Every finding on record at Brothers of Mercy Nursing & Rehabilitation Center

Based on observation, interview and record review conducted during a survey, the facility failed to ensure that each resident received adequate supervision and assistive devices to prevent accidents for one (Resident #1) of three residents reviewed for accidents. Specifically, the facility did not ensure that Resident #1, who was severely cognitively impaired and at risk of elopement, was adequately supervised to prevent them from accessing the maintenance workshop (a non-resident care area).The findings include:The facility policy and procedure titled Elopement Prevention last revised 10/2025, documented to prevent elopement a risk assessment is completed on admission, at the initial care plan meeting, quarterly thereafter and as prompted. Further inter-disciplinary team assessments will be conducted between admission and quarterly assessments if a resident demonstrates new behaviors such as, but not limited to, wandering, if a resident wanders off their assigned floor, increased or new onset confusion of a resident not previously deemed at risk who is mobile (including in wheelchair), or exit seeking behaviors or comments. Residents wear color-coded armbands to signify their ability to travel independently throughout the facility. The color code red signifies; residents should not be off their assigned floor or outside without assistance/direct supervision.The facility policy and procedure titled Accident and Incident Reporting for Residents last revised 12/2024, documented the facility will ensure that a safe environment free of hazards is maintained for all Residents. That each resident will be provided with adequate supervision and appropriate assistive devices for safety. Resident Risks and Environment Hazards included resident vulnerabilities such as unsafe wandering/elopement. Unsafe wandering will include a resident wandering off their assigned floor who is deemed not able to safely do so independently/without supervision and/or a resident wandering into an unsafe location.Resident #1 had diagnoses that included congestive heart failure (heart muscles do not pump blood well enough to meet the body's need), atrial fibrillation (irregular heart rhythm), and chronic kidney disease. The Minimum Data Set (a resident assessment tool) dated 03/01/2026 documented Resident #1 usually understood, usually understands, and had long and short-term memory problems. Resident #1 exhibited signs and symptoms of delirium and had no wandering behavior exhibited.The 48-hour Baseline Care Plan Summary for Resident #1 dated 02/25/2026 at 4:11 PM, documented diagnoses that included altered mental status, confusion and cognitive decline. Elopement was not checked or indicated as a safety concern.The Elopement Risk assessment dated [DATE] at 4:37 PM, documented Resident #1 was moderately impaired with decisions due to acute onset confusion within the last two months, and hospital delirium noted; had visual or auditory deficits; and they were a new admission. Resident #1 was determined to be at risk for elopement.Review of Progress Notes revealed:-on 02/25/2026 at 5:29 PM, Resident #1 was noted as an elopement risk; red arm band was in place, increased confusion noted.-on 02/26/2026 at 6:08 PM and 6:23 PM, Resident #1 was roaming the halls in their wheelchair. Resident #1 was placed back into their room.-on 02/28/2026 at 2:45 PM, Resident #1 was noted with increased anxiety and agitation around 12:00 PM and continuously stated I need to go to the hospital or to go home. I cannot breathe. Someone help me. Resident #1 was unable to be re-directed, family in to visit.Review of facility wandering incident report dated 02/28/2026 at 4:10 PM, documented Resident #1 was found in their wheelchair in the maintenance workshop (first floor) by Dietary Manager #1. Resident #1 was sitting at a tray table that was present in the workshop. Resident #1 was returned to their unit (fourth floor) by Dietary Manager #1, and they notified Licensed Practical Nurse #2 Supervisor of the incident. The Dietary Manager #1 statement documented they found Resident #1 in the maintenance room at a broken tray stand. Resident #1 was confused and scared when a compressor went off and yelled for help. Resident #1 incident description statement was I was at the elevator hitting buttons, it opened and I got on, when it opened again, I rolled into the nearest open door.During an observation on 08/20/2026 at 3:07 PM the Engineering Maintenance Shop door, located in a non-resident area, was opened, and there were no staff present in the shop. There were four doors within the maintenance shop that were unlocked and able to be accessed. The first door was labeled Oxygen Storage, the door was closed, and unlocked; the second door was labeled Equipment Room Authorized Personnel Only, the door to this room was closed, unlocked and had a door leading to the outside of the facility that was opened within that room; the third door, unlabeled, was propped open with a stopper at the base of door; the fourth door was closed, unlocked and labeled Equipment Room Authorized Personnel Only and also had a sign posted stating Danger High Voltage.During an interview on 08/20/2026 at 11:53 AM, Licensed Practical Nurse #1 stated Resident #1 was not at the facility long but was very confused, always up and down from their wheelchair, was very fast and needed lots of redirection. They stated Resident #1 was kept at the nurse's station for observation. They stated they were aware of the wandering incident involving Resident #1 but did not recall if they were working or had just heard about it. They stated if Resident #1 had a red armband they should not have been off the unit without someone.During an interview on 08/20/2026 at 12:03 PM, Registered Nurse #1 Unit Manager stated a resident with a red armband is confused and cannot go outside the unit doors unattended. They stated not all residents with a red arm band are wanderers. They stated a wander guard is placed on a resident if behaviors of wandering are observed. They stated Elopement Risk forms are completed upon admission, quarterly, for significant changes, and as needed. During a telephone interview on 08/20/2026 at 2:54 PM, Dietary Manager #1(former) stated they were working at a station in the kitchen on 02/28/2026 when they heard a resident scream. They stated they responded to the area they heard the scream and located Resident #1 sitting in a wheelchair behind a broken tray table in the maintenance shop around 4:30 PM. They stated the maintenance shop door was open and there were no maintenance personnel present at that time. They stated Resident #1 appeared scared upon locating them over a compressor in the maintenance shop going off but did not appear to be injured. Dietary Manager #1 stated they notified Licensed Practical Nurse #2 Supervisor of the incident and took Resident #1 to the fourth floor.During an interview on 08/20/2026 at 3:14 PM, Maintenance Mechanic #1 stated the Maintenance shop door is usually left open, except for meetings and during lunchtime. They stated the maintenance door should be shut after hours.During an interview on 08/20/2026 at 3:16 PM and 3:42 PM, the Maintenance Director stated that a majority of time the maintenance door is left open. They stated the other doors within the maintenance shop were left unlocked during the day but are locked after 6:00 PM during the week. They stated they did not know why the maintenance shop door would have been left open on 02/28/2026 after the maintenance mechanic had left. The Maintenance Director stated residents should not have access to the maintenance shop, and that it is only meant for employees because there is a potential risk of injury. They stated there are hand tools, drills, parts, and supplies for daily maintenance tasks left in the maintenance shop that residents should not have access to. They stated when maintenance staff leave the maintenance shop the door should be locked behind them. During a telephone interview on 08/20/2026 at 4:09 PM, Certified Nurse Aide #2 stated they remembered Resident #1 being antsy, moving around a lot and fast in their wheelchair, and would go into other resident's rooms. They stated any resident with a red armband should not be off their unit unsupervised for safety and they would