Every finding on record at Bronx Center For Rehabilitation & Health Care

Based on observation, record review, and interviews conducted during survey, the facility failed to ensure a resident was free from physical abuse. This was evident for one out of five residents (Resident #1) sampled. Specifically, on 05/12/2026 at 2:20 PM, Licensed Practical Nurse #1 was called to Resident #1's room and the resident indicated Certified Nursing Assistant #1 hit them after they spit on them (unwitnessed). Certified Nursing Assistant #1 refused to leave the room and continued providing care, and then Resident #1 spat and kicked Certified Nursing Assistant #1 who in turn hit the resident on the right side of the face and covered their mouth with a washcloth. Resident #1 was assessed by Registered Nurse Unit Manager #1 with redness on their right cheek and complaints of pain and was transferred to the emergency room for evaluation on 05/12/2026. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy.The findings are:The facility's policy titled Abuse, dated 07/18/2025 documented the facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including but not limited to staff, family, friends and residents of the facility. The facility prohibits any exploitation of the mentally and physically disabled resident in the facility. The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected of alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property.Resident #1 was admitted to the facility with diagnoses of dementia, anxiety, and major depressive disorder.The Minimum Data Set (a resident assessment tool) dated 04/02/2026, documented Resident #1 had severely impaired cognition and required substantial/maximal assistance (Helper does more than half the effort).A review of the Comprehensive Care Plan for at risk for abuse, neglect, misappropriation, and/or exploitation dated 03/30/2026 documented interventions that included monitor resident for signs/symptoms of abuse, neglect, misappropriation, and/or exploitation and report to facility's abuse officer and medical provider. A review of the Comprehensive Care Plan for behavior symptoms dated 04/10/2026 documented Resident #1 kicks at staff and throws water and other objects at staff. The interventions included determining the cause of the behavior and maintaining resident's safety. Re-approach resident for care/toileting/medication administration/treatments and other needs when resident is more agreeable.A Documentation Survey Report (Accountability Record) dated 05/01/2026 documented that Resident #1 required extensive assistance of one staff for all activities of daily living care. Instructions also are documented for staff to approach the resident in a slow and calm manner and to re-approach resident for care.An Initial Event Documentation by Registered Nurse Supervisor #1, dated 05/12/2026 at 2:20 PM, documented resident abuse allegation report received from Licensed Practical Nurse #1. Resident #1 was assessed with redness to the right side of their face. Resident #1 reported that a black lady hit them, and to get them out of here. Resident #1 was removed from the situation and staff (Certified Nursing Assistant #1) removed from care. Resident #1 denied pain at this time during assessment and no other injury noted. The Director of Nursing, Nurse Practitioner # 1, notified, and 911 called.A Physician's Progress note dated 05/12/2026 documented that Resident #1 was seen and examined for alleged abuse. On assessment, the resident stated that the lady hit them. Resident #1 reported some pain to both sides of the face. Slight facial redness noted. No swelling or bruising. Resident #1 was transferred to the hospital for evaluation due to the nature of the reported incident and ongoing concern for possible injury.The facility's investigation dated 05/12/2026 at 2:20 PM, documented an allegation of staff-to-resident physical abuse involving Resident #1. Licensed Practical Nurse #1 was asked by [NAME] #1 to go to Resident #1's room. The investigation explained that while Certified Nursing Assistant #1 was trying to toilet Resident #1, the resident became agitated, fought and spat on Certified Nursing Assistant #1. Certified Nursing Assistant #1 then hit Resident #1 on the right side of their face and put an incontinent brief around the resident's mouth and nose. Licensed Practical Nurse #1 intervened and asked Certified Nursing Assistant #1 to leave the room while they completed Resident #1's care. Registered Nurse Supervisor #1 and Nurse Practitioner #1 were notified, and a body assessment was done. Resident #1 was observed with redness to their right cheek and was transferred to the hospital for evaluation. 911 was called and responded. The Director of Nursing and the Administrator were notified (time not mentioned). The facility's investigation of the incident concluded there was reasonable cause to believe resident abuse had occurred and Certified Nursing Assistant #1 was suspended pending outcome of the investigation.A review of the hospital discharge record dated 05/12/2026, revealed that a computed tomography scan of Resident #1's head was done. The results revealed no acute intracranial hemorrhage and no acute fracture or dislocation.A Psychology Progress note dated 05/14/2026 at 1:24 PM, documented Resident #1 was seen for allegations of abuse. Resident #1 reported that a staff member hit them on both sides of their face. Resident #1 denied distress and denied fearfulness.During an interview on 05/18/2026 at 10:16 AM, Resident #1 stated that they spit on the lady because they were too rough during care. Resident #1 stated the lady hit them on the right side of the face.During an interview on 05/18/2026 at 1:04 PM, Certified Nursing Assistant #1 stated that on 05/12/2026 at 2:20 PM, they went into Resident #1's room to provide incontinence care and that Resident #1 was calm. Certified Nursing Assistant #1 stated they turned Resident #1 onto their side to wash their back, and the resident began to kick and spit on them. Certified Nursing Assistant #1 stated they put the wet washcloth over Resident #1's mouth and told them to stop spitting. Certified Nursing Assistant #1 stated they did not hit Resident #1. Certified Nursing Assistant #1 stated that this was not the first time they were assigned to Resident #1.Certified Nursing Assistant #1 provided a statement to the facility on [DATE] stating that they gently tapped Resident #1 on their lips and put an incontinent brief in front of Resident #1's mouth.During an interview on 05/18/2026 at 11:00 AM, Licensed Practical Nurse #1 stated they exited the elevator with Nurse Practitioner #1 when [NAME] #1 informed them to go to Resident #1's room. Licensed Practical Nurse #1 stated they arrived at Resident#1's room with Nurse Practitioner #1 when they observed Certified Nursing Assistant #1 providing incontinence care to Resident #1. Licensed Practical Nurse #1 stated they asked what happened and Resident #1 reported that Certified Nursing Assistant #1 was rough during (incontinence) care, and they spat on Certified Nursing Assistant #1 who in turn hit them in the face. Licensed Practical Nurse #1 stated they instructed Certified Nursing Assistant #1 to stop providing care to Resident #1 and to leave the room. However, Certified Nursing Assistant #1 refused to leave Resident #1's room and attempted to continue washing the resident. Licensed Practical Nurse #1 stated they witnessed Resident #1 kick and spit on Certified Nursing Assistant #1. Certified Nursing Assistant #1 then punched Resident #1 in their face and covered the resident's face with the wash towel to prevent them from spitting. Licensed Practical Nurse #1 stated they pulled Certified Nursing Assistant #1 away from Resident #1 and took over washing the resident. Licensed Practical Nurse #1 stated Resident #1's face was red. Licensed Practical Nurse #1 stated they asked Nurse Practitioner #1 at 2:33 PM, to call Registered Nurse Unit Manager #1 to come as they did not see anyone in the hallway (CNAs were in other residents' rooms). Licensed Practical Nurse #1 stated that Certified Nursing Assistant #1 sat on a chair in Resident #1's room and was in their full view until they saw Registered Nurse Unit Manager #1, then Certified Nursing Assistant #1 was removed from the floor. During an interview on 05/18/2026 at 10:30 AM, Registered Nurse Unit Manager #1 stated they were informed by Licensed Practical Nurse #1 that Certified Nursing Assistant #1 hit Resident #1 in their face, and they reported the incident to the Director of Nursing at 2:35 PM on 05/12/2026. Registered Nurse Unit Manager #1 stated they performed a body assessment and Resident #1 was observed with redness on the right side of their face, complaints of pain to the right side of their face and Tylenol (650 milligram) was administered. Registered Nurse Unit Manager #1 stated that they reported the incident to Nurse Practitioner #1 who ordered Resident #1 be transferred to the hospital for evaluation.During an interview on 05/18/2026 at 12:22 PM, Director of Nursing #1 stated they were informed by Registered Nurse Unit Manager #1 at 2:35 PM (on 05/12/2026) that Certified Nursing Assistant #1 hit Resident #1 in their face. Director of Nursing #1 stated Certified Nursing Assistant #1 was with Resident #1 between 2:20 PM - 2:30 PM (on 05/12/2026) less than 10 minutes. Director of Nursing #1 stated Licensed Practical Nurse #1 entered Resident #1's room approximately 2:25 PM and instructed Certified Nursing Assistant #1 to leave the room and they took over the care of Resident #1. Director of Nursing #1 stated Certified Nursing Assistant #1 was removed from resident's care and was suspended pending the outcome of the investigation. Director of Nursing #1 stated that Certified Nursing Assistant #1 never returned to work and has retired from the facility. Director of Nursing #1 stated they investigated the incident and concluded that resident abuse had occurred.During an interview on 05/18/2026 at 1:24 PM, Nurse Practitioner #1 stated they went to Resident #1's room with Licensed Practical Nurse #1 and observed Certified Nursing Assistant #1 providing incontinence care to Resident #1. Nurse Practitioner #1 stated that Certified Nursing Assistant #1 reported that Resident #1 spit on them. Nurse Practitioner #1 stated that Licensed Practical Nurse #1 took over caring for Resident #1 and they left the room to attend to another resident who was distressed. Nurse Practitioner #1 stated they heard Licensed Practical Nurse #1 calling for them and when they went to Resident #1's room, Licensed Practical Nurse #1 asked them to call Registered Nurse Unit Manager #1 because Resident #1 reported Certified Nursing Assistant #1 was rough and hit them. Nurse Practitioner #1 stated that they called Registered Nurse Unit Manager #1, and they also assessed Resident #1 and observed redness to the right side of the resident's face. Nurse Practitioner #1 stated Resident #1 complained of pain to the right side of their face during their assessment. Nurse Practitioner #1 stated Resident #1 was sent to the hospital for evaluation.During an interview on 05/19/2026 at 10:11 AM, the Administrator stated they became aware of the incident on 05/12/2026 within 15 minutes of the incident. The Administrator stated that the Director of Nursing brought Certified Nursing Assistant #1 and their union delegate to their office and Certified Nursing Assistant #1 reported that Resident #1 spit at them and hit their arm and they reacted and hit Resident #1 with an open hand on their mouth. The Administrator stated Resident #1 told the Police Officers that nothing happened and that the Officers did not take any report.10 New York Codes, Rules, and Regulations 415.4(b)(1)(i)

