingers bent making a loose fist and was not wearing a right palm guard on 06/08/2026 at 12:42, PM, 06/09/2026 at 1:42 PM, 06/10/2026 at 12:47 PM, 06/11/2026 at 10:06 AM and 1:46 PM, and 06/12/2026 at 9:58 AM.During an interview on 06/12/2026 at 9:47 AM, Certified Nurse Aide #26 stated Resident #18 had difficulty sitting up straight and their right arm and hand were contracted from a stroke. The resident used to have a right-hand palm guard, but they stopped using it a while ago. They were unsure why the palm guard was still on the resident's care plan because it was not used anymore.During an interview on 06/12/2026 at 10:06 AM, Licensed Practical Nurse #27 stated Resident #18 had decreased range of motion on their right side and a right-hand contracture. They were recently made aware that the resident was supposed to wear a right palm guard at all times, but the order was put in wrong, so it did not show up on the treatment administration record. If it was on the treatment administration record, they would know the resident was supposed to have one because they would have to sign it was in place. The certified nurse aides usually took the palm guards off and put them on during care. They were unsure how long it had been since the resident wore the right-hand palm guard and they did not see a palm guard when the resident transferred to the unit a few months ago.During an interview on 06/12/2026 at 10:09 AM, Registered Nurse Unit Manager #28 stated Resident #18 had a contracture to their right hand and arm. They were unsure why the resident did not have their palm guard in place. It was the certified nurse aides' and nurses' responsibility to ensure the palm guard was applied as ordered. They thought the order was overlooked because it was not on the treatment administration record for the nurses to sign off on. During an interview on 06/12/2026 at 10:54 AM, Occupational Therapist #24 stated they completed an evaluation on Resident #18 upon admission. The resident had a right arm contracture and was using a right palm guard. They put in the order for the palm guard to be worn at all times except for hygiene and skin checks and it was nursing's responsibility to ensure it was being used as ordered to prevent the contracture from worsening. They were not made aware the resident was not wearing the palm guard. They expected staff to notify them if the palm guard was not used or went missing so they could order a new one. 10 New York Codes, Rules and Regulations 415.12(e)(2)

Based on observations, record review, and interviews, the facility failed to ensure each resident received adequate supervision and the environment remained as free of accident hazards as possible for one of 10 residents (Resident #155) reviewed. Specifically, Resident #155 had a history of multiple falls including one fall with major injury, and they did not have fall mats in place as care planned. Findings include:The facility policy Falls Reporting, Investigating, and Implementing Corrective Action, revised 12/2025, documented fall interventions were documented on the resident's care plan, and resident specific interventions were placed on the certified nurse aide care card. After a fall nursing staff implemented additional or different fall interventions with each fall as per the residents' individual needs. Resident #155 had diagnoses including repeated falls, multiple fractures, and traumatic brain injury. The 05/27/2026 Minimum Data Set assessment (a health status assessment tool) documented the resident had moderate cognitive impairment, required supervision with transfers and ambulation, and had not had any falls since admission/ reentry or prior assessment. The comprehensive care plan initiated 04/15/2026 documented the resident had falls. Interventions included areas of high visibility were encouraged when awake, non-skid socks, and two fall mats. Accident Incident Reports for Resident #155 documented:-On 04/15/2026 found sitting upright against their bed on the floor.-On 04/16/2026 two unwitnessed falls: one on the floor in front of the bathroom and one on the floor in the hallway.-On 04/17/2026 an unwitnessed fall resulting in finger fractures.-On 04/18/2026 found on the floor on the door side of the bed.-On 04/25/2026 found on the floor at the bedside.-On 05/28/2026 found on the floor by the bathroom door. The 06/02/2026 Registered Nurse Unit Manager #30 fall risk assessment documented the resident had a history of multiple falls and was at high risk for falls. Resident #155 was observed at the following times:-On 06/08/2026 at 10:46 AM, sleeping in bed. Their bed was approximately three feet off the floor; there was one fall mat on the floor on the door side of the bed.-On 06/09/2026 at 9:42 AM, lying in bed with their legs hanging off the bed to the left side. There was one fall mat on the floor on the door side of the room. At 3:17 PM, seated on the side of the bed attempting to get up and there was one fall mat on the door side of the room.-On 06/10/2026 at 9:43 AM and 11:36 AM, lying in bed with no fall mats in place. There was one fall mat folded under the television.-On 06/11/2026 at 4:50 PM lying in bed. There were no fall mats on the floor. One fall mat was folded next to the bed by the head of the bed. The call bell was wrapped behind the headboard and was not within the resident's reach. During an interview on 06/12/2026 at 8:58 AM, Certified Nurse Aide #35 stated fall interventions were in the care plan at the top of the computer screen where they documented care. Resident #155 had one fall mat and slipper socks. Their bed should be in low position for their safety. During an interview on 06/12/2026 at 9:17 AM, Licensed Practical Nurse #56 stated fall interventions were in the care plan and the care plan was reviewed after every fall. The certified nurse aides saw the interventions in the care card and the expectation was the interventions were followed. Resident #155 used to be a fall risk but did not have any recent falls. They were not sure what their interventions were. During an interview on 06/12/2026 at 9:34 AM, Registered Nurse Unit Manager #30 stated fall mats should be implemented if they were an intervention to prevent injury. Resident #155 was a fall risk, had at least a couple falls in the facility, one with finger fractures. They completed the resident's care plan, and the resident had two fall mats for interventions. The certified nurse aides knew to put the fall mats down when they put the resident in bed. Their bed should be lowered if it was not in low position. 10 New York Codes, Rules, and Regulations 415.12(h)(2)

Based on observations, record review, and interviews, the facility failed to ensure residents maintained acceptable parameters of nutritional status for one of six residents (Resident #194) reviewed. Specifically, Resident #194 had a low body mass index (a calculated measure of weight relative to height) and was not assisted with meals and did not receive their nutritional supplements and other food items as care planned. Findings include:The facility policy Food Service Tray Accuracy Policy, revised 09/2025, documented the dietary department would ensure that each resident received the correct meal, diet, portion size, and nourishments as ordered by the care team and physician. Staff would verify resident name, room number, diet order, and meal selections before tray delivery and meal trays would be checked for accuracy prior to leaving the kitchen.The facility policy Activities of Daily Living, revised/reviewed 06/2025, documented activities of daily living would be completed daily for the resident with the assistance of staff as needed. Activities of daily living included nutritional needs inclusive of ensuring completion and feeding assistance.Resident #194 had diagnoses of dementia, cachexia (severe wasting characterized by unintentional and extreme weight loss), and underweight. The 05/04/2026 Minimum Data Set assessment documented the resident had severely impaired cognition, required supervision or touching assistance with meals, was 62 inches, there was no documented weight, and received a mechanically altered diet.The comprehensive care plan documented the following: -08/4/2024 revised 05/05/2026, the resident required supervision/ touching assistance at meals. Interventions included to provide finger foods, encourage the resident to feed self, encourage fluids, set-up/ open containers, and cut food.