be a wander risk. They stated the maintenance shop has tools that residents could injure themselves on and residents should not have access to the maintenance shop. During an interview on 08/20/2026 at 4:45 PM, the Director of Nursing stated residents should not have access to the maintenance shop because it is not a resident area and there are items present that could pose a risk for injury. The Director of Nursing stated there were no statements from staff on the unit obtained related to Resident #1's wandering incident and they did not know how long Resident #1 was off their unit or how they accessed the maintenance shop.During a telephone interview on 08/20/2026 at 4:56 PM, the former Maintenance Mechanic #2 stated the former Dietary Manager #1 notified them by text message that a resident from the fourth floor had gotten into the maintenance shop. They stated they immediately called the Maintenance Director and notified them of what happened. The (former) Maintenance Mechanic #2 stated they were not present at the building at the time of the incident but had worked the 7:00 AM to 3:00 PM shift that day. They stated the maintenance door was left open at the end of their shift because that is what they were informed to do by the Maintenance Director. They stated during the winter there was no heat in the maintenance shop, and they did not want any pipes to freeze. Maintenance Mechanic #2 stated residents should not be in the maintenance shop for safety reasons; there are tools that could be dangerous to residents.During a telephone interview on 08/21/2026 at 11:48 AM, Licensed Practical Nurse #2 Supervisor stated they were notified by Dietary Manager #1 that Resident #1 was found in the Maintenance shop sitting at a tray table waiting to be served their lunch. They stated Dietary Manager #1 brought Resident #1 back to their unit, they completed the facility incident report and notified the Director of Nursing of the incident. They stated they checked Resident #1's vital signs, completed a skin check and did not recall Resident #1 having any injuries. They stated Resident #1 appeared confused at baseline and did not appear scared. Licensed Practical Nurse #2 Supervisor stated they did not know how Resident #1 gained access to the maintenance shop and did not know how long Resident #1 had been off their unit. They stated they spoke with staff on the unit but could not recall what staff said and they did not recall obtaining statements from the unit nursing staff. Licensed Practical Nurse #2 Supervisor stated Resident #1 should not have access to the maintenance shop as it is a non-resident area, and they were not where they were supposed to be. They stated the maintenance shop has all sorts of stuff a resident could get hurt on.During an interview on 08/21/26 at 4:44 PM, the Administrator stated the maintenance shop is a nonresident area and residents typically do not go back there. They stated they did not know what was in the shop at that time and that Resident #1 did not hurt themselves.10 New York Codes Rules and Regulations 415.12(h)(2)

Based on interview and record review conducted during a survey, the facility failed to ensure that all alleged violations of abuse or mistreatment were thoroughly investigated for two (Residents #1 and #2) of three residents reviewed. Specifically, there was lack of evidence that thorough investigations were completed into allegations of a missing personal item (Resident #1) and physical abuse/mistreatment by a staff member (Resident #2). The findings include:A policy titled Freedom from Abuse, Neglect and Exploitation, Incident Reporting dated 01/2026 documented the facility does not condone any form of resident/patient abuse, neglect, exploitation or mistreatment. The Administrator has appointed the Director of Nursing or designee to coordinate an investigation when alleged incidents of abuse, neglect, mistreatment or misappropriation is reported.A policy titled Reporting Loss of Property with a revision date of 9/10/1999 documented loss of property that is reported by resident, staff or visitors is documented and communicated to designated facility staff. Follow up and investigation are then initiated to ensure that all necessary actions are taken to attempt to locate the missing property.1.Resident #1 had diagnoses including ovarian cancer, anxiety and depression. The Minimum Data Set (a resident assessment tool) dated 01/01/2026 documented Resident #1 was moderately cognitively impaired, was usually understood and usually understands.The Care Plan Report dated 03/09/2026 documented Resident #1 did not have impaired cognitive function, dementia or impaired thought process,Review of the Personal Belongings Checklist dated 01/09/2026 for Resident #1 documented they had a cell phone with a charger.Review of an e-mail provided by the Chief Executive Officer on 06/02/2026, sent by Family Member #1 of Resident #1 to Social Worker #1 dated 01/25/2026 at 10:58 AM, documented the family member was assured Resident #1's cellphone would be replaced and wanted to know when that would be as the resident was in a room with no access to a phone or ability to put one in. It was frustrating not being able to reach the resident.Review of an e-mail provided by the Chief Executive Officer on 06/02/2026, sent by Social Worker #1 to the Chief Executive Officer dated 01/26/2026 at 2:03 PM, documented Resident #1's family asked about the phone that was stolen and when it would be replaced.Review of the Progress Notes dated 01/04/2026 through 02/04/2026 revealed there was no documented evidence regarding Resident #1's missing cell phone.During an interview on 06/02/2026 at 3:17 PM, the Administrator stated they were waiting to hear from the Chief Executive Officer to see if there was any information regarding the missing phone. They were not with the facility at the time the phone went missing but would expect there would be some type of documentation or grievance form completed.During an interview on 06/02/2026 at 4:15 PM with the Administrator present, the Chief Executive Officer stated they recalled the missing phone. The Chief Executive Officer stated they could not provide a grievance form or documented evidence of an investigation to include resident and staff statements. The Chief Executive Officer stated they had some corresponding e-mails regarding the missing phone. The Chief Executive Officer stated the facility offered the family a cell phone they had on site, but the family opted for a landline instead of the phone being replaced and the family would pay for the service. During a telephone interview on 06/03/2026 at 02:33 PM, the former Social Worker #1 stated they recalled the resident's cellphone went missing. They filled out a missing items form and sent it to all departments. The facility searched everywhere for the phone, but it was never found. They never told the family it would be replaced but the family did follow up on a few occasions with other staff members asking if the phone was found. Former Social Worker #1 stated it was hit or miss if the facility would replace missing items and it was on a case-by-case basis. They left the facility shortly after the phone went missing and were unsure of the outcome. They could not recall if the resident had access to a locked drawer in their room but did not think there was one. During a telephone interview on 06/04/2026 at 1:26 PM, Family Member #1 of Resident #1 stated they were never offered a cell phone to use that the facility had. Family Member #1 stated they were told they could buy a landline phone and pay for the service. The cell phone went missing out of Resident #1's room when they were at the hairdresser. It was reported to the Former Administrator #1. Family Member #1 stated they were told the phone would not be replaced by the facility and should have been locked up in the resident's room. Family Member #1 stated there was no locked drawer in Resident #1's room. Family Member #1 stated they never heard anything about the phone again. During a telephone interview on 06/05/2026 at 10:56 AM, the Administrator stated there was no additional information to provide regarding Resident #1's missing phone.2. Resident #2 had diagnoses including hypertension (high blood pressure), fracture of left hip and atrial fibrillation (rapid irregular heartbeat). The Minimum Data