Based on observation, record review, and interviews during the Recertification Survey, the facility did not ensure residents receive treatment and care in accordance with professional standards of practice, and comprehensive person-centered care plan. This was evident for one (1) of five (5) residents reviewed for Unnecessary Medications (Resident #4), out of a sample of 37 residents investigated. Specifically, Resident #4 had a physician's order to notify the physician when Resident's finger stick blood sugar (method of drawing drops of blood from the finger for testing the blood glucose level) result is less than 80 milligrams per deciliter or more than 300 milligrams per deciliter. Licensed Practical Nurse #3 failed to notify the physician when Resident #4's finger stick blood sugar was higher than 300 milligrams per deciliter on 12/02/2025, 12/11/2025, 12/12/2025, and 12/13/2025.The findings include: The facility's policy titled Diabetes Mellitus, Management with a creation date of 07/15/2025 documented the facility provides individualized diabetes management for residents with diabetes mellitus in accordance with Federal/State regulations and current standards of practice, and resident-centered care principles.Resident #4 had diagnoses of Type 2 Diabetes Mellitus, Peripheral Vascular Disease, and Wound Infection.The admission Minimum Data Set assessment dated [DATE] documented that Resident #4 had intact cognition.A Comprehensive Care Plan for Diabetes was initiated on 09/30/2025. The facility interventions include to monitor blood glucose finger stick as per physician orders and monitor for effectiveness of medications given.A physician's order dated 09/29/2025 documented to monitor blood glucose three times a day before meals and to notify the physician if fasting blood sugar results are below 80 milligrams per deciliter and above 300 milligrams per deciliter.The electronic Medication Administration Records for 12/2025 documented the following finger stick blood sugar results: On 12/02/2025 at 7:30 AM, 383 milligrams per deciliter.On 12/11/2025 at 7:30 AM, 360 milligrams per deciliter.On 12/12/2025 at 7:30 AM, 396 milligrams per deciliter.On 12/13/2025 at 7:30 AM, 341 milligrams per deciliter.A review of the nurses' and medical progress notes from 12/02/2025 through 12/13/2025 showed no documentation that the physician was notified when Resident #4's finger stick blood sugar results were above 300 milligrams per deciliter.On 12/19/2025 at 1:31 PM, Licensed Practical Nurse #3 was interviewed and stated they should have notified the nursing supervisor immediately when Resident #4's blood sugar result was over 300 milligrams per deciliter so the supervisor could have notified the doctor. Licensed Practical Nurse #3 stated they were busy and by the time they remembered the nursing supervisor had left for the day.On 12/22/2025 at 2:16 PM, Registered Nurse #4 who was the supervisor was interviewed and stated they were not notified of any high blood sugar results for Resident #4 this month. Registered Nurse #4 also stated Licensed Practical Nurse #3 should have notified them when Resident #4's blood sugar results were above 300 so they can notify the doctor for further instructions.On 12/19/2025 at 1:48 PM, the Medical Director was interviewed and stated they were not notified anytime this month when Resident #4's finger stick blood sugar results were above 300 and they should have been notified as ordered. The Medical Director also stated typical triggers for high blood sugar are infections and noncompliance with diet.On 12/22/2025 at 1:00 PM, the Director of Nursing was interviewed and stated the nurses received in-services back in September 2025 which covered notifying their supervisors and physicians of high blood sugar results. The nursing supervisors are responsible for calling the doctors for follow up instructions.10 NYCRR 415.12

Based on observation, record review, and interviews, the facility failed to ensure that drugs and biologicals were stored in accordance with professional standards. This was evident for two (2) (4th and 5th Floor) of five (5) units observed during medication administration. Specifically, 1.) An expired one (1) liter bag of dextrose intravenous solution and an open undated bottle of liquid hydromorphone was found in the 4th Floor medication storage room. 2.) The 5th Floor medication cart contained expired arginine powder. 3.) The 4th Floor medication cart contained multiple open and undated eye drops and liquid medications.The findings include:The facility policy titled Medication Storage, revised [DATE], documented the facility will store medications safely and securely and in a manner that maintains the integrity of the product in accordance with manufacturer's recommendations, current standards of practice and federal and state regulations. Expired, discontinued and or contaminated medications will be removed from the medication storage areas and disposed in accordance with state and federal regulations.The facility policy titled Multidose Vials, effective [DATE], documented if a multi-dose vial has been opened or accessed the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter) date for that opened vial.On [DATE] at 9:40 AM, during medication administration observation, Licensed Practical Nurse #4 was observed at the medication cart on the Fifth Floor Unit. Prior to medication administration to Resident #92, one (1) box of Arginine Powder containing (10 - 0.32 ounce) individual packets of the supplement was observed stored on the cart and had an expiration date of [DATE]. On [DATE] at 9:45 AM, Licensed Practical Nurse #4 was interviewed and stated all nurses should be checking the expiration dates of the medications and supplements that are stored on the cart and prior to administration and if supplements are expired, they should be discarded immediately.On [DATE] at 11:17 AM, during medication administration and storage observation with Licensed Practical Nurse #5, the Fourth Floor Medication Cart was observed to contain multiple open undated [NAME] dose medications prescribed to the residents including: Sertraline 20 milligrams per milliliter liquid prescribed for Resident #23, Iron 220 milligrams per 5 milliliters prescribed for Resident #6, Lactulose 10grams per 15 milliliter prescribed for Resident #193, Ergocalciferol 100 micrograms per milliliter prescribed for Resident #57. Systane Ophthalmic Solution, Latanoprost Ophthalmic Solution and Dorzolamide Ophthalmic HCI Solution prescribed for resident #190. An 887-milliliter bottle of Pro-Stat Liquid Protein Supplement was observed to have an expiration date of [DATE].On [DATE] at 11:46 AM, During medication storage observation with Licensed Practical Nurse #5, the Fourth Floor Medication Storage Room was observed to contain: (1) One Liter intravenous solution bag of Dextrose (5%) Five Percent with expiration date of 08/2025. (1) One open undated bottle of liquid Hydromorphone (1) One milligram per Milliliter prescribed for Resident #22.On [DATE] at 12:05, an interview was conducted with Licensed Practical Nurse #5 who stated all opened multi-dose medications prescribed should be dated with the date the medication was opened by the nurse who first administered the medication. Licensed Practical Nurse #5 also stated that the intravenous bag bags are not to be left in the medication storage room, they are kept in the nurse's office to be taken to the floor only when needed for administration. Licensed Practical Nurse #5 further stated that the nursing supervisors and managers check the medication storage room and medication administration carts to ensure that the medications are dated and not expired. Both nurses who count the controlled medications at change of shift should have noticed that the Hydromorphone was not dated when opened.On [DATE] at 2:39 PM, an interview was conducted with Registered Nurse #1, The Unit Manager, who stated stored medications should not be expired. The nurses should check for the expiration date of the medication or supplement prior to administration each and every time. Registered Nurse #1 also stated that the nursing supervisors follow up and check the medication administration carts and storage rooms daily and at a minimum weekly and document their findings on an audit sheet. Registered Nurse #1 further stated that the audits include expiration dates of medications, medication reorder dates, they ensure Inhalers, eye drops, and liquid medications are stored in separate bags on the medication administration carts and labeled with the first date used or opened and discarded after 28-30 days or the manufacture's recommendation date. Intravenous administration bags are stored in the nursing office on the first floor and are only to be kept on the floor if actively being administered. A Medication Storage Audit Form dated [DATE] was provided and documented compliance in all areas.On [DATE] at 2:56 PM, an interview was performed with the Director of Nursing who stated that no expired meds should be stored on the medication administration carts. Every time the medication administration cart is used, medication expiration dates should be checked. The nurse should date all eye drops, inhalers and liquid medications prescribed to the resident with the open date, the nurse who first breaks the seal should date and initial these meds. Intravenous medication bags are kept in the nursing office not in the storage room. The bags are taken to the floor only when needed and the expiration dates are checked before use. The Director of Nursing also stated that audits of the medication administration cart, and storage rooms are performed weekly by unit managers, and the findings are documented on an audit tool. The Director of Nursing further stated that they review the audit sheets from the managers and have not seen any documented issues of expired or unlabeled, undated medications. 10 NYCRR 415.18(e)(1-4)