-05/14/2026 the resident was on comfort care, required supervision at meals, and their diet remained heavily supplemented to promote weight maintenance/ weight gain. They received 240 milliliters of Ensure Plus (oral nutrition supplement) 3 times daily, no new weights were obtained per comfort care policy, and the most recent body mass index (BMI) was 11 (severely underweight) and they were 48% of their ideal body weight. The current nutrition plan of care would continue, and changes/ adjustments would be made as needed.The care card (care instructions) documented the resident required supervision or touching assistance at meals. Interventions included provide finger foods, mechanical soft diet with thin liquids.Physician orders documented:-05/10/2022, Do not resuscitate, do not hospitalized , do not intubate, no feeding tube, and comfort care-05/13/2022, 240 milliliters of Ensure Plus three times daily-05/31/2023, mechanical soft (ground) diet with thin liquids.The residents' weight record documented:-12/01/2025 64.4 pounds-03/01/2026 60.6 pounds-06/01/2026 61 poundsThe 04/21/2026 Nurse Practitioner #37 progress note documented the resident's current weight was 60.6 pounds, and their body mass index was 11 (severely underweight). Their assessment and plan documented the resident had stable/chronic protein calorie malnutrition as evidence by history and muscle wasting on physical exam. The resident had chronic/stable cachexia and interventions included to encourage at least 75% of meal consumption and encourage Ensure Plus three times daily.The 05/14/2026 Registered Dietitian #75 Nutrition Assessment documented the resident was on a mechanical soft, thin liquid diet, required supervision at meals, received 240 milliliters Ensure Plus between meals, and their meal intakes averaged 26-50%. The resident was on comfort care and their most recent weight was 60.6 pounds, their body mass index was 11 and they were 48% of their ideal body weight (severely underweight). Their diet provided 1800-2000 calories and 71 grams of protein, which was adequate to meet their nutritional needs. They would continue with the current plan of care.The following observations were made of Resident #194:-on 06/08/2026 at 1:26 PM, seated at a table in the dining room. They appeared thin in appearance, and their cheeks bones were prominent. Their meal ticket documented ground chicken with mushroom sauce, one peanut butter and jelly sandwich, egg noodles, pudding, one Magic Cup, hot chocolate, chocolate milk, cranberry juice, and water. The resident did not have a Magic Cup, and staff did not encourage or assist the resident with their meal. They ate 0-25% of the food and 25-50% of their beverages.-on 06/09/2026 at 1:10 PM, seated at table in the dining room. Their meal ticket documented polish sausage, pork gravy, one peanut butter and jelly sandwich, whipped potatoes, pudding, one Magic Cup, hot chocolate, chocolate milk, cranberry juice, and water. The meal tray did not include the peanut butter and jelly sandwich or pudding. At 1:24 PM, the resident consumed 0-25% of the food and 25-50% of their beverages. They did not receive encouragement or assistance with their meal.-on 06/10/2026 at 12:40 PM, seated at table in the dining room. At 12:45 PM, Certified Nurse Aide #76 provided the resident with their meal tray. Their meal ticket documented ground turkey meatloaf, turkey gravy, one peanut butter and jelly sandwich, whipped potatoes, pudding, one Magic Cup, hot chocolate, chocolate milk, cranberry juice, and water. At 12:54 PM, the resident was eating their Magic Cup with their fork and was taking small forkful bites of food. At 1:36 PM, the resident pushed their meal tray away. They consumed 75% of their peanut butter and jelly sandwich, 25% of the turkey meatloaf, 50% of their magic cup and 25-50% of their beverages. The resident did not receive any encouragement or assistance with their meal.-on 06/11/2026 at 8:08 AM, seated at table in the dining room. Certified Nurse Aide #77 provided the resident their meal tray and was cutting up/opening food items. The resident's meal ticket documented fortified hot cereal, one peanut butter and jelly sandwich, two pancakes, one margarine, one syrup, ground sausage, pork gravy, one banana, pudding, hot chocolate, chocolate milk, orange juice, water, and one tablespoon of brown sugar. The tray did not include the peanut butter and jelly sandwich. At 8:22 AM, the resident ate 100% of their banana and 0-25% of the remaining food and beverages, they were pushing their food around with their fork and taking very small bites of food. At 8:48 AM, the resident continued to push food around their plate and received no encouragement or assistance during the meal. At 8:50 AM, Certified Nurse Aide #77 asked the resident if they were done with their meal and removed the tray.During an interview on 06/11/2026 at 8:34 AM, Dietary Aide #49 stated the cold items were put on the tray in the kitchen and included pudding, sandwiches, and Magic Cups. Hot food items were placed on the meal trays on the unit. A nursing staff member called out the items needed, and nursing checked the tray for accuracy prior to serving the resident their meal. If something was missing, they should call the kitchen and request the missing food items. They were unaware there were any missing items during the breakfast meal.During an interview on 06/11/2026 at 9:00 AM, Certified Nurse Aide #78 stated the meal trays came up to the unit with the cold items on the trays. They called out to the dietary aide what hot food items were needed and checked the meal ticket and tray for accuracy. The nursing staff who passed the tray to the resident was supposed to double check the meal for accuracy. They were aware the resident was missing their sandwich at breakfast but did not tell anyone. If there were missing items they should call the kitchen. During an interview on 06/11/2026 at 9:10 AM, Certified Nurse Aide #77 stated they checked the resident's meal tickets and trays for accuracy prior to serving the residents. They stated Resident #194 did not eat much and did not receive any cues or assistance with meals. Nursing staff was supposed to circulate throughout the dining room and encourage/ assist residents if they were not eating. Resident #194 responded positively at times to encouragement.During an interview on 06/11/2026 at 12:02 PM, Certified Nurse Aide #79 stated Resident #194 did need encouragement at meals, liked their peanut butter and jelly sandwiches, and did not eat a lot. If a resident did not receive their sandwiches staff could make one with the supplies they had the on the unit.During an interview on 06/11/2026 at 12:10PM, Licensed Practical Nurse #52 stated the Licensed Practical Nurses and Nurse Managers supervised the dining room and provided encouragement and assistance as needed. The assigned certified nurse aides were to ensure the residents received their planned assistance at meals. During an interview on 06/11/2026 at 1:36 PM, Food Service Supervisor #16 stated the kitchen staff were supposed to read the meal tickets and put all the items on the tray. If there were missing items, they should let the supervisor know so the items could be put on the tray. During an interview on 06/12/2026 at 9:40 AM, Occupational Therapist stated Resident #194 required supervision/ touching assistance at meals and finger foods. Finger foods were easy for the resident to eat. During an interview on 06/12/2026 at 11:35 AM, Registered Nurse Unit Manager stated Certified Nurse Aide #78 was typically assigned to check trays and call out the hot items to the server and the staff member who passed the resident their meal should also check the tray. Resident #194 was a picky eater and did better with handheld items and typically ate most of their Magic Cup. Staff should encourage any resident who was not eating well at meals.During an interview on 06/12/2025 at 2:25 PM, Registered Diet Technician #42 stated the nutritional supplements, including Magic Cups were recommended by the registered dietitian or diet technicians to provide additional calories and protein. Resident #194 had dementia, did not eat well, had a low body mass index, and did better with finger foods. The resident had variable intakes and needed their Magic Cup and sandwiches for additional calories and protein. 10 New York Codes, Rules and Regulations 415.12(i)1