Set, dated [DATE] documented Resident #2 was cognitively intact, was understood and understands.The Care Plan Report dated 02/25/2026 documented Resident #2 did not have impaired cognitive function, dementia or impaired thought process. The resident was independent with decision making.During an interview on 06/02/2026 at 2:48 PM, the Administrator stated there were no abuse allegations documented or no grievances on file for Resident #2. During a telephone interview on 06/04/2026 at 9:00 AM, Registered Nurse Unit Manager #1 stated there was an abuse allegation from Resident #2 and their family but could not recall the date. They received a voicemail from a family member stating an aide was rough with the resident and pushed them into their wheelchair. When Registered Nurse Unit Manager #1 and the Director of Nursing spoke with Resident #2, the resident stated the aide was rough with them and pushed them into the wheelchair when they were not ready to get out of bed. Registered Nurse Unit Manager #1 stated they spoke with the aide, and the aide denied the allegation stating they thought someone was falling outside the resident's room, so they put the resident in their chair and went to investigate the noise in the hallway. The aide stated they returned to the resident to finish their care. Registered Nurse Unit Manager #1 stated when they interviewed Resident #2 again the resident stated it was no big deal and you're making something out of nothing. The family also stated it was nothing. Registered Nurse Unit Manager #1 stated they did not document any information in the progress notes and usually do not document abuse allegations. Registered Nurse Unit Manager #1 stated they were unsure what happened after that or if an investigation was completed. During a telephone interview on 06/04/2026 at 11:58 AM, the Director of Nursing stated there was no abuse allegation, Family Member #2 called them on 03/19/2026 and stated a staff member was rough with Resident #2. The Director of Nursing stated they spoke with Resident #2, and the resident told them the staff rushed them and stated it was no big deal. The Director of Nursing stated Resident #2 was becoming annoyed that everyone was asking them the same questions. The Director of Nursing stated they interviewed Certified Nurse Aide #1 and Certified Nure Aide #1 told them they rushed the resident into the wheelchair because they heard a noise in the hallway and went to check to make sure no one was hurt. The Director of Nursing stated they were unable to provide resident or staff statements or an investigation but had some notes they can provide.During a telephone interview on 06/04/2026 at 1:12 PM, Family Member #2 stated they received a phone call from Resident #2 who was upset and stated the aide pushed them into their wheelchair. Family Member #2 stated Resident #2 liked most of the staff at the facility except this one aide which was not the first time the resident stated the aide was rough. Family Member #2 stated they spoke to Administration and/or a nursing supervisor, possibly the Director of Nursing who said they would go and check on Resident #2 but never heard back from anyone. Family Member #2 stated they spoke with Resident #2 the next day and the resident was told the aide did not mean to do it because the aide thought someone was falling in the hallway. Family Member #2 stated Resident #2 was upset and fearful and could have told staff it was no big deal to prevent retaliation.During a telephone interview on 06/05/2026 at 8:55 AM, Certified Nurse Aide #1 stated they recalled this resident and the incident. Certified Nurse Aide #1 stated they were transferring the resident from bed, and the resident was taking a long time to transfer to the wheelchair. Certified Nurse Aide #1 stated they heard a big boom in the hallway, and they explained to the resident they had to go see what happened and put the resident in the chair. The Director of Nursing spoke to them that day and stated Resident #2 complained Certified Nurse Aide #1 was rough to the resident. Nothing else was further said about the incident after Director of Nursing spoke with them and they were not asked to write a statement.During a telephone interview on 06/05/2026 at 10:50 AM, the Administrator stated they were not with the facility at the time of the incident but discussed it with the Director of Nursing yesterday (06/04/2026) and was unsure of all the details. The Administrator stated they would expect an investigation to start immediately if a resident claimed a staff member was rough and reported to the state agency if any abuse was suspected. 10 New York Codes, Rules, Regulations 415.4(b)(3)

Based on interview and record review conducted during the survey, the facility failed to ensure that all alleged violations involving abuse or mistreatment are reported immediately but not later than 2-hours after the allegation is made if the events that cause the allegation involve abuse, to the Administrator of the facility and to other officials (including to the State Survey Agency) for one (Resident #2) of three residents reviewed. Specifically, an allegation of staff to resident physical abuse or mistreatment was not reported to the New York State Department of Health within the required two-hour timeframe. The findings include: A policy titled Freedom from Abuse, Neglect and Exploitation, Incident Reporting dated 01/2026 documented the facility does not condone any form of resident/patient abuse, neglect, exploitation or mistreatment. The policy documented if there was reasonable cause that abuse, mistreatment, or neglect occurred the Assistant Director of Nursing, Director of Nursing and/or Administrator were to notify the State Health Department. All alleged violations involving abuse, neglect, exploitation or mistreatment were to be reported immediately to the Assistant Director of Nursing, Director of Nursing or the Administrator/Compliance Officer, but not later than two hours after the allegation was made. Resident #2 had diagnoses including hypertension (high blood pressure), fracture of left hip and atrial fibrillation (rapid irregular heartbeat). The Minimum Data Set (a resident assessment tool) dated 02/25/2026 documented Resident #2 was cognitively intact, was understood and understands.The Care Plan Report dated 02/25/2026 documented Resident #2 did not have impaired cognitive function, dementia or impaired thought process. The resident was independent with decision making.During an interview on 06/02/2026 at 2:48 PM, the Administrator stated there were no abuse allegations documented or no grievances on file for Resident #2.During a telephone interview on 06/04/2026 at 9:00 AM, Registered Nurse Unit Manager #1 stated there was an abuse allegation from Resident #2 and their family but could not recall the date. They received a voicemail from a family member stating an aide was rough with the resident and pushed them into their wheelchair. They stated they reported this to the Director of Nursing right away. Registered Nurse Unit Manager #1 stated when they and the Director of Nursing spoke with Resident #2, the resident stated the aide was rough with them and pushed them into the wheelchair when they were not ready to get out of bed. Registered Nurse Unit Manager #1 stated they spoke with the aide, and the aide denied the allegation stating they thought someone was falling outside the resident's room, so they put the resident in their chair and went to investigate the noise in the hallway. The aide stated they returned to the resident to finish their care. Registered Nurse Unit Manager #1 stated when they interviewed Resident #2 again the resident stated it was no big deal and you're making something out of nothing. The family also stated it was nothing. Registered Nurse Unit Manager #1 stated they did not document any information in the progress notes and usually do not document abuse allegations. Registered Nurse Unit Manager #1 stated they were unsure what happened after that or if an investigation was completed, the aide was moved to a different unit. They stated all abuse allegations should be reported immediately to the Director of Nursing or Administrator.During a telephone interview on 06/04/2026 at 11:58 AM, the Director of Nursing stated there was no abuse allegation, Family Member #2 called them on 03/19/2026 