Based on observation, record review, and interviews, the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents. This was evident on the 4th Floor dining room. Specifically, a live cockroach was sighted crawling on the pantry counter near the ice machine where food and beverages were placed during lunch. In addition, the facility's pest control service record documented numerous cockroach sightings on the 4th Floor Unit.The findings include but are not limited to:The Facility Policy titled Pest Control dated 11/2022 documented that the facility shall maintain an ongoing effective pest control program to ensure the building is kept free of pests and rodents. Pest control services are provided through contract with an approved pest control provider. Pest control service visit documentation will be kept on file in the facility.On 12/15/2025 at 11:55 AM, during lunch dining observation a medium sized (1/2 inch) one half inch live cockroach was observed crawling on the [NAME] counter in the dining room under the ice machine and where sandwiches, fruit and cold desserts were placed. The dietary staff was plating food from a steam table. The certified nursing assistants and nurses were serving plates of food to the seated residents. Certified Nursing Assistant #6 was observed to have killed the cockroach with a paper towel. The cockroach sighting was not documented on the consumer sighting report.A review of the 4th Floor Consumer Sighting Report and Pest Control Service Record documented the following pest sightings were reported and treated on: 12/04/2025 - roaches 420B, 12/2/2025 and 11/20/2025 - roaches crawling on the walls and floors in rooms and bathrooms in the late evening, 11/13/2025 x 2 - mice and roaches on the entire unit, 11/04/2025 - lots of roaches in the bathrooms, 11/11/2024 - lots of roaches in the bathrooms, 10/06/2025, 10/14/2025, 10/21/2025, 10/28/2025 - mice in room [ROOM NUMBER], 10/05/2025 - roaches in the nightstand drawer in room [ROOM NUMBER]B.A Pest Management Inspection Report dated 11/25/2025, documented roach complaint on the 2nd Floor unit, room [ROOM NUMBER]. Inspection - positive. Several live roaches observed under the side bottom of the garbage can and in the hinge side of the door jam.A Pest Management Inspection Report dated 12/09/2025, documented roach complaint 4th Floor unit, room [ROOM NUMBER]. Inspection - positive. Live roaches observed in the bathroom door jam at floor hinge side.On 12/22/2025 at 10:00 AM, an observation of the 4th Floor Dining Room and Pantry was performed with the Director of Housekeeping and Maintenance. The pantry counter where the cockroach was previously sighted was observed with damp paper towels beneath the legs of the ice machine. The cabinet beneath the pantry counter was observed with a black dirt smudged floor. The flooring was half torn and covered with a wet towel. Roach traps were observed on the dirty wet floor. The Director of Housekeeping and Maintenance stated that the ice machine filter was changed on Friday 12/09/2025 so under the cabinet was wet and dirty but should have been cleaned up the day of the service especially being that roaches had been sighted there. The Director of Housekeeping and Maintenance further stated that the housekeeper who was assigned on Friday is on vacation.On 12/22/2025 at 10:06 AM, an interview was conducted with Certified Nursing Assistant #6 who stated that they see roaches at least weekly in the dining area. The staff reports the sighting to housekeeping and logs the details in the consumer sighting logbook. Certified Nursing Assistant #6 also stated the 4th Floor unit is serviced by the exterminator weekly.On 12/22/2025 at 8:56 AM, an interview was conducted with the Director of Housekeeper and Maintenance who stated that they were told about the cockroach sighting in the 4th Floor dining room and that everyone staffed on the floor is responsible to keep that area clean though the housekeeper is ultimately responsible. The Director of Housekeeper and Maintenance also stated they have seen roaches in the dining rooms one or two approximately once every 2 months and they normally call the exterminator who will come and perform an extra visit outside of every Tuesday extermination. The exterminator checks the floor logs for sightings and are also directed to additional area of concern. The exterminating company signing off in the logbook is the proof that the area was serviced, and a report weekly is provided after the service and findings. The weekly service includes areas of concern and the entire unit including the dining area. The exterminator places gel and glue traps in the pantry cabinet. The Director of Housekeeper and Maintenance further stated that the logbook does not document the roach sighting on 12/15/2025 though the sighting was reported by a Certified Nursing Assistant who should have documented the incident in the book.10 NYCRR 415.29(j)(5)

Based on observation, record review, and interviews, the facility failed to ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, 1.) Infection prevention and control practices were not maintained during residents' meal service. This was evident for one (1) of five (5) units observed during dining. 2.) The resident's clean laundry was observed hanging in a cart without a cover in the lobby and on the 3rd Floor unit. The findings include: 1. The facility policy and procedure titled Use of Gloves - Food Service dated 04/2017, last revised 04/2021 documented that vinyl or latex gloves will be worn when handling foods that will not be further cooked to ensure microorganisms are not transferred from food handler's hands to the food product served. Anytime a gloved hand touches a contaminated surface, the glove must be changed. On 12/15/2025 at 12:28 PM, Dietary Aide #1 was observed using gloved hand to pick up a cover that fell on the floor during meal service and continued to use the same gloved hand to serve residents' food. Dietary Aide #1 was advised by the Surveyor on the need to change their gloves, to wash their hands and put on clean gloves. Dietary Aide #1 was reluctant and continued to use the same glove to serve residents' food.On 12/15/2025 at 12:48 PM, Dietary Aide #1 was interviewed and was asked why they did not change their gloves after picking up a dirty item from the floor. The Dietary Aide stated it was because the box of gloves they keep at the back of the serving area was taken downstairs. On 12/18/2025 at 2:12 PM, the Food Service Director was interviewed and stated that Dietary Aide #1 should know that dirty gloves must be changed, and that they must wash their hands and put on new gloves before continuing to serve food to the residents. 2. The undated facility policy and procedure titled Handling of Personal Laundry documented that to prevent the development and transmission of disease and infection, the laundry will be delivered to the resident's room in a clean, covered laundry cart, and placed in the resident's closet or dresser. Laundry staff will keep closets and dressers neat and organized upon delivery of clean laundry. On 12/16/2025 at 8:20 AM, residents' washed clothes were observed uncovered, hanging on a cart in the lobby. Draft and cold air was blowing on the clothes as staff and visitors enter and exit through the sliding door. On 12/16/2025 at 8:35 AM, Housekeeping Staff #1 was interviewed and stated that residents' clothes were just delivered to the facility by an outside vendor, and they are taking the carts to the units one after the other. Housekeeping Staff #1 stated that the cover was removed after delivery of the clothes to the facility gate. Housekeeping staff #1 further stated that they will cover the clothes before taking them to the unit for distribution. On 12/16/2025 at 9:27 AM, residents' clean clothes / clean laundry were observed uncovered, hanging on the cart in the hallway near the staircase on the 3rd Floor. Registered Nurse #1, who was the unit manager was interviewed and stated that the residents' clean clothes were brought to the unit by Housekeeping Staff #1 without cover. On 12/16/2025 at 9:39 AM, Housekeeping Staff #1 was interviewed and stated they just delivered the residents' clean clothes to the 3rd Floor and went to get the rest of the clothes for other residents on the remaining units. Housekeeping Staff #1 was unable to explain why the residents' clothes were left uncovered on the cart. On 12/19/2025 at 9:17 AM, residents' clean clothes were observed on the 3rd Floor hallway near the staircase, hanging on the cart uncovered. Registered Nurse #1 was interviewed stated that the clean laundry was brought to the unit by the Housekeeping Department earlier in the morning to be distributed to residents' closets. On 12/19/2025 at 9:46 AM, Housekeeping Staff #2 was interviewed and stated that the cart was delivered to the unit earlier in the morning at about 8:00 AM without a cover because the cover was wet and was removed outside prior to taking the cart to the unit. On 12/19/2025 at 9:48 AM, The Director of Maintenance and Housekeeping was interviewed and stated that residents' clean clothes are delivered on Tuesdays and Fridays. They stated that the clean clothes are always covered when delivered and must remain covered when distributing them to the residents' rooms by the housekeeping staff. On 12/22/2025 at 9:23 AM, the Director of Nursing was interviewed and stated they have a contractor who does the residents' laundry. The dirty laundry is picked up on Mondays and Thursdays and clean laundry is delivered on Tuesdays and Fridays. The Director of Nursing stated that residents' clothes must be covered until they are placed in residents' closets. 10 NYCRR415.19 (b)(4)10 NYCRR 415.19 (c)

Based on observation, record review, and interviews the facility failed to ensure that a physician reviewed the resident's total program of care, including treatments at each visit. This was evident for one (1) (Resident #159) of one (1) resident reviewed for respiratory care out of 37 total sampled residents. Specifically, Resident #159 was observed receiving oxygen via nasal cannula. A review of interdisciplinary progress notes revealed that Resident #159 was receiving oxygen via nasal cannula, however, there was no attending practitioner's orders and indication for oxygen use.Cross refer to F-tag 695 The findings are:The facility policy titled Oxygen Therapy Administration revised 09/17/2025 documented oxygen therapy is administered by licensed nurses or respiratory therapists in accordance with healthcare provider orders and in accordance with the state scope of practice and nurse practice act.Resident #159 had diagnoses of Diabetes Mellitus and Influenza.The admission Minimum Data Set assessment dated [DATE] documented Resident #159 had severely impaired cognition and received oxygen therapy.On 12/17/2025 at 10:37 AM and 12/18/2025 at 9:58 AM, Resident #159 was observed with Oxygen in use at 2.5 liters per minute via nasal canula. A Comprehensive Care Plan for at risk/has an alteration in respiratory system, oxygen use was initiated on 12/01/2025. The facility interventions included observing for signs of poor airway clearance and observing vital signs and report those that are not within normal limits to the physician. A medical history and physical completed by the Medical Director dated 12/02/2025 documented that Resident #159 was treated in the hospital for Influenza A infection. The resident was treated conservatively with guaifenesin 100 milligram every 6 hours as needed and oxygen that they have been weaning off.Review of the nurses' progress notes from 12/04/2025 through 12/16/2025 documented that Resident #159 was on oxygen via nasal cannula. A physical medicine and rehabilitation evaluation note dated 12/12/2025 documented that Influenza, an acute condition has been resolved, and to continue oxygen via nasal cannula as needed. The interdisciplinary meeting progress notes dated 12/18/2025 documented that the meeting was attended by nursing, social services, rehabilitation therapy, and the resident's representative via phone call. The note documented that according to nursing, Resident #159 was being weaned off oxygen. A review of the physician's order for 12/2025 revealed no attending practitioner's orders and indication for oxygen use.On 12/22/2025 at 11:08 AM, Registered Nurse #3 was interviewed and stated Resident #159 does not need oxygen during the day, but requests to use oxygen at night. Registered Nurse #3 also stated there should be an order when oxygen is used.On 12/19/2025 at 2:09 PM, the Medical Director, who was the attending provider, was interviewed and stated when they visited Resident #159 after admission, they were not using oxygen and not complaining of shortness of breath. The Medical Director also stated they have not received any hypoxic (low level of oxygen) reports regarding Resident #159, but they heard Resident #159 requested oxygen.10 NYCRR 415.15(b)(2)(iii)