Based on observations, record review, and interviews, the facility failed to ensure a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one of two residents (Resident #318) reviewed. Specifically, Resident #318 had a tracheostomy (a surgical opening in the neck to allow breathing) and was not provided with consistent oral care per professional standards. Findings include: The facility policy Tracheostomy Care on Disposable Inner Cannula Trachs, revised 10/2025, documented residents received tracheostomy care twice daily and as needed. The policy did not include the provision of oral care for residents with tracheostomies. Resident #318 had diagnoses including tracheostomy status, difficulty swallowing, and yeast infection of the mouth. The 05/30/2026 Minimum Data Set assessment (a health status assessment tool) documented the resident had severely impaired cognition, was dependent on oral hygiene, and did not refuse care. The 05/28/2026 hospital discharge summary documented discharge instructions of strictly nothing by mouth except for occasional scant ice-chips following direct assistance for stringent oral care when awake/ alert. The comprehensive care plan initiated 05/28/2026 did not document provision of oral care. The 05/28/2026 physician orders documented mouth care by respiratory therapy at bedtime and mouth care every shift. The 06/03/2026 Registered Nurse #32 admission assessment under teeth/ oral documented the resident had their own teeth. There was no documented evidence of an assessment of the oral cavity. The May 2026 and June 2025 Treatment Administration records documented the resident received mouth care every shift at 4:30 AM, 12:30 PM, and 8:30 PM. There was no documented evidence the resident received mouth care by respiratory therapy at bedtime. Resident #318 was observed at the following times lying in bed with their mouth open:-On 06/08/2026 at 11:19 AM, there was a light green dried build up on their tongue.-On 06/09/2026 at 9:51AM, their lips had a dry crust, and their tongue had dried green build up. -On 06/10/2026 their tongue had dried green build up.-On 06/11/2026 from 11:37-11:56 AM, Licensed Practical Nurse #33 hung the resident's tube feeding. The resident had buildup on their teeth, and green dried build up on their tongue and the roof of their mouth. The nurse did not provide oral care, but it was signed for the 12:30 PM time frame. During an interview on 06/08/2026 at 11:19 AM, the resident's family member stated they wondered if the buildup on the resident's tongue was addressed. They told Licensed Practical Nurse #33 about it on 06/06/2026. During a follow up interview on 06/11/2026 at 11:57 AM, the resident's family member stated the resident's mouth was disgusting. There was buildup on the roof of their mouth, their teeth and tongue that looked hard and they were sure it was uncomfortable for the resident. They stated they performed mouth care with an oral swab, but they did not want to work too hard at it because they were afraid they would dislodge a chunk, and it would go down the resident's throat and they could choke. The resident had a fungal infection in the mouth in the hospital, but it did not look this bad, and it had cleared before their admission to the facility. On 06/10/2026 they told and showed a respiratory therapist and Registered Nurse Unit Manager #30 about the resident's mouth but was not sure what was being done about it. During an interview on 06/12/2026 at 9:01 AM, Certified Nurse Aide #35 stated Resident #318 had a tracheostomy, so oral care was completed by nursing and respiratory therapy. They had noticed thick gunky build up in their mouth on 06/10/2026 and told a respiratory therapist but they were not sure who. During an interview on 06/12/2026 at 9:11 AM, Respiratory Therapist #31 stated oral care on a resident with a tracheostomy was a shared effort between nursing and respiratory. They were not sure how often oral care was provided by nursing, but they provided care once a shift. Resident #318 had buildup on their tongue and some on their teeth. The resident's family brought it to their attention yesterday and they attempted oral care but told them it would take some time to get the buildup off. They did not notice the buildup prior to the family bringing it to their attention. Resident #318's mouth was open, so it got very dry and oral care provided moisture and prevented infection. During a telephone interview on 06/12/2026 at 10:12 AM, Licensed Practical Nurse #33 stated both respiratory therapy and nursing could perform oral care on a resident with a tracheostomy. Nursing completed oral care in the morning, and respiratory therapy did it at bedtime. They tried to perform oral care on a couple of tracheostomy residents every day, but it varied. They were not sure if it should be done at any particular time, but it was done two or three times a day by nursing or respiratory therapy and documented in the Treatment Administration Record. The family verbalized Resident #318 looked like they could use oral care, so they tried with the toothette (a small sponge on a stick used as a toothbrush) but the resident had dried on build up that was stubborn and not coming off. They told Registered Nurse Unit Manager #30 to look at it. During an interview on 06/12/2026 at 10:22 AM, Licensed Practical Nurse #34 stated during the day, oral care was completed by the respiratory therapist and overnight the nurse's provided oral care. They were not responsible for oral care. During an interview on 06/12/2026 at 10:30 AM, Registered Nurse Unit Manager #30 stated respiratory therapy did oral care during the days and during the evening and night it was done by nursing. Oral care was scheduled twice a day and should also be completed as needed. They completed oral care on Resident #318 yesterday because the family had concerns. There was a thick yellow coating on the resident's tongue, and the teeth had buildup. They did not visualize the roof of the mouth. Infrequent mouth care caused build up. The point was to keep the mouth moist to prevent infection and thrush. 10 New York Codes, Rules, and Regulations 415.12(k)(6)

Based on observations, record review, and interviews (IQIES intake 482787), the facility failed to ensure accommodation of resident food preferences for one of one resident (Resident #9) reviewed. Specifically, Resident #9's meal trays were missing preferred food items and included foods they requested not to receive.Findings include: The facility policy Food Service Tray Accuracy, revised 9/2025, documented the Dietary Department will ensure that each resident receives the correct meal, diet, portion size, and nourishments as ordered by the physician and care team to promote safety, satisfaction, and compliance with physician ordered diets while ensuring quality meal service. Special diets, allergies, food preferences, and texture modifications shall be prepared and served as ordered. Meal trays would be checked for accuracy prior to leaving the kitchen and when errors were identified it should be corrected immediately.Resident #9 had diagnoses including anxiety and diabetes. The 3/24/2026 Minimum Data Set assessment documented the resident had intact cognition, required set up assistance with eating, and was on a therapeutic diet.The comprehensive care plan initiated 3/17/2025, documented Resident #9 had a nutritional deficit related to cellulitis, anemia, diabetes mellitus, anxiety, and chronic kidney disease. Interventions included maintaining weight, following prescribed diet, providing food preferences and a sandwich with lunch and dinner.The 01/16/2026 physician order documented no added salt, no concentrated sweets, regular consistency diet. During an observation and interview on 06/08/2026 at 1:08 PM, a certified nurse aide brought the lunch tray to Resident #9 room. The lunch meal ticket documented no gravy. The meal tray was missing margarine, tossed salad, and a grilled cheese sandwich. The pork chop had gravy on it. The resident stated they specifically asked for no gravy, yet they get it all the time. They stated they were missing margarine for their noodles, therefore they were unable to eat the noodles. They wanted their salad for the fiber as it made them feel full and without the sandwich, they felt hungry all afternoon. The 06/09/2026 Registered Dietitian #43 progress note documented the resident had a significant weight loss of 45 pounds, but the last available weight was in February 2026 as the resident refused weight measurements. Average meal intakes were 70 % and the resident frequently refused meals when preferences were not met. The resident regularly contacted the nutrition office regarding food related concerns and preferences, requiring ongoing attention to promote meal acceptance and satisfaction. The