and stated a staff member was rough with Resident #2. The Director of Nursing stated they spoke with Resident #2, and the resident told them the staff rushed them and stated it was no big deal. The Director of Nursing stated Resident #2 was becoming annoyed that everyone was asking them the same questions. The Director of Nursing stated they interviewed Certified Nurse Aide #1 and Certified Nure Aide #1 told them they rushed the resident into the wheelchair because they heard a noise in the hallway and went to check to make sure no one was hurt. The Director of Nursing stated they were unable to provide resident or staff statements or an investigation but had some notes they can provide. The Director of Nursing stated they did not remember if they reported this to the Administrator.During a telephone interview on 06/04/2026 at 1:12 PM, Family Member #2 stated they received a phone call from Resident #2 who was upset and stated the aide pushed her in the wheelchair. Family Member #2 stated Resident #2 liked most of the staff at the facility except this one aide which wasn't the first time the resident stated the aide was rough with her. Family Member #2 stated they spoke to Administration and/or a nursing supervisor, possibly the Director of Nursing who said they would go and check on Resident #2 but never heard back from anyone. Family Member #2 stated they spoke with Resident #2 the next day and the resident was told the aide did not mean to do it because the aide thought someone was falling in the hallway. Family Member #2 stated Resident #2 was upset and fearful and could have told staff it was no big deal to prevent retaliation. During a telephone interview on 06/05/2026 at 8:55 AM, Certified Nurse Aide #1 stated they recalled this resident and the incident. Certified Nurse Aide #1 stated they were transferring the resident from bed, and the resident was taking a long time to transfer to the wheelchair. Certified Nurse Aide #1 stated they heard a big boom in the hallway, and they explained to the resident they had to go see what happened and put the resident in the chair. The Director of Nursing spoke to them that day and stated Resident #2 complained Certified Nurse Aide #1 was rough to the resident. Nothing else was further said about the incident after Director of Nursing spoke with them and they were not asked to write a statement.During a telephone interview on 06/05/2026 at 10:50 AM, the Administrator stated they were not with the facility at the time of the incident but discussed it with the Director of Nursing yesterday (06/04/2026) and was unsure of all the details. The Administrator stated they would expect an investigation to start immediately and report to the state agency if any abuse was suspected. 10 New York Codes, Rules, Regulations 415.4(b)(2)

Based on observation, interview, and record review during the Standard survey completed on 01/16/2026, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes. Specifically, the facility was not in compliance with Section 915 of the 2020 Fire Code of New York State, which requires carbon monoxide detection in buildings with fuel-burning appliances and on-going preventative maintenance of carbon monoxide detectors. This affected four (4) (first, second, third, and fourth floors) of four (4) resident use floors.The finding is:The undated Directive and Procedure titled Testing of Carbon Monoxide Detectors documented the detectors will be manually tested weekly as per manufacturers specifications and must be kept free of dust and debris. Observations during the building tour on 01/12/2026 from 8:15 AM until 4:00 PM revealed fuel-burning appliances were located on the first and fourth floors of the facility. Further observation revealed single-station battery-operated carbon monoxide detectors were located at several locations on the first and fourth floors of the facility, and they were mostly Brand A and Brand B. The User Guide for Brand A carbon monoxide detectors documented to keep your alarm in good working order, you must test the alarm once a week by pressing the test/ reset button and vacuum the alarm cover once per month to remove accumulated dust. The User Manual for Brand B combination smoke and carbon monoxide alarm documented to keep your smoke/ carbon monoxide alarm in good working order, verify the unit's alarm sound and indicators are working properly by testing the unit once a week. Remove the unit from the ceiling or wall and clean the alarm cover and vents with a soft brush attachment once a month to remove dust and dirt. Review of the log titled Weekly Carbon Monoxide Detector Audit revealed it included eight (8) units and entries were dated for the seven (7) weeks between 11/18/2025 and 01/06/2026. During an interview on 01/13/2026 at 2:42 PM, the Maintenance Director stated they personally performed weekly carbon monoxide detector checks since they started working at this facility in November 2025, but they could not locate any documentation of carbon monoxide detector checks prior to November 2025. During an interview on 01/13/2026 at 2:50 PM, Maintenance Technician #1 stated they had not personally performed any carbon monoxide detector checks. At this same time, Maintenance Technician #2 stated they had tested the carbon monoxide detectors located in the Maintenance Shop a few times in Fall 2025, but did not document it. During an interview on 01/16/2026 at 1:05 PM, the Administrator stated they expected the carbon monoxide detectors in the building to be tested per manufacturer's guidelines. 42 CFR 483.70(b)10NYCRR: 415.29(a)(2), 711.2(a)(1)2020 Fire Code of New York State, Section 915: 915.3.1, 915.6

Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and a comfortable environment, to help prevent the development and transmission of communicable diseases and infections for two (2) (Residents #15 and #152) of six (6) residents reviewed. Specifically, Resident #15 had a pressure ulcer with drainage that required a dressing and was not placed on Enhanced Barrier Precautions (interventions designed to reduce the transmission of multi-drug resistant organisms, including gowns and glove use during high contact resident care activities); staff did not wear personal protective equipment (gowns) while providing incontinent care for Resident #152 who was on Enhanced Barrier Precautions for a chronic wound. The findings are:The Policy titled Surveillance, Prevention and Control of Infection and Enhanced Barrier Precautions revised 12/25/2024, documented residents/patients are placed on Enhanced Barrier Precautions in appropriate situations as defined/guided by Centers for Disease Control, Centers for Medicaid/Medicare Services, and New York State Department of Health. Appropriate situations include but are not limited to presence of a chronic open wound that is determined to not heal in 14 days such as: pressure ulcers, venous ulcers, arterial ulcers, diabetic ulcers, open lesions, dehisced or open surgical wounds. The purpose of Enhanced Barrier Precautions is to protect residents/patients that are susceptible to contacting and or spreading MDRO's (multi-drug-resistant organism). An Enhanced Barrier Precautions, orange sign will be obtained and placed on the resident/patient's door. Gloves and gowns are indicated when care/tasks are high contact.1.Resident #15 had diagnoses that included dementia, protein calorie malnutrition, and hypothyroidism (underactive thyroid gland). The Minimum Data Set (a resident assessment tool) dated 10/23/2025 documented Resident #15 was rarely understood, rarely understands and had severe cognitive impairment. Resident #15 was at risk for impaired skin integrity and there was no pressure ulcers documented.The comprehensive care plan revised on 01/07/2026, documented Resident #15 had an unstageable (full thickness wound where base is covered by dead tissue) pressure ulcer to their right and left trochanter. Interventions included to administer treatments as ordered and provide wound consults and follow up as needed. Further review of the care plan revealed Enhanced Barrier Precautions had not been implemented until 01/15/2026.Review of the Kardex (guide used by staff to provide care) Report dated 01/15/2026 revealed no documented evidence that Resident #15 required Enhanced Barrier Precautions.Review of the Order Review Report dated 10/17/2025 - 01/31/2026 