Based on observation, record review, and interviews, the facility failed to ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 (two) hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the New York State Department of Health. This was evident for 1 (one) (Resident #11) of 2 (two) residents reviewed for abuse out of 37 total sampled residents. Specifically, on 10/20/2025, Resident #11 alleged that Certified Nursing Assistant #2 told them I heard you like to have your balls rubbed. Resident #11 felt that this was inappropriate. The alleged incident was not reported to the New York State Department of Health. The findings are:The facility's policy titled Abuse which was last revised on 07/18/2025 documented that the facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including but not limited to staff, family, friends and residents of the facility. Allegations/reports of suspected abuse, neglect, mistreatment, distortion, injury of unknown etiology or misappropriation shall be promptly and thoroughly investigated by the facility management. The reporting protocol documents that it is the facility's policy to notify local law enforcement and appropriate State Agency(s) immediately (no later than 2 (two) hours after allegation/identification of allegation) by the Agency's designated process after identification of alleged/suspected incident.Resident #11 had diagnoses which included Cerebral Infarction and Diabetes Mellitus.The quarterly Minimum Data Set assessment dated [DATE] documented that Resident #11 had moderate cognitive impairments. It also documented that Resident #11 did not experience hallucinations or delusions, and did not exhibit physical or verbal behaviors, or rejection of care during the assessment period.The Comprehensive Care Plan initiated on 07/12/2023 documented Resident #11 was at risk for misappropriation, neglect, abuse, and/or exploitation related to their dependence on others for care.A Grievance Form dated 10/20/2025 documented that Resident #11's family member contacted the Social Worker and informed them that on 10/19/2025, the aide, whose name was not known, went to the resident's room to change their incontinence briefs. The aide allegedly told Resident #11 I heard you like to have your balls rubbed. The grievance form documented that the Director of Nursing spoke with Certified Nursing Assistant #2 who stated they only used the word balls because the resident used it. The form documented that Certified Nursing Assistant #2 was apologetic and that it appeared to be a case of poor judgment on Certified Nursing Assistant #2's part. The grievance investigation concluded there was no evidence of abuse and neglect and that the Department of Health was not notified. Certified Nursing Assistant #2 was removed from employment at the facility. The Accident/Incident Statement Form completed by Certified Nursing Assistant #3 documented that Resident #11 informed them that Certified Nursing Assistant #2 asked if Resident #11 wanted their balls to be massaged.On 12/16/2025 at 11:47 AM, Resident #11 was interviewed and stated that Certified Nursing Assistant #2 was providing incontinence care to Resident #11 on the evening shift on 10/18/2025 when Certified Nursing Assistant #2 stated Oh, I hear you like to have your balls rubbed. Resident #11 stated that they informed their family member who then notified the facility, and Resident #11 also notified Certified Nursing Assistant #3 who worked the morning shift on 10/20/2025. Resident #11 stated that they felt that Certified Nursing Assistant #2's comment was inappropriate.On 12/19/2025 at 11:30 AM, Social Worker #2 was interviewed and stated that on 10/20/2025, Resident #11's family member called them and reported that a Certified Nursing Assistant asked Resident #11 if they wanted their balls rubbed. Social Worker #2 stated that they immediately called the Director of Nursing so that the Director of Nursing could begin an investigation. Social Worker #2 stated that the Director of Nursing is responsible for investigating abuse allegations and reporting them to the proper authorities.On 12/18/2025 at 10:19 AM, the Director of Nursing was interviewed and stated that they are responsible for investigating and reporting allegations of abuse. Social Worker #2 received the initial report from Resident #11's family member. The Director of Nursing stated that the report they received from Social Worker #2 stated that Certified Nursing Assistant #2 had used the word balls while providing care to Resident #11. The Director of Nursing stated they were not aware that Resident #11 alleged that Certified Nursing Assistant #2 asked the resident if they wanted their testicles to be rubbed or massaged. The Director of Nursing stated that because they believed the concern was related to unprofessional language, they did not treat the allegation as a potential abuse allegation and therefore, did not report it to the New York State Department of Health. 10 NYCRR 415.4(b)

Based on observation, record review, and interviews the facility failed to ensure that all alleged violations involving abuse were thoroughly investigated. This was evident for 1 (one) (Resident #11) of two (2) residents reviewed for abuse out of 37 total sampled residents. Specifically, on 10/20/2025, Resident #11's family member alleged that on 10/19/2025, Certified Nursing Assistant #2 allegedly made an inappropriate remark towards Resident #11 that offended the resident. The facility initiated the investigation but did not thoroughly investigate the allegation. The facility failed to interview other staff on the unit who may have potentially witnessed the alleged incident. Cross Reference F-tag 609 The findings are:The facility's policy titled Abuse last revised 07/18/2025 documented that the facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including but not limited to staff, family, friends and residents of the facility. Allegations/reports of suspected abuse, neglect, mistreatment, distortion, injury of unknown etiology or misappropriation shall be promptly and thoroughly investigated by facility management. Upon receiving an incident or suspected incident of resident abuse, neglect, misappropriation of resident property, or injury of an unknown source, the Administrator/Director of Nursing/designee will conduct an investigation to include but not limited to: complete designated report form for investigation of abuse, neglect, misappropriation; interview the person reporting the incident; interview any witnesses to the incident; interview the resident; interview the resident's attending physician and review the resident's record; interview staff members on all shifts having contact with the resident during the period of the alleged incident; interview the resident's roommate, family members, and visitors; interview other residents to which the accused employee provides care or services; review all circumstances surrounding the incident. The Administrator/Director of Nursing is responsible to receive and investigate all alleged violations in a timely objective manner. The Administrator/ DON should analyze the report and consult with other resources such as the Medical Director to investigate medical circumstances, or the social worker, as appropriate.Resident #11 had diagnoses including Cerebral Infarction and Diabetes Mellitus.The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #11 had moderate cognitive impairments. It also documented that Resident #11 did not experience hallucinations or delusions, and did not exhibit physical or verbal behaviors, or rejection of care during the assessment period.The Comprehensive Care Plan initiated 07/12/2023 documented Resident #11 was at risk for misappropriation, neglect, abuse, and/or exploitation related to their dependence on others for care.A Grievance Form dated 10/20/2025 documented that Resident #11's family member contacted the Social Worker and informed them that on 10/19/2025, the aide, whose name was not known, went to the resident's room to change their incontinence briefs. The aide allegedly told Resident #11 I heard you like to have your balls rubbed. The grievance form documented that the Director of Nursing spoke with Certified Nursing Assistant #2 who stated they only used the word balls because the resident used it. The form documented that Certified Nursing Assistant #2 was apologetic and that it appeared to be a case of poor judgment on Certified Nursing Assistant #2's part. The grievance investigation concluded there was no evidence of abuse and neglect and that the Department of Health was not notified. Certified Nursing Assistant #2 was removed from employment at the facility. A written statement dated 10/22/2025 by Certified Nursing Assistant #2, who was the accused, documented that Resident #11 was in their assignment on the evening shift of 10/18/2025 and that they cleaned the resident about four (4) times that shift. The Certified Nursing Assistant documented that the resident told them to wash my balls again which she did and after that the resident told them to hand them the washcloth so they could do it themselves. Certified Nursing Assistant #2 stated they never had inappropriate conversation with Resident #11 and had not disrespected the resident. There was no documented evidence that other staff members who had contact with Resident #11, who may have potentially witnessed the alleged incident, were interviewed or provided statements regarding the allegation. On 12/16/2025 at 11:47 AM, Resident #11 was interviewed and stated that Certified Nursing Assistant #2 was providing incontinence care to Resident #11 on the 10/18/2025 evening shift when Certified Nursing Assistant #2 stated Oh, I hear you like to have your balls rubbed. Resident #11 stated that they informed their family member who then notified the facility, and Resident #11 also notified Certified Nursing Assistant #3 who worked the morning shift on 10/20/2025. Resident #11 stated they felt that Certified Nursing Assistant #2's comment was inappropriate.On 12/18/2025 at 11:28 AM, Certified Nursing Assistant #3 was interviewed and stated that at an unknown time during the 7:00 AM to 3:00 PM shift on 10/20/2025, Resident #11 told them that Certified Nursing Assistant #2 , who worked the evening shift, had asked Resident #11 if they wanted their balls to be massaged. On 12/19/2025 at 11:30 AM, Social Worker #2 was interviewed and stated that on 10/20/2025, Resident #11's family member called them and reported that a Certified Nursing Assistant asked Resident #11 if they wanted their balls rubbed. Social Worker #2 stated that they immediately called the Director of Nursing so that the Director of Nursing could begin an investigation. Social Worker #2 stated that the Director of Nursing is responsible for investigating abuse allegations and reporting them to the proper authorities.On 12/18/2025 at 10:19 AM, the Director of Nursing was interviewed and stated that they are responsible for investigating and reporting allegations of abuse. Social Worker #2 received the initial report from Resident #11's family member. The Director of Nursing stated that the report they received from Social Worker #2 stated that Certified Nursing Assistant #2 had used the word balls while providing care to Resident #11. They stated they were not aware that Resident #11 alleged that Certified Nursing Assistant #2 asked the resident if they wanted their testicles to be rubbed or massaged. The Director of Nursing stated that because they believed the concern was related to unprofessional language, they did not treat the allegation as a potential abuse allegation. The Director of Nursing was unable to provide an explanation for why they did not interview other staff members on the unit following the allegation.10 NYCRR 415.4(b)(3)