resident received many extras items in their meal plan to support skin integrity and wound healing; supplements included two eggs, yogurt at breakfast, sandwich at lunch and dinner in addition to entree and sandwich at night for their snack. During an observation and interview on 06/09/2026 at 8:16 AM, Resident #9 stated they did not get their grilled cheese sandwich for dinner on 06/08/2026 and got upset. They told staff the sandwich was missing. They sent their tray back without eating anything, was not brought a new tray with the ordered items or offered their grilled cheese sandwich. They stated they were hungry all night. During an observation and interview on 06/09/2026 at 8:20 AM, Certified Nurse Aide #19 brought Resident #9's breakfast tray to their room. The tray was missing toast and was used as a test tray. Certified Nurse Aide #19 ordered a replacement tray, and the replacement tray was also missing toast. The resident stated they were upset the toast was missing because they wanted the toast. During an observation and interview on 06/09/2026 at 12:45 PM, a lunch tray was brought to Resident #9. The resident stated they never received their toast for breakfast even after asking for it. Their lunch ticket documented no gravy and the mashed potatoes had gravy on them. The tossed salad was missing, and the sandwich was missing the mustard and mayonnaise. The resident stated they could not eat the sandwich without the mustard and mayonnaise. During an observation and interview on 06/10/2026 at 8:19 AM, Certified Nurse Aide # 44 brought Resident #9's breakfast tray to their room. The meal ticket documented wheat toast, and the resident received white toast and the diet jelly one each (no grape) was missing along with coffee x 2. Certified Nurse Aide #44 was not sure why the coffee or jelly was missing and stated they would get them. They returned to the room with 2 coffees and left the room for the diet jelly. During an observation and interview on 06/10/2026 at 12:40 PM, Certified Nurse Aide #45 brought Resident #9's lunch tray to their room. The meal ticket documented Italian dressing, and the meal tray had ranch dressing and no Italian dressing. The resident stated they did not like ranch dressing. During an interview on 06/11/2026 at 8:34 AM, Food Service Worker #49 stated the tray line in the main kitchen put condiments, sandwiches, and cold items on the tray and the trays were sent to the units in carts. The server on the unit placed the hot items on the tray and an assigned certified nurse aide completed the final check for meal accuracy before the tray was served to the resident. When items were missing from a resident tray, staff should call the kitchen for the items. During an interview on 06/11/2026 at 11:33 AM, Certified Nurse Aide #7 stated residents complained items documented on their meal ticket were often missing. Kitchen staff were responsible for making sure the tray contained all items listed on the meal ticket. The certified nurse aides completed the second check for accuracy before they delivered the tray to the resident. There were many times when the kitchen ran out of food, they called the main kitchen, and food eventually arrived. There were also times when certain items were not on trays and staff called the main kitchen and they were out of the item and other times they would send the item up when available. During an interview on 06/12/2026 at 8:32 AM, Dietary Aide #50 stated they were responsible for matching the food items to the meal tickets. Sometimes items were not available and were not put on the resident tray. Sometimes they ran out of food and called the main kitchen. When it was available, the main kitchen sent it up but other times it was not available. They were not sure why Resident #9 was missing their salad, coffee, diet jelly, mayonnaise, mustard, or sandwich but should get all items listed on their meal tickets. They were not sure why the resident had gravy on their food when the meal ticket documented NO GRAVY, but they must have missed it when they were reading the meal ticket even though it was documented in all capital letters. During an interview on 06/12/2026 at 9:42 AM, Licensed Practical Nurse #5 stated the puller (assigned certified nurse aide) gives the tray to the kitchen staff from the cooler cart with condiments and other items already on the tray. The kitchen staff completes the preparation of the meal tray, and the puller verified tray accuracy before they brought the tray to the resident. Residents complained about missing items and the kitchen was notified to give additional items to the resident. Resident #9 reported missing items frequently and staff called the kitchen to get the items. During an interview on 06/12/2026 at 10:34 AM, Registered Nurse Unit Manager #4 stated residents often complained about food items missing from their trays. Resident #9 has a sandwich on their meal ticket for lunch and dinner and when it is missing staff will call the kitchen for one. They were not sure why the sandwich was not on the tray. Sometimes items listed on the meal ticket were not available and residents were offered substitutions. 10 New York Codes Rules Regulations 415.14(d)(3)(4)

48446 Based on observations, record review, and interviews during the recertification and abbreviated (NY00355972, NY00357410, NY00358321, and NY00367882) surveys conducted 2/19/2025-2/25/2025, the facility did not ensure a safe, clean, comfortable, and homelike environment for 3 of 8 resident units (Units 2 A, 3 A, and 4 A) reviewed. Specifically, Unit 2 A had a strong smell of urine, unclean bedrooms floors, a bathroom with brown splatter on the toilet, and an over bed table with food debris; Unit 3 A's dining room floor was unclean and sticky, there was debris on the base of the food carts, and brown material on a raised toilet seat in a resident room; and Unit 4 A had a continuously running sink in a resident room, unclean floors in multiple resident rooms, and food splatter on the floors and walls. Findings include: The facility policy, Resident Room Cleaning, revised 3/2020, documented resident rooms were cleaned daily to ensure optimal levels of cleanliness and sanitation, prohibit the spread of infection and bacteria, and maintain the outward appearance of the facility. Wastebaskets were cleaned and sanitized daily, surfaces were cleaned and dusted including over the bed tables, floormats, doors, walls, and floors were cleaned with a dust mop and damp mop. The facility's Strip and Wax binder documented the following room floors were stripped and waxed: - in August 2024 Rooms 341, 343, 347, 360, 361, 365, 366 and 367. - September 2024 Rooms 300, 301, 303, 304, 306, 307, 308, 309, 310, 311, 312, 314, 332, 340, 341, 350, 356, 357, 358, 353, and 441. - in October 2024 Rooms 262, 263, 320, 321, 322, 323, 324, 325, 327, 326, 329, 331, 347, 501, 503, 505, 506, 507, 510, 511, 512, 515, 520, 521, 522, 523, 524, 525, 526, 527, 528, 529, 530, 531, and 532. - in November 2024 Rooms 244, 242, 243, 245, 251, 252, 255, 256, 257, 258, 259, 261, 264, 265, 266, 267, 422, and 429. - in December 2024 Rooms 504, 514, 526, and 533. - in January 2025 rooms [ROOM NUMBER]. There was no documented evidence that floor areas other than resident rooms were stripped or waxed on the 2nd, 3rd, 4th, or 5th floor. The following observations were made on Unit 2 A: - on 2/19/2025 at 1:19 PM room [ROOM NUMBER] had old, dried food splatter and debris on the floor, concentrated to the left side of bed where the floor mat was and at the foot of bed. The bed side table base had dried splatter. The bathroom floor had debris on the floor, the toilet had brown splatter, and on the left handle of toilet frame there was dried brown debris. - on 2/19/2025 at 1:34 PM, room [ROOM NUMBER] had scattered food debris all over the floor. - on 2/19/2025 at 2:46 PM, room [ROOM NUMBER] had food debris on the side of the bed towards the door, the bathroom had dried debris on floors and walls, 1 cotton swab was on the floor, and the toilet had brown splatter on it. - on 2/19/2025 at 2:50 PM, room [ROOM NUMBER] had dried debris on the floor mat and liquid on the floor to the right side of the bed. The over the bed table was covered with dry splatter. - on 2/20/2025 at 10:10 AM, there was a strong smell of urine that permeated the entire unit. - on 2/20/2025 at 2:26 PM, room [ROOM NUMBER] had debris on the floor, the over the bed table had a large amount dried splatter on the top and the frame, and there was dust and debris in the corners of