which included all active, completed and discontinued orders revealed there was no order in place for Enhanced Barrier Precautions until 01/14/2026.Review of the Wound Assessment Report dated 01/06/2026, the Wound Consultant documented that Resident #15 had an unstageable pressure ulcer to their right and left trochanter (bony prominence at the top of the thigh bone) that was acquired on 01/02/2026. The wound status documented both unstageable pressure ulcers as being new with 100 percent eschar (black or brown dead tissue) to wound base, erythema (redness of skin) to peri wound, and light amount of serous drainage (clear/yellow drainage) was noted.Review of the Wound Assessment Report dated 01/13/2026, the Wound Consultant documented Resident #15's wound status as being stable with 100 percent eschar to wound base, erythema to peri wound and light amount of serous drainage was noted to both right and left unstageable pressure ulcers.During intermittent observations made on 01/12/2026 at 9:12 AM, 01/13/2026 at 11:05 AM, and 01/14/2026 at 10:11 AM, there was no Enhanced Barrier Precaution signage posted on Resident #15's door and no personal protective equipment was located outside or inside of Resident #15's room.During a wound care observation on 01/14/2026 at 3:25 PM, Licensed Practical Nurse #8 and Certified Nurse Aide #13 entered Resident #15's room, performed hand hygiene and applied gloves. There was no Enhanced Barrier Precaution sign on Resident #15's door and no gowns were present in the room. Licensed Practical Nurse #8 removed the old dressing from Resident #15's right hip and immediately placed it in the garbage, the right hip unstageable pressure ulcer was observed with eschar present to the wound bed, wound edges were moist, and the peri wound was reddened. Licensed Practical Nurse #8 cleansed the wound with normal saline, applied Medi-honey (cream use to treat acute and chronic wounds including ulcers) and covered the wound with an adhesive foam dressing. Licensed Practical Nurse #8 repositioned Resident #15 and removed the old dressing from their left hip. The dressing removed from Resident #15's left hip was observed with a moderate amount of drainage that covered 75 percent of the dressing, the wound bed was covered with eschar and the wound edges were yellow and moist. During the wound care observation Licensed Practical Nurse #8 stated the drainage was a mixture of the old Medi -honey cream with yellow/green pus colored drainage present. Licensed Practical Nurse #8 cleansed the wound with normal saline and applied Medi-honey as ordered and covered the wound with an adhesive foam dressing. Licensed Practical Nurse #8 and Certified Nurse Aide #13 utilized gloves and masks for personal protective equipment and did not wear a gown during the observation.During an interview 01/14/2026 at 3:46 PM, Licensed Practical Nurse #8 stated Enhanced Barrier Precautions were initiated for residents that had foley catheters (insertion of tube to drain urine), infections such as urinary tract infection or wound infections. Licensed Practical Nurse #8 stated if a resident was on Enhanced Barrier Precautions there would be a sign posted on their door to alert them to what residents required precautions. They stated Resident #15 was not on Enhanced Barrier Precautions because there was no sign posted on their door. Licensed Practical Nurse #8 stated Resident #15 had unstageable pressure ulcers to both hips and there was a small amount of drainage noted during wound care. They were unsure if Resident #15 should have been on Enhanced Barrier Precautions for their wound.During an interview on 01/14/2026 at 3:51 PM, Certified Nurse Aide #13 stated they would look for signs posted on resident doors to identify what residents required Enhanced Barrier Precautions. They stated residents who had wounds or foley catheters were on Enhanced Barrier Precautions and they would need to wear gowns, gloves and masks when providing care to prevent infection. Certified Nurse Aide #13 stated Resident #15 did not have an Enhanced Barrier Sign on their door, they assisted the nurse in providing hands on care and did not wear a gown.During an interview on 01/14/2026 at 3:56 PM, the Inservice Instructor stated staff had been educated on Enhanced Barrier Precautions, they were to be utilized for any resident with an indwelling device, or wounds with an active infection. They stated if there was no active infection in the wound, Enhanced Barrier Precautions would not be indicated.During an interview on 01/14/2026 at 4:02 PM, Registered Nurse Manager #1 stated any resident with a draining wound would be placed on Enhanced Barrier Precautions. They stated that Enhanced Barrier Precautions would be important to protect staff and residents from the spread of infections. Registered Nurse Manager #1 stated that Resident #15 had unstageable pressure ulcers to both hips and were not on Enhanced Barrier Precautions because their wounds were dry and did not have drainage. They stated if Resident #15's wounds started to drain they would have expected the nursing staff to inform them so that proper precautions could be initiated. During the interview Resident Nurse Manager #1 reviewed the wound consultants notes from 01/06/2026 and 01/13/2026, they stated the wound consultant documented Resident #15's wounds had light serous drainage. Registered Nurse Manager #1 stated after they reviewed the Wound Consultant notes Resident #15 should have been placed on Enhanced Barrier Precautions for their wounds.During an interview on 01/16/2026 at 8:58 AM the Assistant Director of Nursing/Infection Preventionist stated Enhanced Barrier Precautions were utilized when a resident had an indwelling medical device, history of multidrug-resistant organisms (MDROs), or a chronic open wound. They stated if a resident had an unstageable pressure ulcer that was intact with no drainage Enhanced Barrier Precautions would not be required, additionally they stated once the wound opened or had drainage, they would expect that resident to be placed on Enhanced Barrier Precautions to prevent the risk of infection.During an interview on 01/16/206 at 9:26 AM, the Director of Nursing stated they expected Enhanced Barrier Precautions to be implemented for all wounds unless they were superficial. They stated an unstageable pressure ulcer was considered a significant wound and not superficial. The Director of Nursing stated nurse managers and supervisors were responsible for initiating Enhanced Barrier Precautions when needed and expected staff to utilize the proper protective equipment when providing resident care to prevent the spread of infection form staff to resident. They stated Resident #15 had unstageable pressure ulcers and should have been on Enhanced Barrier Precautions.2. Resident #152 had diagnoses of dementia, chronic kidney disease, and adult failure to thrive (a state of decline that is caused by chronic concurrent disease). The Minimum Data Set, dated [DATE] documented the resident had severe cognitive impairment, was dependent on staff for toileting, and did not currently have any pressure ulcers, deep tissue injuries or venous/arterial ulcers.The Comprehensive Care Plan dated 12/07/2025, documented that Resident #152 was at risk for multidrug resistant organism infection due to a chronic wound. Interventions included but were not limited to, use of Enhanced Barrier Precautions with gown and gloves during high contact resident care activities. The resident had the potential for pressure ulcers due to decreased mobility, history of a right heel pressure and a left heel pressure injury on 11/19/2025; interventions included but were not limited to Enhanced Barrier Precautions.The Kardex dated 01/16/2026, documented Resident #152 required total lift transfers with two staff and was on Enhanced Barrier Precautions which included use of gown and gloves during high contact resident care activities that have been demonstrated to result in transfer of multidrug resistant organisms to hands and clothing of healthcare personnel.Review of a nursing Progress Note dated 01/09/2026 at 3:06 PM, documented for Resident #152 Enhanced Barrier Precautions were to remain in place due to the presence of a chronic wound.Review of a medical provider Progress Note dated 01/14/2026 at 10:11 AM, documented Resident #152 was being