Based on observation, record review, and interviews the facility failed to ensure that a resident received necessary respiratory care in accordance with professional standards of practice. This was evident for one (1) (Resident #159) of one (1) resident reviewed for respiratory care out of 37 total sampled residents. Specifically, Resident #159 was observed receiving oxygen via nasal cannula without a physician's order. The findings are:The facility policy titled Oxygen Therapy Administration revised 09/17/2025 documented oxygen therapy is administered by licensed nurses or respiratory therapists in accordance with healthcare provider orders and in accordance with the state scope of practice and nurse practice act.Resident #159 had diagnoses of Diabetes Mellitus and Influenza.The admission Minimum Data Set assessment dated [DATE] documented Resident #159 had severely impaired cognition and received oxygen therapy.On 12/17/2025 at 10:37 AM and 12/18/2025 at 9:58 AM, Resident #159 was observed with Oxygen in use at 2.5 liters per minute via nasal canula. A Comprehensive Care Plan for at risk/has an alteration in respiratory system, oxygen use was initiated on 12/01/2025. The facility interventions included observing for signs of poor airway clearance and observing vital signs and report those that are not within normal limits to the physician. A medical history and physical completed by the Medical Director dated 12/02/2025 documented that Resident #159 was treated in the hospital for Influenza A infection. The resident was treated conservatively with guaifenesin 100 milligram every 6 hours as needed and oxygen that they have been weaning off.Review of the nurses' progress notes from 12/04/2025 through 12/16/2025 documented that Resident #159 was on oxygen via nasal cannula. A physical medicine and rehabilitation evaluation note dated 12/12/2025 documented that Influenza, an acute condition, has been resolved, and to continue oxygen via nasal cannula as needed. The interdisciplinary meeting progress notes dated 12/18/2025 documented that the meeting was attended by nursing, social services, rehabilitation therapy, and the resident's representative via phone call. The note documented that according to nursing, Resident #159 was being weaned off oxygen.A review of the physician's order for 12/2025 revealed no attending practitioner's orders and indication for oxygen use.On 12/19/2025 at 11:03 AM, Licensed Practical Nurse #2 was interviewed and stated Resident #159 receives oxygen through a concentrator when in their room. After reviewing Resident #159's medical record, Licensed Practical Nurse #2 stated, That's weird when Resident #159 was admitted they had an oxygen order. Licensed Practical Nurse #2 was unable to provide an explanation for oxygen use without a medical doctor's order and for how the flow rate of 2.5 liters per minute was determined.On 12/22/2025 at 11:08 AM, Registered Nurse #3 was interviewed and stated Resident #159 does not need oxygen during the day, but requests to use oxygen at night. Registered Nurse #3 also stated there should be an order when oxygen is used, and it is their fault that there was no order.On 12/19/2025 at 2:09 PM, the Medical Director was interviewed and stated when they visited Resident #159 after admission, they were not using oxygen and not complaining of shortness of breath. The Medical Director also stated they have not received any hypoxic (low level of oxygen) reports regarding Resident #159, but they heard Resident #159 requested oxygen.On 12/22/2025 at 12:50 PM, the Director of Nursing was interviewed and stated Resident #159's Patient Review Instrument did not document the need for oxygen and Resident #159's oxygen saturation rate had not fallen below 95% since admission. They stated it is possible Resident #159 felt that they needed oxygen, however, the doctor would be called for an order and then a care plan would be implemented.10 NYCRR 415.12(k)(6)

Based on observation, record review, and interviews, the facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This was evident for one (1) (Resident #9) of two (2) residents reviewed for position and mobility out of 35 total sampled residents. Specifically, Resident #9 who had a right-hand contracture, was not provided with a right palm guard as per rehabilitation recommendations.The findings are:The facility policy titled Adaptive Equipment with a revised date of 01/20/2025 documented the Rehabilitation Department will recommend safe and appropriate adaptive equipment used to enhance Activities of daily living, safety, quality of life and independence. The facility will provide adaptive equipment and appropriate assistance to assure that the resident can use the adaptive device properly. Recommendations to the resident's care plan and Certified Nursing Assistance Kardex should be provided as indicated with the necessary adaptive equipment and parameters for its use.The facility policy and procedure titled Therapy Referral and Communication with a revised date of 07/30/3025 documented the facility utilizes an interdisciplinary team collaborative process to communicate a potential and or actual resident need for rehabilitation therapy services and to receive communication from rehabilitation services regarding resident needs in accordance with Federal and State Regulations and current standards of practice. The Rehabilitation Recommendation and Communication User defined Assessment Form will be utilized to communicate and document in the clinical record the therapy referral recommendations. The recommendations may include but are not limited to adaptive and assistance devices, adaptive feeding equipment, communication devices, mobility devices, restorative nursing program, and splints, prosthetics and orthotics.Resident #9 was admitted to the facility with diagnoses that included Cerebrovascular accident and Hemiplegia.The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #9 had intact cognition, and impaired mobility with functional limitation in range of motion on one side of their upper and lower extremities.On 12/15/2025 at 11:20 AM, Resident #9 was observed with an unsupported contracted right hand. No device was observed on the contracted extremity.Resident #9 was interviewed and stated that they could not recall having a device applied to their hand or arm in 2025.On 12/17/2025 at 10:17 AM, Resident #9 was observed in bed. The resident's right hand was observed contracted without a device.The Rehabilitation Recommendation and Communication User-defined Assessment Form dated 10/03/2025 documented that Resident #9 was placed in skilled therapy for contracture management. A right palm guard was provided to replace the right-hand resting splint.An Occupational Therapy Discharge Summary with dates of service 10/03/2025 to 10/29/2025, documented discharge recommendations: Right palm guard to be used at all times except for skin checks, activities of daily living and hygiene.A Care Plan Activity Report reviewed 12/03/2025, documented that Resident #9 had a musculoskeletal flexion impairment to the right upper extremity for which a right palm guard should be applied during the day.On 12/18/2025 at 3:40 PM, an interview was conducted with the Rehabilitation Director who stated that an occupation therapy recommendation for Resident #9 was provided to the nursing staff for discharge recommendations on 10/29/2025 that included the application of a right palm guard to be used at all times.On 12/18/2025 at 4:13 PM, an interview was conducted with Occupational Therapist #1 who stated that Resident #9 was initially wearing a resting splint to the right hand that was to be removed only for hygiene and skin checks. The resident's hand was painful, and they would ask the staff to remove the hand roll. The Occupational therapist further stated that after therapy reassessment in October, they communicated with the Interdisciplinary team the recommendation for a palm guard to be always applied to the right hand except for skincare, activities of daily living and hygiene. On 12/22/2025 at 2:24 PM, an interviewed was conducted with Registered Nurse #1, who was the nurse manager for Unit 4, who stated that the process for receiving rehabilitation recommendations includes receiving a written communication form the therapists, Recommendations can include splints and other devices. The nurse manager updates the electronic chart with the order and care plan, and a copy is placed in the resident's record.On 12/22/2025 at 10:53 AM, an interview was performed with the Director of Nursing who stated that they reviewed Resident #9's clinical record and found that the therapy recommendation for application of a right palm guard was not picked up and entered into the electronic medical record by nursing. Therefore, the application of the right-hand palm guard was not placed as a Kardex task for the certified nursing assistant to perform and they did not perform the task. The Director of Nursing also stated that the nurse manager on the unit is responsible to review the paper rehabilitation recommendations that is placed in the manager's mailbox and enter the recommendations into the electronic medical record, they also receive a copy but do not recall receiving these recommendations for Resident #9, as they would have followed up. The Director of Nursing further stated that the rehabilitation recommendation form for Resident #9 is signed by nursing, but they cannot read the signature. 10 NYCCR 415.12 (e) (2)

Based on observation, record review, and interviews conducted during the Recertification Survey from 12/15/2025 to 12/22/2025, the facility did not ensure that the results of the most recent health survey were posted in a place readily accessible to residents, visitors, or legal representatives of residents, where individuals wishing to examine survey results do not have to ask to see them. Specifically, the facility stored a copy of their health survey results on the inner side of the reception desk that required those wishing to examine the results to ask the Receptionist to hand them the results.The findings are:During multiple observations made on 12/15/2025 and 12/16/2025, the health survey results for the Recertification Survey conducted from 07/10/2023 to 07/14/2023 were observed in a binder located on the inner side of the reception desk in a location that required those wishing to examine survey results to ask the Receptionist to hand them the binder.On 12/16/2025 at 10:30 AM, 11 residents of the Resident Council were interviewed and stated that they did not know where to locate the survey results in the facility.On 12/16/2025 at 12:04 PM, the Receptionist was interviewed and stated that the binder containing survey results is typically stored in its current location, which was on the inner side of the reception desk. The Receptionist further stated that if anyone requests to review the survey results, the Receptionist will hand them the binder.On 12/16/2025 at 12:09 PM, the Director of Nursing was interviewed after observing the survey results on the inner side of the reception desk with the Surveyor. The Director of Nursing stated that they are responsible for ensuring the survey results are in the binder and that the binder is accessible to anyone who wishes to view the survey results. The Director of Nursing stated that the survey results are supposed to be stored on the outer side of the desk where those wishing to examine the results do not need to ask the Receptionist to see them. The Director of Nursing further stated that they believed the results were always being stored on the outer side of the desk and was unable to provide an explanation for why it was observed on the inner side of the desk on 12/15/2025 and 12/16/2025. The Director of Nursing stated that there was no facility policy or procedure related to accessibility of survey results.10 NYCRR 415.3(d)(1)(vi)

Based on observation, record review, and interviews, the facility failed that nurse staffing information was consistently posted in a prominent place readily accessible to residents and visitors. Specifically, staffing information was not consistently posted daily; and the posting of staffing did not indicate the daily resident census. The findings are: The facility policy and procedure titled Staffing-Posting of Hours, Payroll Based Journal dated 10/2014, last revised on 10/2022, documented that the facility will post hours daily in a clear readable format in a prominent place, readily accessible to residents and visitor. Posting should include facility name, current date, and resident census (residents in the facility at midnight). On 12/15/2025 at 9:00 AM, during the Survey entrance, there was no documentation of resident census on nurse staffing information dated 12/15/2025 that was posted at the facility lobby. On 12/22/2025 at 8:36 AM, there was no nurse staffing information posted at the facility lobby or a prominent place readily accessible to residents and visitors. There was no documented evidence of resident census on the nurse staffing information dated from 12/15/2025 to 12/19/2025. On 12/22/2025 at 12:23 PM, the Director of Nursing was interviewed and stated that the Staffing Coordinator is responsible for posting the nurse staffing information every day during weekdays, and the morning shift nursing supervisor is responsible for posting it on weekends. The Director of Nursing further stated that they are not aware that the resident's census was not being documented on the nurse staffing information. 10 NYCRR 415.13