the room. - on 2/24/2025 at 12:43 PM, room [ROOM NUMBER] had 4 straws and 2 cartons of an oral nutrition supplement under the bed, and a large amount of debris covering the floor. - on 2/25/2025 at 8:51 AM, room [ROOM NUMBER] had 4 straws, 2 cartons of an oral nutrition supplement under the bed, and other debris on the floor. room [ROOM NUMBER] had a large amount food debris on the floors in both the bedroom and bathroom. room [ROOM NUMBER] A had food debris and splatter on the floor, on the floor mat, and the over the bed table. - on 2/25/2025 at 9:01 AM, room [ROOM NUMBER]'s over the bed table was covered with splatter and the floors in the room and bathroom were unclean. -Oo 2/25/2025 at 8:56 AM, room [ROOM NUMBER] A's floor had debris, and the bathroom had brown splatter on the floor and walls. The following observations were made on Unit 3A: - on 2/19/2025 at 11:59 AM, 3 food carts holding meals trays located outside room [ROOM NUMBER] had dried debris on the base of the carts. - on 2/19/2025 at 1:09 PM, the floor in the dining room was sticky and unclean. - on 2/24/2025 at 12:20 PM, the floor in the dining room was sticky and covered with several differed sized dry spots some as large as a grapefruit. During an interview and observation on 2/24/2025 at 12:31 PM, the resident in room [ROOM NUMBER]'s family member stated they were in at least weekly to visit, and the facility was unclean each time. On multiple visits there was stool on the toilet and the bathroom floor. Last week the bathroom was so dirty they told the nurse. When they opened the bathroom door, they it appeared it had not been cleaned from the previous week. There was dried brown debris covering the entire back of the raised toilet seat and the floor around the toilet had black dried debris on it. The resident in room [ROOM NUMBER] said their room was never cleaned and they thought the room was not homelike. The daily cleaning logs for Unit 3A documented feces was noted in room [ROOM NUMBER] on 2/14/2025 and one other undetermined date in 2/2025. During an observation on 2/25/2025 at 11:29 AM, the first floor entry to the A side building had a foul smell. Corporate Registered Dietitian Consultant #8 stated they believed the odor was coming from the rubbish chute in the area. The following observations were made on Unit 4 A: - on 2/19/2025 at 12:15 PM, the sink in room [ROOM NUMBER] B was continuously running. - on 2/19/2025 at 1:24 PM, there was food and crumbs on the floor in room [ROOM NUMBER] with red splatter under the television. - on 2/18/2025 at 1:59 PM, room [ROOM NUMBER] had spilled dried red liquid covering two floor tiles and brown stains under the over the bed table between the bed and the wall. - on 2/19/2025 at 2:33 PM, room [ROOM NUMBER]'s floor had multiple areas covered with food and dried debris. During an interview on 2/24/2025 at 11:56 AM, [NAME] #19 stated they were responsible for cleaning hallways, stairwells, elevators, pantries, and dining areas every day. They swept and mopped the floors, sprayed doorknobs, and sanitized handrails every day. If floors were sticky, dirty, stained, or covered with debris it was not homelike. During an interview on 2/25/2025 at 8:34 AM, Certified Nurse Aide #15 stated housekeepers were responsible for cleaning resident rooms except bodily fluids, nursing staff was responsible for cleaning bodily fluids. Housekeeping was then notified and completed a deep cleaning. It was an infection control issue if bodily fluids were left on a toilet in shared bathrooms. Sticky floors, floors covered with food and debris, and over the bed tables covered in debris was not homelike. During an interview on 2/25/2025 at 8:52 AM, Registered Nurse Unit Manager #16 stated nursing was responsible for cleaning bodily fluids, then housekeeping was notified and completed a deep cleaning. Housekeeping cleaned resident rooms and bathrooms. They did not expect to see sticky floors, floors covered with debris, and tables covered with debris. It was not homelike for residents to have dirty or sticky floors, brown debris on toilet seats, or debris on surfaces or walls. During an interview on 2/25/2025 at 9:20 AM, Housekeeper #18 stated their job duties included cleaning resident rooms every day. Room cleaning included changing and emptying trash, sweeping the floors, cleaning the bathroom, dusting all surfaces, sweeping, mopping, and sanitizing the rooms. They were not allowed to touch bodily fluids until they were cleaned by nursing. After nursing cleaned the fluids, they completed a deep cleaning. They stated if rooms had food and debris on the floors and other surfaces, brown debris on toilet seats, sticky floors, and dust it was not homelike. During an interview on 2/25/2025 at 11:37 AM, Assistant Director of Housekeeping #20 stated they were responsible for making sure units and resident bedrooms and bathrooms were clean. Porters were responsible for floor care in offices, dining rooms, hallways, and completed the floor stripping and buffing of their designated areas every three months. Resident rooms were completed as requested and documented in the waxing and buffing logs in a binder. Housekeepers were responsible for cleaning resident rooms and bathrooms. Housekeepers disinfected bathrooms, cleaned bed frames, windows, changed trash, swept and mop the floors, and dusted all surfaces including walls and over the bed tables. Daily room cleaning was documented in a log. They stated nursing was responsible for cleaning bodily fluids and after the initial cleaning notified housekeeping. It was not homelike to have walls with splatter or brown debris on toilet seats, and unclean floors. 10 NYCRR 415.29(j)(1) 50561

48446 48675 50561 Based on observations and interviews during the recertification survey conducted 2/19/2025-2/25/2025, the facility did not ensure that each resident received food and drink that was palatable, attractive, and at a safe and appetizing temperature for 2 of 2 lunch meals (2/21/2025 and 2/24/2025 lunch meals) reviewed. Specifically, the 2/21/2025 and 2/24/2025 lunch meals were not served at palatable and appetizing temperatures and the 2/24/2025 lunch meal was not palatable or attractive. Additionally, 7 of 7 anonymous residents at the Resident Council meeting stated the food was not appetizing and not served at appropriate temperatures; and Residents #46, #47, and #210 stated the food was not served at appetizing temperatures. Finding included: The facility policy, Food Temperatures and Test Tray Audits, revised 4/5/2024, documented the minimum temperatures at the time of service for: - milk and milk products were less than 45 degrees Fahrenheit. - hot entrees was greater than 135 degrees Fahrenheit. - hot beverages was greater than 140 degrees Fahrenheit - cold beverages was less than 55 degrees Fahrenheit. During an interview on 2/19/25 at 12:35 PM, Resident #47 stated the milk was warm, the hot food was cold, and the food was not good. During an interview on 2/19/2025 at 1:00 PM Resident #46 stated the food was always cold and never hot. During an interview on 2/19/2025 at 1:38 PM, Resident #210 stated the food was not good, the chicken could not be cut, and if they ate in the dining room, they would get hot food but if they ate in the hallway they might not. During a resident group interview on 2/20/2025 at 10:35 AM, 7 anonymous residents stated the warm food was served cold, cold food was served warm, milk and juices were served warm, and the food was not appetizing. During a lunch meal observation on 2/21/2025 at 12:27 PM on Unit 3 A, a lunch tray was tested . The slice of fish measured at 125 degrees Fahrenheit and was bland, the baked potato was bland, the 2% milk measured at 53 degrees Fahrenheit, the apple juice measured at 58 degrees Fahrenheit, and the ginger ale measured at 53 degrees Fahrenheit. During a lunch meal observation on 2/24/2025 at 1:48 PM, Resident #210's lunch tray was tested , and a replacement was requested. The chicken had a pink center, the ends were brown, and it was difficult to cut. The cottage cheese had a ring of clear liquid surrounding it and was measured at 54.1 degrees Fahrenheit. The coffee measured at 133.9 degrees Fahrenheit, the peaches and mandarin oranges measured at 52.5 degrees Fahrenheit, and the chocolate milk measured at 53.2 degrees Fahrenheit. During a follow up interview on 2/24/2025 at 12:31 PM, Resident #47 stated the food was not good and their family member brought in food every time they visited. They lost weight because they were not eating. They did not eat