followed for a left heel unstageable pressure ulcer. The left heel wound had 100 percent stable eschar (dark dead tissue) with smaller wound dimensions today. Edges are lifting.During an observation on 01/16/2026 at 1:58 PM, Certified Nursing Aide #3 and #11 were observed providing incontinent care for Resident #152 without wearing gowns as required. Resident #152 had an Enhanced Barrier Precaution sign posted on their door, and a personal protective equipment storage bin located outside the room.During an interview on 01/16/2026 at 2:04 PM with Certified Nursing Aide #11, they stated they were aware a resident in the room was on Enhanced Barrier Precautions but did not don (put on) personal protective equipment because they believed Resident #152's roommate was on precautions. They acknowledged they should have checked the Kardex, and personal protective equipment, including a gown, was required to prevent cross contamination.During an interview on 01/16/26 at 2:12 PM with Certified Nursing Aide #3, they stated Resident #152 was placed on Enhanced Barrier Precautions due to having pressure ulcers and acknowledged forgetting to don personal protective equipment. They stated this was important to reduce cross contamination and they should have worn a gown for high contact care.During an interview 01/16/2026 at 2:44 PM with Licensed Practical Nurse #10, Unit 3 East Manager, they stated Certified Nursing Aide #3 and #11 should have worn personal protective equipment that included a gown while care was provided. They stated staff are expected to check door signage and the Kardex before care was provided.During an interview on 01/16/2026 at 2:54 PM with the Director of Nursing, they stated their expectation was for staff to review door signage and don personal protective equipment before providing care and personal protective equipment was provided in bins outside the resident's rooms. They stated Certified Nursing Aide #3 and #11 should have worn gloves, masks, and gowns during incontinent care because this was high contact care.10 NYCRR 415.19(a)(1,2)

Based on observation, interview and record review, the facility did not ensure that a resident who entered the facility with an indwelling (foley) catheter (tube inserted into the bladder to drain urine) was assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary for one (1) (Resident #168) of one (1) resident reviewed. Specifically, there was lack of a voiding trial (removal of a urinary catheter to see if someone can pass urine normally) when the resident was admitted to the facility from the hospital with a foley catheter. Additionally, there was lack of documented medical justification for the use of the foley catheter; and the catheter bag and tubing were observed on the floor on several occasions. The finding is:The policy titled Foley Catheter Care, effective 1/2026, documented to reduce the risk of catheter-associated urinary tract infections (CAUTIs) and other complications by ensuring proper technique, maintenance, and monitoring of indwelling urinary catheters. Indwelling catheters will be used only when clinically indicated, maintained using aseptic technique, and removed as soon as no longer medically necessary. Proper catheter care is essential to prevent infection, trauma, and resident harm. Licensed Nursing staff are responsible to advocate for timely catheter removal. Certified Nursing Assistants are responsible to ensure drainage bag positioning and tubing safety. Daily foley catheter care daily and after any episode of incontinence; ensure catheter is securely anchored, free from kinks or tension. Drainage bag care included do not allow bag to touch the floor.1. Resident #168 had diagnosis that included fracture of right femur (a break of the thigh bone), dementia, major depressive disorder. The Minimum Data Set (resident assessment tool) dated 12/28/2025 documented Resident #168 was rarely/never understood, rarely/never understands and was severely cognitively impaired. Resident #168 was dependent for toileting hygiene and had an indwelling catheter. The Visual/Bedside Kardex (overview of resident care) dated 01/15/2026 documented foley catheter care every shift per facility protocol and was dependent on staff for hygiene.The Care Plan Report dated 12/30/2025 documented Resident #168 had a foley catheter on admission, has urinary retention. Approaches included foley catheter care every shift per facility protocol, monitor for signs/symptoms of infection, output monitoring, position catheter bag and tubing below the level of the bladder at all times.Hospital Discharge summary dated [DATE] documented the foley catheter was to be removed once they were more ambulatory. There was no documented evidence of a diagnosis to clinically indicate/support the use of a foley catheter. Nursing admission Data Collection Form dated 12/22/2025, documented Resident #168's usual bladder pattern was incontinent with use of a pad/brief/liner. There was no history of urinary retention or urinary tract infections. An indwelling catheter was documented as present with no reason for its use. Order Review Report for 12/22/2025-01/15/2026, documented provide foley care every shift. There were no other orders for the size or maintenance of the foley catheter. Review of interdisciplinary Progress Notes from 12/22/2025 to 01/15/2026, revealed a social services note dated 01/07/2026 at 9:46 AM, documented Resident #168 was admitted from the hospital with diagnosis of acute urinary retention and the Director of Nursing planned to ask for a void trial. There was no documentation that a voiding trial was ordered or completed.Review of Medical Visits dated 12/23/2025, 12/24/2025, 01/06/2026, 01/08/2026, 01/13/2026 lacked documented evidence of the presence of an indwelling catheter and a valid clinical indication to support the use of an indwelling catheter. Intermittent resident observations revealed the following:-on 01/12/2026 at 9:39 AM, Resident #168 was lying in bed with the foley catheter drainage bag spigot and bottom of bag resting on the floor. No privacy bag was observed. -on 01/14/2026 at 4:38 PM, Resident #168 was lying in bed with a brief on, their lower extremities were uncovered, and foley catheter drainage bag secured to side of bed touching the floor. Strong urine odor was present. Urine in foley drainage bag was dark honey colored. The foley catheter appeared to be pulling and was not secured to Resident #168's leg. -on 01/14/2026 at 4:44 PM, Licensed Practical Nurse #3 observed Resident #168 and stated the foley drainage bag was touching the floor and should not be. They stated that foley drainage bags should be in a privacy bags, so they are out of sight and not touching the floor for infection control purposes. Licensed Practical Nurse #3 stated the foley catheter should be secured with a leg strap to Resident #168's leg to keep the foley catheter from tugging. They stated it was nursing staffs' responsibility to make sure that foley catheters were not kinked and were draining properly so urine was not stuck in the bladder causing problems. -on 01/15/2026 at 12:24 PM-12:58 PM, Resident #168 was lying in bed, Certified Nurse Aide #6 and Certified Nurse Aide #8 were preparing for incontinent care when it was noted that the foley catheter had disconnected from the foley draining bag after their pants were removed. The foley catheter was not secured to the resident and was taut/stretched. Certified Nurse Aide #8 retrieved a new foley drainage bag, handed it to Certified Nurse Aide #6 whom connected the foley catheter to the drainage bag then placed the drainage bag directly on the floor. Certified Nurse Aide #8 assisted with placing a leg strap to Resident #168's right thigh to secure their foley catheter. During an interview on 01/15/2026 at 12:37 PM, Certified Nurse Aide #8 stated they secured Resident #168's foley catheter to their thigh with a leg strap to help keep the foley catheter from pulling and to help placement. They stated without securing the foley catheter it could cause tension. During an interview on 01/15/2026 at 12:58 PM, Certified Nurse Aide #6 stated they did not know why a foley drainage bag should not be placed on the floor. They stated the facility did not teach them the things they are supposed to know.During an interview on 01/16/2026 at 8:53 AM and 11:00 AM, the Director of Nursing