Based on observation, record review, and interviews conducted during the recertification and abbreviated (NY00302315) survey from 7/10/2023 to 7/14/2023, the facility did not ensure that all alleged violations involving abuse, were reported immediately to the New_York State Department of Health (NYSDOH), but not later than 2 hours after the allegation was made. This was evident for 1 (Resident #338) of 3 residents reviewed for Abuse out of 35 total sampled residents. Specifically, Resident #338 reported a Certified Nursing Assistant (CNA) hit them in the head and the facility did not report the allegation to the NYSDOH within 2 hours. The findings are: The facility policy titled Abuse dated 12/2022 documented the facility shall report any allegation of abuse to the appropriate state agency no later than 2 hours after the facility is made aware of the allegation. Resident #338 had diagnoses of coronary artery disease (CAD) and peripheral vascular disease (PVD). The Minimum Data Set 3.0 (MDS ) assessment dated [DATE] documented Resident #338 had intact cognition. The facility Investigative Report dated 9/15/2022 documented at 11:20 AM, Resident #338 reported CNA #1 from the night shift hit Resident #338 on the side of the head on the night shift, at approximately 3AM. The Aspen Complaint Tracking System (ACTS) intake dated 9/15/2022 documented the facility reported the incident involving Resident #338 on 9/15/2022 at 2:39 PM, more than 2 hours after becoming aware of the abuse allegation at 11:20 AM. During an interview on 07/14/2023 at 01:11 PM, the Director of Nursing (DON) stated their abuse prevention training includes reporting abuse to the supervisor timely because the facility is mandated to report abuse to the NYSDOH timely. 10 NYCRR 415.4(b)(2)

42 CFR 483.90(i) Other environmental conditions. The facility must provide a safe, functional, sanitary, and comfortable environment for the residents, staff and the public. 10NYCRR 415.29 Physical environment. The nursing home shall be designed, constructed, equipped, and maintained to provide a safe, health, functional, sanitary, and comfortable environment for residents, personnel, and the public. Based on observations and staff interview conducted during a Life Safety Code Recertification survey, the facility did not ensure to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Specifically, a) missing cove base within the soiled utility room and b) lights in soiled utility room not functional. This occurred on 2 of 7 floors, including basement. The findings are: Observations during the tour of the facility on 07/19/2023 between 09:00AM - 03:00PM, identified the following: a) two portions of cove base approximately 2 ft X 4 in were observed missing from the walls inside the soiled utility room on the 6th floor. That was revealing interstitial spaces of the walls and could be potential source for infestation. b) light fixture was not functional and not illuminating inside the soiled utility room on the 3rd floor. In an interview on 07/19/2023 at approximately 10:00AM, the Director of Maintenance stated they would address issue immediately. 42 CFR 483.90(i) 415.29(f)(4)

Based on observation, interviews, and record review conducted during the recertification survey from [DATE] to [DATE], the facility did not ensure biologicals were stored in accordance with professional principles. This was evident for 1 (2nd floor) of 5 medication storage rooms observed during the Medication Storage Task. Specifically, an emergency medication box (EMB) with expired medication was not removed the 2nd Floor medication room. The findings are: The facility policy titled Interim, Stat, Emergency Supplies of Medications dated [DATE] documented the emergency supply of medication should be stored in a known, secured location per policy with the contents of the supplies determined by the facility's Administration, Director of Nursing (DON), Medical Director, and along with the Pharmacist in accordance with applicable law. On [DATE] at 9:23 AM, the 2nd Floor Medication Room was observed with the Licensed Practical Nurse (LPN) #3. The EMB was observed sealed and affixed with a label listing the medications contained inside the EMB. The EMB label documented the Box Expires ,d+[DATE] and the expiration date of the Dexamethasone Sodium Phosphate Injection (Decadron) contained inside of the box was ,d+[DATE]. The Pharmacy slip affixed t the EMB was dated [DATE] and was not countersigned by a nurse from the facility to acknowledge receipt of the EMB. On [DATE] at 9:33 AM, LPN #3 was interviewed and stated the day and evening nurses are responsible to check EMB daily to ensure that items are sealed in the box and items listed on the label are not expired. LPN #3 stated that they did not check the label today to ensure that the box was not expired or close to expiring. LPN #3 further stated that expired box will be removed from the medication room immediately and sent to DON. On [DATE] at 10:32 AM, Registered Nurse Manager (RNM #1) was interviewed and stated the EMB is used in an emergency, and it must be restocked if the medication was used. It should also be monitored for dates to ensure that they are not stored beyond the expiration dates as per the label affixed to the box. RNM #1 stated that they were not aware that the EMB stored in the medication storage room was already expired in [DATE]. On [DATE] at 12:32 PM, the DON was interviewed and stated the [NAME] are checked by DON during their weekly rounds. [NAME] with expiring items/broken seal are immediately removed from the unit and returned to the pharmacy. The DON stated the EMB is only replenished and/or replaced by the pharmacy. The EMB on the 2nd floor was replaced by the pharmacy recently and the DON did not inspect the box sent from the pharmacy. The DON acknowledged that the replenished box should have been inspected to ensure that it is properly sealed and labeled prior to sending it to the 2nd Floor. 10 NYCRR 415.18(e)(,d+[DATE])

Based on observation, record review, and interviews conducted during the recertification survey from 7/10/2023 to 7/14/2023, the facility did not ensure that the Physician (MD) reviewed the resident's total program of care, including medications and treatments, at each visit. This was evidenced for 1 (Resident #176) of 35 total sampled residents. Specifically, the MD did not order insulin coverage for Resident #176, a resident with a diagnosis of Diabetes Mellitus (DM). The findings are: The facility policy titled Physician Services dated 04/2019 documented the MD will complete or review, sign, and date medical orders. Resident #176 was admitted to the facility on [DATE] with diagnoses of status post diabetic ketoacidosis (DKA) and DM. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #176 was cognitively intact. The MD Note dated 4/4/2023 documented Resident #176 had hyperglycemia and DKA and fingerstick (FS) baseline range is 150-300, greater than 200. Increase Lantus insulin to 25 units at bedtime and Humalog insulin with meals FS three times daily (TID). The MD Note dated 5/2/2023 documented Resident #176's FS was 216 with no signs or symptoms of hypo/hyperglycemia. DM with FS range 108-348 baseline and Resident #176 is on Humalog insulin. Increase Lantus insulin to 30 units. The MD Note dated 5/30/2023 documented Resident #176 had a FS of 150 and hemoglobin A1c (HgbA1c)of 7.1% (greater than range of 5.6%). Resident's control compromised by noncompliance with recommended diet restrictions. Resident #176 is on Humalog and Lantus insulin. The FS Blood Sugar (BS) reading for Resident #176 dated 7/1/2023 documented the resident had a FSBS of 318 at lunch. The MD Note dated 07/11/2023 documented Resident #176 has a HgbA1c of 7.1% and remains on Humalog and Lantus insulin. The Comprehensive Care Plan (CCP) related to DM last reviewed 7/11/2023 documented Resident #176 was insulin dependent, will be free of episodes of hyper/hypoglycemia, will demonstrate a blood glucose level within acceptable range, have medications administered per MD order, and have FSBS monitored per MD order. The MD Orders renewed 7/12/2023 documented Resident #176 receive have their blood glucose monitored before each meal and notify the MD if lesser than 70 or greater than 300. There was no documented evidence Humalog or Lantus insulin was ordered for Resident #176 in accordance with their DM treatment plan. During an interview on 07/13/2023 at 12:50 PM, Licensed Practical Nurse (LPN) #5 stated Resident #176 does not have an MD order for and is not receiving any medications to treat their DM. FSBS testing is done and documented, but there is no insulin coverage. During an interview on 07/13/2023 at 12:45 PM, Registered Nurse Manager (RNM) #2 stated medication orders drop off the resident's medication list if they have a 30-day limit set. It will not automatically pre-populate the MD Order sheet. RNM #2 stated they are responsible for ensuring the MD Orders are picked up and the monthly visits are performed but the nurses are busy. RNM #2 helps but does not review the list of medications to check what the MD orders. RNM #2 follows whatever the MD orders. During an interview on 07/13/2023 at 12:30 PM, MD #1 stated they did not discontinue Resident #176's Humalog or Lantus insulin. MD #1 was unable to provide a reason Resident #176's MD Orders did not include an order for Lantus or Humalog insulin. MD #1 stated they review medications and conditions of their residents, and they cannot understand why Resident #176's insulin was omitted from their MD Orders since 5/5/2023. 10 NYCRR 415.15(b)(2)(ii)

Based on observation, interview, and record review conducted during the recertification survey from 7/10/2023 to 07/14/2023, the facility did not ensure each resident was treated with respect and dignity. This was evident for 2 (Resident #21 and #107) of 35 total sampled resident. Specifically, staff were observed standing over Resident #21 and Resident #107 while feeding them. The findings are: The facility policy titled Meal Assistance dated 3/2019 documented residents receive assistance with meals in a manner that meet the individual needs of each resident. Staff shall not be standing over residents while assisting them with meals. On 07/12/2023 at 12:13 PM, the lunch meal was observed in the 3rd Floor dining room. Certified Nursing Assistant (CNA) #3 was observed standing over Resident #21 while feeding them their lunch from the meal tray. Licensed Practical Nurse (LPN) #3 was observed standing over Resident #107 while feeding them their lunch from their meal tray. On 07/12/2023 at 12:30 PM, CNA #3 was interviewed and stated it is more convenient for both the resident and the staff if they stand while feeding Resident #21. CNA #3 was unaware that they should not feed residents while standing over them in order to promote dignity. On 07/12/2023 at 12:50 PM, LPN #3 was interviewed and stated they were not aware that feeding residents while standing is a dignity concern. LPN #3 usually feeds residents while standing and no one ever corrected them. LPN #3 stated this was the first time they heard standing over a resident while feeding them is a dignity concern. On 07/12/2023 at 12:59 PM, LPN #4, the charge nurse for the 3rd Floor, was interviewed and stated LPN #4 told CNA #3 they cannot stand while feeding residents. LPN #4 saw CNA #3 feeding Resident #21 while standing and told CNA #3 to sit while feeding the resident. LPN #4 was surprised that CNA #2 continues to feed the resident while standing over the resident. 10 NYCRR 415.3(d)(1)(i)