the hot entree (chicken [NAME]) at lunch that day as it was not appetizing. During an interview on 2/25/2025 at 10:45 AM, Dietary Supervisor #26 stated cooked foods were checked for temperature when sent to the units where they were served from steam tables. Cold items should be 38 degrees Fahrenheit or less. Cottage cheese should not have a lot of liquid on top as that signified it was too warm and should have been discarded prior to serving. During an interview on 2/25/2025 at 11:10 AM, Dietary [NAME] #27 stated cold foods were kept below 40 degrees Fahrenheit and hot foods above 165 degrees Fahrenheit to prevent bacterial formation. Food temperatures were checked by a cook using a digital thermometer when coming out of the oven and before leaving the kitchen to go to the unit. All cooks were educated on this during orientation. The facility supplied new thermometers weekly to kitchen staff and they were calibrated prior to use. Food should not be difficult to cut as a residents could have a hard time chewing and eating the food. The cooks knew if a food item was cooked correctly when they took the temperature the food. The chicken should not be pink on the inside. If chicken was not fully cooked, bacteria could form, and a resident might get sick from it. During an interview on 2/25/2025 at 11:28 AM, the Food Service Director stated the pink in the chicken may have occurred if it was cut near the bone or vein and did not mean it was under cooked. Milk and milk products should be served at 45 degrees Fahrenheit or below for palatability reasons. Hot foods should be served at 135 degrees Fahrenheit or above. 10NYCRR 415.14(d)(1)(2)

Based on observations, record review, and interviews during the recertification survey conducted 2/19/2025-2/25/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards in the main kitchen and on1 unit (Unit 2A). Specifically, the main kitchen had multiple unclean surfaces, there were stored food items past their expiration dates, and staff did not wear hair nets. Unit 2A had a steam table with dried food, discolored water, and debris: and there was debris and 3 mouse traps behind the unit ice machine. Findings include: The facility policy, Dining and Meal Service, revised 4/5/2024, documented the dining room would be cleaned promptly after every meal. The facility policy, Dining Services Department Traffic, revised 4/5/2024, documented anyone coming into the kitchen must have a hair net on. All employees were educated to comply with the procedure and reasoning for implementation (i.e. cross contamination). Hair nets would be placed in an area within entrance to the department. The facility policy, Food Storage- Refrigerators and Freezers, revised 4/5/2024 documented all foods prepared on-site were stored for a maximum of 3 days at 41 degrees Fahrenheit or lower before it should be discarded. That day count began the day the food was prepared, or a commercial can was opened. The refrigerator interior was kept clean. Food was kept 6 inches off the floor on an enclosed shelf. The facility policy, Food Storage Dry Goods, revised 4/5/2024, documented dry foods were stored 2 inches from the wall and 6 inches off the floor. Floors, walls, ceilings, and shelving were kept clean. The facility policy, General Kitchen Cleaning, revised 4/5/2024, documented staff would maintain the sanitation of the kitchen. Tasks would be assigned to specific staff positions. The policy did not specify a cleaning schedule. The following observations were made in the main kitchen on 2/19/2025 from11:24 AM-11:56 AM: - milk was stored on the floor in crates - 3 dietary staff were not wearing hair nets. - trays of 2% milk set up for the 5th floor were warm to touch. - Dietary Aide #21 was plating fruit plates without wearing a hair net. - there was debris on the floor and a strawberry behind the 3-bay sink behind the milk cooler. - there was a [NAME] coffee cup with coffee in a milk crate. - Dietary Aide #22 was making snack sandwiches and was not wearing a hair net. - Dietary Supervisor #23 was making sandwiches and was not wearing a hair net. - there were 15 crates of milk and a box of cantaloupe on the floor of a cooler. - there was debris on the floor. - there were pre-wrapped cookies stored on the floor under a food prep table. - there were 3 uncovered sheet pans in a cooler containing pork butt and turkey roasts dated 2/19. - there was debris and build-up under the 3-bay sink. - a dry storage door was propped open about 2 inches and there were fruit flies by the dishwashing machine. The following observations were made on Unit 2 A on 2/19/2025 at 11:40 AM: - the kitchenette steam table contained discolored water with food remnants. There was dried macaroni and cheese on the steam table and one of the shelves had dried food splatter. - there was a plate rack with dried food debris on the top. - the steam table cord was cut in several different areas. - there was a loaf of moldy bread in an upper cabinet in the kitchenette. - the kitchenette cabinet drawers had dried food splatters and crumbs. - there was food debris, bottle tops, and aluminum foil behind the ice machine. - there were 3 empty mouse traps behind the ice machine. During an interview on 2/19/2025 at 12:04 PM, Dietary Aide #24 stated the steam table cord was usually not plugged in. They stated they did not know why the areas were dirty or if a work order was placed for the steam table cord. The following observation were made in the main kitchen with the Food Service Director on 2/24/2025 at 12:55 PM: - the nourishment cooler had a temperature reading of 44 degrees Fahrenheit. - there was brown debris along the interior floor edges of the dairy cooler and a cellophane wrap ball under a rack on the rear of the cooler. - another cooler contained a tub of gravy dated 2/20, a pan of green beans dated 2/21, a pan of broccoli dated 2/21, and yellow cake dated 2/19. - in the freezer, there was a pan of frozen Beefaroni dated 2/17, a pan of frozen turkey tetrazzini dated 2/1, and turkeys were being rapid cooled uncovered on bare racks. The Food Service Director stated the gravy was made on the evening of 2/20 and was good until the end of 2/24/2025. The green beans, broccoli, and cake were good for 5 days as they were already cooked. During an interview on 2/25/2025 at 10:45 AM, Dietary Supervisor #26 stated all dietary staff should clean the kitchen and prep areas. They were assigned a specific area daily. Floors and counters should be cleaned daily and after each use. Floors were cleaned twice daily and as needed. The dish area was cleaned after every meal. The refrigerators and freezers were cleaned every 3 days, and all interior items were pulled out to clean under them. All spills and debris should be cleaned immediately as soon as staff saw it. Cooks were responsible for cleaning the oven areas. The dietary supervisors performed cleanliness audits daily. All dietary staff were educated on cleaning during monthly meetings and as needed. The freezer and cooler floors should be cleaned prior to inspection. All foods should be dated when made or opened and discarded after 3 days to prevent bacterial formation. Hair nets were to be worn at all times in the kitchen and put on when entering the kitchen area to prevent hair or hair products from getting into food items. Informal audits were done by the Food Service Director and supervisors. On the spot education was done for violations. All kitchen staff were aware of this. Food should not be stored on the floors to prevent contamination. Cooked foods were checked for temperature when sent to the units where they were served from steam tables. Cold items should be 38 degrees Fahrenheit or less. Cottage cheese should not have a lot of liquid on top as that meant it was too warm at one point and have been discarded prior to serving it. During an interview on 2/25/2025 at 11:10 AM, Dietary [NAME] #27 stated cooks were assigned to clean specific areas in the cooking, freezers, and oven areas. The coolers were swept and mopped daily and as needed. Freezers were generally cleaned weekly, and spills should be cleaned when noticed. None of the areas should have debris on the floors. All food should be discarded 3 days after making them due to possible bacterial contamination. This included the yellow cake. Cooked foods that were frozen were to be discarded after a week. Gravy should be made daily, so it was fresh for the residents. The gravy and cake should have been discarded and the cook did not know why they were not. Hair nets should be