stated they were not sure why Resident #168 had a foley catheter. They stated there should be documentation from the medical providers as to why the foley catheter is warranted because they would not just want a foley catheter present without a reason as it was a source of infection. The Director of Nursing stated a foley catheter bag, tubing should never be on the floor due to infection control. The foley drainage bags should be placed in a dignity (privacy) bag. Additionally, they stated a voiding trial would be determined by the medical providers. During an interview on 01/16/2026 at 8:58 AM, the Assistant Director of Nursing/Infection Preventionist stated certified nurse aides and nurses were responsible to complete catheter care. The Assistant Director of Nursing/Infection Preventionist stated the foley drainage bag should be positioned below the level of the bladder and placed in a privacy bag. They stated the drainage bag, spout, and tubing should never be placed on the floor, it was an infection control issue and could lead to an infection. During an interview on 01/16/2026 at 9:12 AM, Licensed Practical Nurse #1 stated Resident #168 had a foley catheter since admission and did not know why. They stated they would have to look for the reason. They stated the medical providers determine when a foley catheter is removed and when to perform a voiding trail. During an interview and observation on 01/16/2026 at 11:10 AM, Nurse Practitioner #1 stated they try to have foley catheters removed as soon as possible. They stated they were aware that Resident #168 had a foley catheter and believed per the family Resident #168 had several failed voiding trials at the hospital. Nurse Practitioner #1 stated typically foley catheter use and reason for use were documented in the admission note by the medical provider. The Nurse Practitioner #1 reviewed their progress notes and stated the indication for use of a foley catheter was not addressed and it was an oversight. They stated it was important for the use of foley catheters to be documented on in their progress notes per regulation, resident plan of care, and foley management. They stated removal of foley catheters reduced the risk of catheter-associated urinary tract infections. 10NYCRR 415.12(d)(1)

Based on observation, interview, and record review conducted during the Standard survey completed on 01/16/2026, the facility did not ensure that residents who are unable to carry out activities of daily living receives the necessary services to maintain personal hygiene to meet the resident's needs for two (Resident #1 and #168 of two residents reviewed for toileting. Specifically, residents were not provided with toileting assist as planned. The findings are:The procedure titled Careplanning, Closet Careplans, Careguides- Nursing dated 06/19 documented comprehensive care plans were developed for each resident that includes measurable objectives and timetables to meet the resident's needs.The procedure titled Incontinent Care dated 1/2016 documented incontinent care was to be provided after each episode of incontinence by nurses and certified nursing assistants according to current standards of practice and the goal of this is to promote cleanliness, comfort, and personnel hygiene for the resident. Residents who were incontinent will be checked every two hours for incontinence unless care planned otherwise.1. Resident #1 had diagnoses that included congestive heart failure (heart cannot pump blood as well as it should), cerebral infarction (stroke), and type 2 diabetes mellitus. The Minimum Data Set (a resident assessment tool) dated 12/11/2025 documented Resident #1 was understood, understands and was cognitively intact. Resident #1 was dependent on staff for toilet transfer, and toileting hygiene.The Care Plan Report dated 12/06/2025 documented Resident #1 had a self-care deficit related to impaired mobility and physical limitations. Interventions revised 01/09/2026 documented the resident required partial/moderate assist of one (1) staff member; go slow and remind them to push up from the wheelchair armrests. Additionally, the care plan initiated 11/21/2025 documented that Resident #1 was at high risk for falls related to deconditioning, and gait/balance problems. Interventions documented for the call light to be within reach and the resident needed prompt response to all requests for assistance.The Kardex Report (guide used by staff to provide care) dated 01/15/2026 documented Resident #1 toilet transfer was touching assist of one (1), brief use needed. Resident alert and oriented times three (3) and able to make needs known.During an interview on 01/13/2026 at 11:55 AM, Resident #1 stated their call light went unanswered over the weekend for almost an hour. They stated after they waited almost an hour, they wheeled themselves to the nurses' station and reported to staff, sitting at the nurses' station, they needed to use the bathroom. Resident #1 stated nobody came and they had to transfer themselves onto the toilet, even though they knew they were not supposed to. They stated they notified Licensed Practical Nurse #2 in the morning the following day, who stated they reported it to a nurse supervisor.Review of call light system log Group Incident List date range 01/09/2026-01/11/2026, documented Resident #1's room call light on 01/10/2026 was on from 5:32 PM to 6:31 PM.During an interview on 01/14/2026 at 9:39 AM, Resident #1 stated the delayed response time to their call light and being ignored at the nurses' station upset them. They needed help, no one came, and they had an incontinent episode.During a follow up interview on 01/16/2026 at 8:42 AM, Resident #1 stated after they had already transferred themselves onto the toilet, an unknown staff member entered the bathroom and threw a pull up and gown on their wheelchair and left. They stated they did not report concern to the nurse working at the time because they were busy passing medications.During an interview on 01/16/2026 at 8:31 AM, Licensed Practical Nurse #2 stated Resident #1 was upset when speaking to them while taking their vital signs first thing in the morning over the weekend. They stated that Resident #1 reported that the evening before they were made to wait over an hour for their call light to be answered, then they went in their wheelchair to the nurses' station, informed and asked staff if they could take them to the bathroom and nobody did. Licensed Practical Nurse #2 stated Resident #1 then reported to them that they had to put themselves on the toilet and did not fully make it in time on the toilet and soiled themselves.During a telephone interview on 01/16/2026 at 10:30 AM, Registered Nurse Supervisor #2 stated if resident needs were not being met in a timely manner it could be considered neglectful.During a telephone interview on 01/16/2026 at 11:40 AM, Certified Nurse Aide #1 stated they worked evening shift, 2:30 PM-10:30 PM, full time on 4 (four) [NAME] and had worked Saturday evening shift on 01/10/2026. Certified Nurse Aide #1 stated Resident #1 had voiced concerns that staff were not attentive to their needs at times. They did not recall Resident #1 being upset that evening and was not aware there was a delay in their call light being answered.During a telephone interview on 01/16/2026 at 12:01 PM, Certified Nurse Aide #11 stated their shift started at 6:30 PM on Saturday, 01/10/2026, and that Resident #1 told them they had not had a good day prior to them (Certified Nurse Aide #11) coming in.During an interview on 01/16/2026 at 12:32 PM, the Director of Nursing stated it was not reasonable for a resident to have to wait an hour to be toileted. They stated they would have expected nursing staff to assist Resident #1, if sitting at the nurses' station whether they were assigned to Resident #1 or not.2. Resident #168 had diagnoses that included fracture of right femur (a break of the thigh bone), dementia, major depressive disorder. The Minimum Data Set, dated [DATE] documented Resident #168 was severely cognitively impaired was rarely/never understood, and rarely/never understands others. Resident #168 was dependent for toileting hygiene and bowel incontinence was not rated.The Kardex Report dated 01/15/2026 documented Resident #168 required dependent assist with hygiene. Toileting: bedpan/incontinent care. Bladder/Bowel check