Based on observation, interviews, and record review conducted during the recertification and complaint (NY00316765) survey from 7/10/23 to 7/14/23, the facility did not ensure each resident participated in their treatment in a language the resident can understand. This was evident for Resident #77 reviewed for Communication out of 35 total sampled residents. Specifically, Resident #77 was offered a tuberculosis test without being educated in Spanish, their preferred language. Findings are: The facility policy titled Translation Services dated 1/2020 documented this facility's language access program will ensure that individuals with limited English proficiency shall have meaningful access to information and services provided by the facility. Resident #77 was admitted with a diagnosis of right hip fracture status post (s/p) fall. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #77 was cognitively intact and their preferred language is Spanish. The New_York State Department of Health Aspen Complaint Tracking System intake dated 5/17/2023 documented Resident #77 speaks Spanish and the nurse did not provide interpretation services to explain an injection the nurse was offering to Resident #77 on 5/17/2023. The Comprehensive Care Plan (CCP) related to language initiated 5/8/2023 documented Resident #77 speaks Spanish, residents/staff who speak Spanish should be encouraged to visit Resident #77 regularly, a telephone translator should be provided, and Resident #77 should have a communication tool in their room and at the nursing station for staff to use. The Medical Doctor Order (MDO) dated 5/2/2023 documented Purified Protein Derivative (PPD) injection (tuberculosis test) 0.1 cc intradermally for Resident #77 on 5/17/2023. The Nursing Admission Evaluation dated 5/2/2023 documented Resident #77 required a translator because the resident does not speak English. The Medication Administration Report (MAR) for May 2023 documented Resident #77 refused the PPD injection on 5/17/2023. The Nursing Note dated 5/17/2023 documented Resident #77 refused the PPD injection. There was no documented evidence Resident #77 was provided with translation services when being educated re: the PPD injection. On 7/12/2023 at 3:13 PM, Certified Nurse Aide (CNA #4) was interviewed and stated they are one of the Spanish-speaking staff who translate for the resident in the facility. They did not assist with communicating with Resident #77 in Spanish re: the PPD injection education on 5/17/2023. On 7/12/2023 at 3:34 PM, CNA #5 stated they can have conversation with Resident #77 in Spanish and they were not asked to translate or educate the resident in Spanish re: the PPD injection offered on 5/17/2023. On 7/13/2023 at 4:04 PM, Licensed Practical Nurse (LPN #4) was interviewed and stated on 5/17/2023 LPN #4 used gesture, pointing to their arm, to explain the PPD injection to Resident #77. LPN #4 was aware that Resident #77 speaks primarily Spanish and did not use an interpreter to educate Resident #77 re: the PPD injection. LPN #4 assumed Resident #77 understood their gestures. On 7/14/2023 at 12:18 PM, the Director of Nursing (DON) was interviewed and stated Resident #77 should have been assisted by staff to use the language translation service via telephone. There are Spanish speaking staff on all units who can assist in translating. The DON stated that Resident #77 should have been provided with translator when offered the PPD injection on 5/17/2023. DON further stated that this issue will be reinforced and educated to all staff as a corrective action plan. 10 NYCRR 415.13(f)(1)(i)