always worn in the kitchen area to prevent hair or hair products from getting into the food. All dietary staff were aware of this. Food should not be stored on the floor as they could be contaminated from the dirty floor. Cold foods were to be kept below 40 degrees Fahrenheit and hot foods above 165 degrees Fahrenheit to prevent bacterial formation. Food temperatures were checked by a cook using a digital thermometer when coming out of the oven and before leaving the kitchen to go to the unit. All cooks were educated on this during orientation. Freezer and cooler temperatures were checked by a cook first thing in the morning, about mid-day, and at the end of the day. The temperatures were documented on each piece of equipment's log. The facility supplied new thermometers weekly to kitchen staff and they were calibrated prior to being put in use. During an interview on 2/25/2025 at 11:28 AM, the Food Service Director stated the kitchen coolers were mopped twice a day. The kitchen freezers were swept nightly and deep cleaned on a weekly basis. Both were also cleaned as needed. The gravy was outdated and should be discarded. Milk should be served at 45 degrees Fahrenheit or below due to palatability. The milk was kept in the kitchen cooler prior to being sent to the unit for each meal. Hot foods should be served at 135 degrees Fahrenheit or above. The food was prepared in the kitchen and sent to the units to be served from team tables. They should not have been served below that temperature. The facility performed random test trays at least monthly. All staff should always wear hair nets in the kitchen area to prevent hair or hair products from coming into contact with food products. All staff were aware of this. They stated the green beans and broccoli with the dates of 2/21 were thawing and waiting to be cooked. 10NYCRR 415.14(h) 40803 50561

Based on review of facility policies and procedures and staff interviews conducted during the standard survey, it was determined for all 299 residents, the facility failed to develop detailed emergency procedures related to the piped-in oxygen system in their emergency and disaster plan. Specifically, the facility: - failed to develop criteria for the shutdown of oxygen; - failed to designate the responsible party who would determine when the piped-in oxygen system was to be turned off; - failed to designate the responsible party to turn off the piped-in oxygen system in the event of a disaster; - failed to designate the responsible party to ensure an alternative source of oxygen was provided to the ventilator and/or oxygen dependent residents. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to the health and safety of all the facility's 299 residents. The Immediate Jeopardy situation was removed on July 1, 2011, prior to the survey exit. Findings include: A review of the Facility Disaster Plan, last revised March 2007, documented "During business hours, the Administrator, Director of Nursing, and/or Nurse Supervisor should assume responsibility at the scene of the disaster, for coordination with police and fire departments." After normal business hours, the "Nursing Supervisor is in charge at the scene until other designated personnel arrive. The Nursing Supervisor has full control of the facility and personnel until the Administrator or Designee arrives." The disaster plan did not provide specific instructions regarding situations that may warrant shutting off the piped-in oxygen; and did not clearly specify who would make that determination, prior to the city's Fire Marshal's arrival. The plan did not address the procedures for providing an alternate supply of oxygen to residents requiring it to sustain life. The facility's Oxygen Safety policy, dated September 2007, was provided to the survey team on June 29, 2011 at 12:00 PM. The policy documented respiratory therapy, RNs, and licensed practical nurses (LPN) were responsible for providing a safe environment for oxygen usage. Administration, Nursing Supervisors, and respiratory personnel were to know the location of the oxygen shut off valves. The Oxygen Safety policy did not address when the oxygen shut off valve would be turned off, nor who would determine when this would happen. The policy did not establish a plan for the administration of oxygen to those residents affected by the loss of oxygen when the shut off valve was turned off. On June 29, 2011 at 9:15 AM, a surveyor observed a plastic, protective covering over 2 valves in a wall on the the 4B Vent (ventilator) unit. The surveyor interviewed the Director of Respiratory Therapy at that time who stated 1 of the valves was for the piped-in oxygen system. The Director stated the only time the piped-in oxygen supply valve was to be turned off, was under the direction of the city's Fire Marshal. The surveyor interviewed the registered nurse (RN) Manager for the 4B and 4B Vent units on July 29, 2011 at 11:15 AM. She stated the respiratory therapist, Administrator, maintenance staff, and/or "whoever's in charge of the building" during a "massive fire" would be the individual who made the determination to turn off the piped-in oxygen supply to 4B and 4B Vent units. On June 29, 2011 at 11:30 AM, the surveyor interviewed the Director of Nursing (DON), the Director of Maintenance, and the consultant respiratory therapist. The Director of Maintenance stated he would need to shut off the oxygen as soon as possible in the event of a fire. The consultant respiratory therapist stated before the oxygen was shut off, someone had to determine the scope and severity of the fire. He stated Administration would make the determination. The DON stated whoever was in charge of the building, the Supervisor or Administrator, would determine whether to turn off the piped-in oxygen supply, in the event of a disaster. The DON stated fire trucks would arrive at the facility "instantly" and would assist in determining whether the oxygen supply was to be shut off. The surveyor interviewed the Director of Maintenance on June 29, 2011 at 1:30 PM. He stated that piped-in oxygen was supplied to all rooms on the 4B and the 4B vent unit, from an outside, bulk liquid, oxygen tank. He stated maintenance employees knew where the shut off valves on the units were located and, knew how to shut them off, if they were told to do this. The Director stated the respiratory therapist and the Unit Managers should know where the shutoff valves were located and how to use them. The Director said he was not aware whether the disaster manual addressed the operation of these shutoff valves. He stated that during a fire or other disaster, the Nursing Supervisor or the Administrator would be in charge, until the city's Fire Marshal arrived. During an interview on June 29, 2011 at 1:30 PM with the RN on 4B Vent unit, she told the surveyor she did not know anything about the piped-in oxygen system, as it was handled by respiratory therapy. The RN stated she might turn it off during a fire, "but I do not know" if it "would be my responsibility". A respiratory therapist working on the unit on June 29, 2011 at 1:40 PM told the surveyor that she would not touch the oxygen shut off valves, until she was directed to do so by the city's Fire Marshal. During a second interview with the DON, in the presence of the Administrator on June 29, 2011 at 2:40 PM, they both stated they were unaware there was no system in place regarding when to shut off the piped-in oxygen supply. In summary, the facility: - failed to develop criteria for the shutdown of oxygen; - failed to designate the responsible party who would determine when the piped-in oxygen system was to be turned off; - failed to designate the responsible party to turn off the piped-in oxygen system in the event of a disaster; - failed to designate the responsible party to ensure an alternative source of oxygen was provided to the ventilator and/or oxygen dependent residents. ********************************************************************** The Immediate Jeopardy situation was removed on July 1, 2011 based on the following corrective actions taken by the facility: - Policies and Procedures were developed and/or revised to define the steps facility staff will take in an emergency and/or a disaster that affects the facility's piped-in oxygen system. This included polices and procedures that addressed the responsible party and the procedures needed to shut down the piped-in oxygen and provide an alternative source of oxygen to all those residents on a ventilator and/or are oxygen dependent. - Staff interviews revealed an understanding of the new policies and procedures relating to emergencies and disasters, and staff responsibilities with the piped-in oxygen system. 10 NYCRR 415.26(f)(1)

Based on review of facility policies and interviews with staff during the standard survey, it was determined the facility failed to train all employees in emergency procedures regarding the shutdown of their piped-in oxygen system in the event of fire and other emergencies, having the potential to directly affect 299 residents residing in the facility at the time of survey. Specifically, the facility: - failed to provide documented evidence that all levels of staff were trained on staff response to the shutdown of the piped-in oxygen system, in the event of a fire or other disaster; - failed to train staff on detailed procedures for all potential emergencies and disasters that affect the piped-in oxygen supply; - failed to train staff, and ensure their awareness, of who would make the decision to turn off the piped-in oxygen system, and who was responsible to turn it off, in the event of an internal disaster; - failed to train and inform staff who the responsible party was to provide an alternative source of oxygen to the ventilator and oxygen dependent residents on 4B and 4B Vent unit. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to the health and safety of all the facility's residents. The facility implemented appropriate measures to remove the Immediate Jeopardy prior to the survey exit. Findings include: A review of the Facility Disaster Plan, last revised March 2007, revealed the disaster plan did not provide specific instructions or guidance to facility staff related to situations that may warrant shutting off the piped-in oxygen. The disaster plan did not specify who was trained and who would shut down the piped-in oxygen supply; and did not address and train staff on the procedures needed to provide an alternate supply of oxygen to residents requiring it to sustain life. The facility Respiratory Therapy Policy and Procedure, titled "Oxygen Safety", dated September 2007, was provided to the survey team on June 29, 2011 at 12:00 PM. The policy stated that respiratory therapy, registered nurses, and licensed practical nurses were responsible for providing a safe environment for oxygen usage. There was no documented specifications for a "safe environment for oxygen usage". Administration, nursing supervisors, and respiratory personnel were to know the location of the oxygen shut off valves. The policy did not address when the oxygen shut off valve would be turned off, who would make the decision to shut off the oxygen supply system, or how the oxygen system valve would be shut off. The policy did not provide guidance/education for the administration of oxygen to those residents affected by the loss of oxygen caused by the shut off valve being turned off. On June 29, 2011 at 9:15 AM, the surveyor observed a plastic protective covering over 2 valves in the wall on the 4B Vent unit. At this time, the surveyor interviewed the Director of Respiratory Therapy who stated 1 of the valves was for their piped-in oxygen system. She stated the "only time" the piped-in oxygen supply valve could be turned off was when the city's Fire Marshal made the determination to do so. At 11:15 AM on June 29, 2011, the surveyor interviewed the registered nurse (RN) Unit Manager for 4B and 4B Vent units. She stated the respiratory therapist, the Administrator, "Maintenance", or "whoever's in charge of the building" during a "massive fire" would be the individual who made the determination to turn off the oxygen supply to 4B and 4B Vent units. At 1:15 PM on June 29, 2011, a licensed practical nurse (LPN) who worked on 4B unit told the surveyor he did not have any training on their piped-in oxygen supply or the oxygen shut off valves. The LPN stated the oxygen shut off valves would be turned off if "Maintenance or the Administrator" gave the direction to do so. When the surveyor interviewed the Director of Maintenance on June 29, 2011 from 1:30 PM to 2 PM, he was asked multiple questions regarding his department's responsibilities of equipment on the vent unit. The Director stated the piped-in oxygen was supplied from an outside bulk liquid oxygen tank to all rooms on unit 4B and the vent unit. He said his department had no role in maintaining or calibrating any of the equipment on the vent unit. He stated his department's employees were trained on November 4, 2010 regarding how to perform and document daily visual checks of the valves and gauges on the bulk oxygen tank, located outside the facility in a fenced-in area. The Director did state there was no documentation of this training kept on file. He also said maintenance staff were provided with an emergency number to call if there were any problems. The Director of Maintenance told the surveyor that he went to each of his staff members "that day" and asked them if they each knew where the oxygen shut off valves on the units were located, and how to shut them off. He stated each staff member was able to answer his questions correctly. He stated the respiratory therapist and the nursing unit managers should know where the shutoff valves were located and how to use them. He said he was unaware of any training or "any mention" in the disaster manual regarding the operation of the oxygen shutoff valves. The Director of Maintenance stated that during a fire or other disaster, the Nursing Supervisor or the Administrator would be in charge until the city's Fire Marshal arrived. An RN who worked 4B was interviewed by a surveyor on June 29, 2011 at 1:35 PM. The RN stated she was not in-serviced regarding the facility's piped-in oxygen system or on their oxygen shut off valves. She said she did not know if the piped-in oxygen supply would be turned off. The RN said "respiratory therapy" would turn off the piped-in oxygen; however, she said she "could probably figure it out". The surveyor interviewed the respiratory therapist (RT), with the Director of Respiratory Therapy present, on June 29, 2011 at 1:40 PM. The RT stated when the ventilator unit first opened, the former Director of Respiratory Therapy trained her on the piped-in oxygen system and the oxygen shut off valves. She stated the current Director of Respiratory Therapy was going on vacation and she was recently trained "on oxygen". The RT stated she would not turn off the oxygen supply valve, unless the city's Fire Marshal directed her to do so. At this time, the Director of Respiratory Therapy stated the education she provided to the respiratory therapist was how to do preventative maintenance on the liquid oxygen system. The Director of Nursing was interviewed on June 29, 2011 at 2:40 PM, and stated the former Director of Respiratory in-serviced "everyone" regarding the location of the oxygen shut off valves and how to shut them off. She stated she could not find his (former Director of Respiratory's) signature sheets for the in-service education. In summary, the facility: - failed to provide documented evidence that all levels of staff were trained on staff response to the shutdown of the piped-in oxygen system, in the event of a fire or other disaster; - failed to train staff on detailed procedures for all potential emergencies and disasters that affect the piped-in oxygen supply; - failed to train staff, and ensure their awareness, of who would make the decision to turn off the piped-in oxygen system, and who was responsible to turn it off, in the event of an internal disaster; - failed to train and inform staff who the responsible party was to provide an alternative source of oxygen to the ventilator and oxygen dependent residents on 4B and 4B Vent unit. ********************************************************************* The Immediate Jeopardy situation was removed on July 1, 2011 based on the following corrective actions taken by the facility: - All facility staff were in-serviced on the new policies and procedures that defined the steps facility staff will take in an emergency and/or a disaster that affects the facility's piped-in oxygen system. - All staff on leave were not allowed to return to work until they received the required training. - Staff interviews revealed an understanding of the new policies and procedures relating to emergencies and disasters, and their responsibilities with the piped-in oxygen system. - The facility conducted a drill to test staff members responses to an emergency affecting the piped-in oxygen system. 10 NYCRR 415.26(f)(3)