Based on observations and interviews during the Recertification Survey, the facility did not ensure that residents were cared for in a manner that maintained or enhanced his or her dignity. Specifically, two resident's Foley catheter bag and tubing were left uncovered and exposed to public view. Two residents were observed in the dining room with a gown on without any pants and the resident back was exposed. This was evident for 3 of 3 residents reviewed for Dignity (Residents# 157, Resident #484 and Resident #142). The findings are: 1) The facility's policy titled Catheter Guidelines, created in 2019, does not document that the nursing staff should ensure and maintain privacy of all residents with the use of dignity bags when the residents are in bed and out of bed. Resident #157 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that the resident is alert and oriented. The resident requires the total assist of two persons for most activities of daily living. On 05/13/21 at 12:18 PM, and on 05/14/21 at 11:10 AM, the resident was observed lying in the bed closest to the door of the room. The resident's Foley catheter drainage bag and catheter tubing were on the side of the bed facing the door (right side). There was yellow urine draining into the uncovered catheter bag. On 05/18/21 at 02:45 PM, CNA #6 was interviewed and stated that the resident needs extensive assistance and one-person assistance for most activities of daily living. CNA #6 stated that when the catheter bag is emptied, the amount plus color of urine is reported to the nurse. The privacy bag is supposed to be placed on the catheter bag when the resident is seated in the wheelchair and when the resident is in bed. CNA #6 stated that the privacy bag should be on when resident is inside and outside of the room. The catheter bag and tubing should not be visible to others, and the privacy bag should have been on. CNA #6 apologized for the error. On 05/18/21 at 02:56 PM, LPN #6 was interviewed and stated that the catheter bag is supposed to be covered when the resident is in the room. The catheter bag is not supposed to be visible. LPN #6 further stated that there are privacy bags on the unit. LPN #6 stated that she will ensure that the CNAs always apply privacy bags over catheter bags. On 05/18/21 at 03:02 PM, RN supervisor #4 was interviewed and stated that she is responsible for supervising the nursing staff on the unit. RN supervisor #4 stated that she makes rounds several times during the shift. RN supervisor #4 stated that the staff are supposed to apply the privacy bag over the catheter bag. The drainage bag should not be visible to others. If the resident is in bed, the catheter bag should be placed on the left side of the bed. On 05/19/21 at 01:33 PM, the Director of Nursing (DON) stated that the catheter bag should be covered when the resident comes out of bed. When the resident is in bed, the catheter bag should be placed on the left side of the bed. The catheter bag and tubing should not be visible to others. The DON further stated that all staff will be re-trained on using privacy bag at all times for residents with indwelling catheters. The DON further stated that the issue will be corrected right away. 2) The facility policy titled Quality of Life/Dignity dated created 9/2014 and last revised dated 9/2019 documented under the section titled procedure Residents will be encouraged and assisted to dress in their own clothes, rather than in hospital gown. Resident #142 was initially admitted to facility on 10/01/2020 and last admitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident has moderately impaired cognition. The MDS further documented the resident required extensive assist of two persons with dressing. On 05/13/21 at 11:22 AM, the resident was observed sitting in a wheelchair (w/c) in the dining room wearing a hospital gown tied in the back around the neck. The resident moved forward in the w/c, and the gown opening exposed the resident's upper to mid lower back. On 05/13/21 at 12:35 PM, the resident was observed sitting in a w/c in the dining area still wearing the hospital gown during lunch. Staff were feeding the resident. The resident had no shirt on underneath the gown, and the back opening exposed the resident's upper back when the resident leaned forward. The resident was wearing gray sweatpants. On 05/14/21 at 11:05 AM, the resident was observed sitting in a w/c in the dining area wearing a hospital gown tied in the back around the neck. The back of the gown opened every time the resident leaned forward in the chair, exposing the upper to mid back of the resident. The resident was not wearing pants. Their bare legs were visible with, and the resident wore sneakers with no socks. On 05/19/21 at 09:56 AM an interview was conducted with Resident #142. The resident stated they have clothing, but most of the clothing is too tight, so the staff put a gown on them. Resident #142 stated they were upset right now and did not want to answer any questions. Resident stated when they are in the dining area and other resident have their own clothing on, they do not think about how they feel. In loud tone of voice resident repeated they just do not think about it. The resident had clothing in the closet. The Comprehensive Care Plan titled ADL's: Dressings dated effective 10/1/2020 documented resident will be dressed according to the season in clothes/shoes that are clean and in good repair. The resident Comprehensive Care Plan (CCP) titled Resident's preferred/prefers dated 5/14/2021 documented dress attire is casual. No documented evidence of resident preference of gown in dining area. The progress notes from 2/2/2021 to 5/19/2021 were reviewed. There was no documented evidence that the resident had a preference for wearing a gown in the dining area, and the notes had no documentation of behaviors of resident refusing own clothing in dining area. The CNA Accountability tasks dated May 2021, with last documentation on 5/19/2021, had no documentation regarding a resident preference to wear a hospital gown in the dining area in the Dressing section. On 05/19/21 at 10:29 AM, an interview was conducted with CNA #2. CNA #2 stated the resident's clothing is mostly clothing given to them by the facility with the facility logo on it. The resident's clothing is too small, and the resident needs larger clothing, especially tops. From admission to present, the resident gained weight so the clothing is too small. The resident is given a gown to wear, depending on the staff that care for the resident. CNA #2 stated, at times, the resident will wear a gown and sweatpants because the larger tops are not available. CNA #2 stated sometimes the resident refuses to go in the dining room because they have a gown on because all the other residents have their own clothing. CNA #2 stated they reported the lack of having a top and they will go downstairs to the laundry room to get a large donated top if it is available, but, at times, it is not available. CNA #2 also stated because of the weight gained it is harder to put the current clothing on resident. CNA also stated it all depends on the CNA assigned to the resident if they have patience to put the resident's clothing on or do the quick thing of putting a gown on. CNA #2 stated they took care of resident this morning and put own clothing on that fits. On 05/19/21 at 12:53 PM an interview was conducted with CNA #3. CNA #3 stated they took care of the resident sometime last week. CNA #3 stated the resident is alert able to make their needs known. CNA #3 stated the resident wore a gown with pants because the resident requested a gown because the resident's shirt did not fit. CNA #3 stated they did not report the shirt did not fit to anyone because the resident is usually in a gown and does not like to wear shirts. CNA #3 stated the resident stated it is easier to wear a gown, and they placed a gown with a pants on the resident. CNA #3 stated the next time they dressed the resident, the resident had no pants to wear. CNA #3 informed the nurse, and the nurse instructed CNA #3 to put a gown on the resident and bring the resident to the day room because the resident had to come out. On 05/20/21 at 11:11 AM, an interview was conducted with the Licensed Practical Nurse (LPN #1). LPN #1 stated they worked on the unit on 5/13/21 and the Certified Nursing Assistance (CNA#3) did report that the resident had no clothing in the closet. LPN #1 stated they instructed the CNA to place a gown on the resident because the resident stated they were fine with the gown on. LPN #1 stated the resident has behaviors of yelling and cursing at staff and they wanted to be nice, so LPN #1 agreed for the resident to go in the dining area with the gown. LPN #1 did not document anything in the resident's chart or report this to the Unit manager (UM). The usual process is to call downstairs to get a facility logo sweat suite for the resident, and report to the UM. LPN #1 stated they did not report this to anyone and call for clothing because the resident was ok with wearing the gown in the dining area. On 05/20/21 at 11:15 AM, an interview was conducted with Registered Nurse #1 (RN#1), the Unit Manager. RN #1 stated they were not aware that the resident had no clothing, and this was not reported by the staff. RN #1 stated if the resident has no clothing this is reported to the social worker to follow-up. RN #1 stated in the interim, the staff immediately go downstairs and get a facility logo sweatsuit and T-shirt to clothe the resident. RN #3 stated they were not aware that the resident prefers using a gown in dining area and added privacy, dignity, and way the resident is presented are very important. RN #1 stated if this is the resident preference, this needs to be care planned and documented; staff must respect the resident's right to use a gown if they choose to do so. RN #1 stated a preference to use a gown in the dining area was not care planned and documented. 05/20/21 at 02:50 PM, the Director of Nursing (DON) was interviewed. The DON stated that the facility is aware of the above concerns including resident wearing a gown in the dining area. The DON stated an in-service was done on the need to maintain resident's dignity and privacy. Laundry was called to check for donation clothes, and they reached out to family members to bring clothes. 415.5(a) 3) The facility policy and procedure regarding Catheter Care dated 05/2019 did not indicate how staff would assist residents with Foley Catheter care maintain their dignity and privacy when in non-private areas with of the unit. Resident #484 was readmitted to the facility on [DATE] with active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Discharge Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that the resident's cognitive status was intact. The resident required extensive assistance with dressing, toileting, and personal hygiene. The MDS also indicated that the resident had an Indwelling Foley Catheter. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that the resident's cognitive status was intact. The resident required extensive assistance with dressing, toileting, and grooming. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS also indicated that the resident had an Indwelling Foley Catheter. On 05/14/2021 at 09:47 AM, the resident was observed dressed in a hospital gown by the nurse's station on the unit talking to the doctor. On 05/14/2021 at 4:26 PM, the resident was observed sitting in the dining room dressed in a double gown and interacting with CAN and leg bag strapped to left thigh with no dignity bag and gown was covering bag but straps were still visible. On 05/17/2021 at 09:40 AM, the resident was sitting in his wheelchair using an IPAD that was playing music dressed in hospital gown and urine bag strapped to right leg and not visible. On 05/17/2021 at 1:23 PM and 4:31 Pm, the resident was observed sitting in a wheelchair (w/c) in the dining room wearing a hospital gown and no pants. The resident had a foley catheter drainage bag strapped to the right thigh, that was visible to others in the room. There were other residents in the dining room during the observation. On 05/18/2021 at 10:15 AM, 12:36 PM, and 1:20 PM, the resident was observed sitting in a w/c in the dining room wearing a hospital gown and no pants. The resident's foley catheter drainage bag was strapped to the right thigh, visible to others in the room. On 05/18/2021 at 1:28 PM, the resident was sitting in a w/c by nurses' station still wearing a hospital gown with no pants. The foley catheter drainage bag was still visible on the right thigh. On 05/18/2021 at 4:19 PM, the resident was sitting in the dining room and urine bag visible while resident sitting at table. Catheter care plan dated 2/16/2021 documented the following intervention: wash perineum with water and soap frequently, maintain urine collection bag below the level of the bladder, monitor/record/report to MD for signs/symptoms of urinary tract infection (UTI). There were no interventions related to using a privacy bag or concealing the urinary catheter drainage bag. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Catheter Care/Bowel Continence: Suprapubic Catheter Point of Care Audit report documented audit started on 05/01/2021. On 05/18/2021 at 2:39 PM, an interview conducted with the Certified Nurse Assistant (CNA# 5) who stated in the morning they empty the resident's urine bag. CNA #5 stated they put the catheter leg bag on the resident, dress the resident, and transfer the resident to the w/c. They further stated that the resident has not had clothes since returning to the unit from the hospital. They stated they will let their supervisor know and Director of Nursing (DON) and will find out where the residents' clothes is. CNA #5 stated the resident does not have a privacy bag to cover the catheter bag, and they have not seen the privacy bag in one week. CNA #5 stated they did not inform anyone that the resident did not have a privacy bag. They attempted to cover the resident's urine bag using their hospital gown. On 05/18/2021 at 04:14 PM, an interview conducted with LPN #4 who stated if the resident is out of bed, a leg bag is used. A privacy bag cannot be used with the leg bag. When the resident is in bed, the catheter drainage bag is covered with a privacy bag and attached to the bed rail. The leg bag should be covered, and a blanket or sheet can be placed over the resident's lap so it is not exposed to maintain the resident's privacy and dignity. LPN #4 stated that they were not aware that the resident was missing clothes. LPN #4 confirmed there were no privacy bags in the unit supply closet or the resident's room after a search. On 05/18/2021 at 04:36 PM, an interview conducted with RN #2 who stated that When resident is roaming around the unit the catheter drainage bag has to be covered. If the resident is in the wheelchair, the drainage bag should be covered to maintain the resident's privacy and self-esteem. RN #2 stated that some residents request to have the drainage bag covered, and some residents don't care. Most residents on the unit are alert and have to be dressed. If the resident has no clothing, they ask the family to supply clothing. RN #2 stated they usually put the drainage bag in a cover. On 05/18/2021 at 05:27 PM, an interview conducted with the Director of Nursing (DON) who stated that when the leg bag is in use, residents can be given pants or be given something to cover the lap if wearing a gown. A privacy bag is offered to residents to use when out of the room so the urinary drainage bag is not seen as long the resident cooperates. If the resident is going out of the room, staff should offer the over leg bag if the hospital gown is long enough to cover it. Some residents like to wear a gown and cover the leg bag with a blanket and sheet. The leg bag is offered to maintain privacy. 415.5(a)

Based on observations, record review, and interviews, during the re-certification survey, the facility did not ensure that each resident's person-centered, comprehensive care plan, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment was reviewed and revised timely to address resident's change in dental and Activities of daily Living (ADL) status. Specifically, the Comprehensive Care Plan (CCP) for Dental Care and Oral/Dental Health problems was not reviewed and revised to include the loss of the resident's dentures. This was evident of 1 of 2 residents investigated for dental status out of an Investigative sample of 35 residents (Resident #142). The finding is: The facility policy titled Care Plans- Comprehensive, revised 10/2019, documented the comprehensive, person centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychological well-being; incorporate identified problem areas. The comprehensive, person centered plan is developed within seven days of the completion of the required comprehensive assessment (MDS). Assessments of residents are ongoing and care plans are revised as information are about the residents and the resident's conditions change. Resident #142 was readmitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had moderately impaired cognition. The MDS further documented the resident had no dental problems. On 05/13/21 at 12:35 PM, the resident was observed being fed in the dining area. The resident was eating well with no difficulty chewing and swallowing food, and the resident had no teeth. The CCP titled The resident has oral/dental health problem dated initiated 2/21/2021 documented resident had missing teeth and had dentures. The CCP titled Dental care dated effective 10/1/2020 and last updated 1/15/2021 documented clean teeth/dentures daily. The Dental consult dated 2/4/2021 documented dental admission exam. Patient edentulous upper and lower. No treatment at present. Speech Therapy Note dated 3/12/2021 documented Resident well known to clinician with History of dysphagia and has been on advanced mechanical soft diet since 11/23/20 with full feeding assistance with good intake and tolerance. Dentures previously worn but not routinely with meals despite encouragement however were reportedly lost in the hospital (1/13-1/14/21). Evaluation revealed no significant changes in swallow function and recommend referral to dental for dentures as indicated. There was no documented evidence that the comprehensive care plan was reviewed and revised to include the resident's missing dentures and any interventions and care needs implemented to address it. On 05/20/21 at 10:04 AM, a telephone interview was conducted with the Speech Therapist (ST). ST stated the resident was on therapy secondary to some difficult swallowing regular diet in the past. ST stated when saw the resident in March was informed by the resident that the dentures was lost in the hospital in January and resident verbalized wanting dentures back. ST stated the resident diet was already advanced to regular before they went to the hospital did have dentures but did not use the dentures to eat. ST stated without the dentures the resident was able to manage and continue to manage regular texture foods. ST added they just wanted the dentures back and documented that the process needs to start over by referring to the dentist to get the denture process started. On 05/20/21 at 11:15 AM, an interview was conducted with Registered Nurse, Unit Manager (UM) (RN#1). RN #1 stated the resident was transferred to the unit from another unit. The RN is responsible for updating the dental care plan. RN #1 stated any changes in the resident including missing dentures should be care planned and they will follow up. RN #1 stated care plans are updated at least every 90 days and as needed On 05/20/21 at 11:11 AM, an interview was conducted with the Licensed Practical Nurse (LPN#1). LPN #1 stated assisted the resident was assisted with feeding last Friday and the resident had no dentures. LPN stated the resident ate well and verbalized no complaints during feeding and consumed 100% of meal. 415.11(c)(2)(i-iii)