every two hours and assist with toileting as needed.The Care Plan Report dated 12/23/2025 documented impaired cognitive function/dementia. Interventions documented for staff to anticipate residents needs as needed. The Care Plan Report dated 12/30/2025 documented Resident #168 had bowel incontinence. Interventions documented to check resident every two hours and assist with toileting as needed. The Care Plan Report dated 01/02/2026 documented Resident #168 had an activities of daily living deficit related physical impairments and interventions included to assist with hygiene and the resident was dependent on staff for the use of a bedpan and incontinent care.During a continuous observation on 01/15/2026 from 8:45 AM to 11:45 AM, Resident #168 was sitting in their wheelchair across from the nurse's station. At 11:45 PM the resident was transported from nurse's station by Certified Nurse Aide #8 into the dining room and served their lunch tray.During an observation and interview on 01/15/2026 at 12:11 PM, Resident #168 was in bed, fully dressed and Certified Nursing Aide #6 was covering resident with a sheet. Certified Nurse Aide #6 stated that Resident #168 was dependent on staff for their care, and they were assigned to them. They stated they try to check Resident #168 for incontinence every hour and do that by opening their incontinent brief. Certified Nurse Aide #6 stated they had not checked Resident #168 for incontinence since they arrived at 6:30 AM because it was hectic. They stated they try to follow the care plan and do the best they can. Certified Nurse Aide #6 stated they did not know if Resident #168 had any skin issues on their buttocks. Certified Nurse Aide #6 stated it was important to provide timely incontinent care because residents were human beings, to prevent urinary tract infections and skin breakdown. Additionally, Certified Nurse Aide #6 stated Resident #168 was already out of bed this morning when they arrived, and this would be the first time providing incontinent care on them that day.During a care observation on 01/15/2026 at 12:34 PM Resident #168 had been incontinent of stool, and at this time was provided with fecal incontinence care.During an interview on 01/16/2026 at 8:46 AM, Certified Nurse Aide #8 stated they had not assisted Certified Nurse Aide #7 and had not provided any care on Resident #168 until after lunch on 01/15/2026.During an interview on 01/16/2026 at 9:12 AM, Licensed Practical Nurse #1 stated Resident #168 was care planned to be checked every two hours and assisted with care as needed. They stated it was important for the care plan to be followed for hygiene purposes, infection control, and to prevent skin breakdown. They stated nurses were responsible to ensure that certified nurse aides were performing care per the resident's care plan.During an interview on 01/16/2026 at 11:00 AM, the Director of Nursing (covering Nurse Manager 4 West) stated unit managers and charge nurses were responsible for ensuring the resident's care plan/Kardex was followed. They stated if care was not completed per the care plan/Kardex a resident's dignity may be compromised, infections and skin breakdown could occur.10NYCRR 415.12(a)(3)

Based on interview and record review the facility did not ensure that all alleged violations involving abuse were reported immediately but not later than two (2) hours after the allegation was made to the State Survey Agency for two (2) (Residents #32 & Resident #59) of five (5) residents reviewed for abuse. Specifically, an allegation of verbal abuse was not reported to the New York State Department of Health within the required (2) two-hour timeframe. The findings are: The procedure titled Freedom from Abuse, Neglect and Exploitation, Incident Reporting revised 12/2025 documented the facility does not condone any form of resident/patient abuse, neglect, exploitation or mistreatment. The policy documented if there was reasonable cause that abuse, mistreatment, or neglect occurred the Assistant Director of Nursing, Director of Nursing and/or Administrator were to notify the State Health Department. All alleged violations involving abuse, neglect, exploitation or mistreatment were to be reported immediately, but not later than two (2) hours after the allegation was made. 1. Resident #32 had diagnoses that included congested heart failure (chronic condition where the heart cannot pump enough blood), anxiety disorder, and chronic obstructive pulmonary disease (chronic lung disease). The Minimum Data Set (a resident assessment tool) dated 11/04/2025 documented Resident #32 was cognitively intact, understands and was understood by others.The comprehensive care plan dated 11/18/2025 documented that Resident #32 was independent with decision making and had capacity for health care decisions. Resident #59 had diagnoses that included parkinsonism (a movement disorder with tremors, stiffness, and slow movement), depression, and anxiety. The Minimum Data Set, dated [DATE] documented Resident #59 was cognitively intact, understands, and was understood by others. The comprehensive care plan dated 11/25/2025 documented Resident #59 did not have impaired cognitive function/dementia or impaired thought processes. They required modified independence in decision making and had capacity for health care decisions. During a resident council meeting conducted on 01/13/2026 at 10:15 AM, Resident #32 reported to the state surveyor that on 01/12/2026 Certified Nurse Aide #2 had been assisting their roommate (Resident #59) when Certified Nurse Aide #1 and Certified Nurse Aide #3 entered their room and began a personal conversation. Resident #32 stated when they asked the staff to leave and continue their conversation outside, Certified Nurse Aide #1 responded we wipe your (vulgar slang) all day and take care of you and this is how you talk to us. Resident #32 stated this was their home and Certified Nurse Aide #1's comment was rude and unacceptable. The incident was reported to the Assistant Director of Nursing and Director of Nursing immediately by the State Surveyor. Review of the Nursing Home Facility Incident Report Submission completed by the Director of Nursing dated 01/15/2026 documented an allegation of verbal/mental abuse that involved Resident #32 and Resident #59. The report documented nursing staff were made aware of the allegation on 01/13/2026 at 10:00 AM, the Administrator was notified on 01/13/2026 at 1:00 PM and the allegation of verbal/mental abuse was reported to the Department of Health on 01/15/2026 at 12:16 PM. During an interview on 01/15/2026 at 10:16 AM, Social Worker #1 stated they were notified on 01/13/2026 by the Director of Nursing that Resident #32 reported a staff concern during the resident council meeting that took place that morning. Social Worker #1 stated they interviewed both Resident #32 and Resident #59 after being made aware of their concern with Certified Nurse Aide #1, they had documented both resident's statements and forwarded them to the Director of Nursing and Administrator on 01/13/2026. During an interview on 01/15/2026 at 3:28 PM, the Assistant Director of Nursing stated they were informed on 01/13/2026 by a state surveyor that Resident #32 had reported a concern during the resident council meeting that Certified Nurse Aide #1 had made an inappropriate comment to them 01/12/2026. The Assistant Director of Nursing stated the Director of Nursing had been made aware, Certified Nurse Aide #1 was suspended, and the Director of Nursing was responsible to conduct the investigation. During a telephone interview on 01/16/2026 at 11:15 AM, Licensed Practical Nurse #9 stated on 01/12/2026 Resident #32 had complained to them about staff speaking loudly and having personal conversations in their room. Licensed Practical Nurse #9 stated Resident #32 reported when they asked the staff to leave their room, Certified Nurse Aide #1 mumbled something under their breath and walked out. They stated Resident #32 reported to them they did not understand what Certified Nurse Aide #1 had said to them and did not inform them that any profanity was used. Licensed Practical Nurse #9 stated they did not report Resident #32's concern to anyone because the resident could not say what Certified Nurse Aide #1 had said to them. They stated the use of profanity directed towards a resident could be considered verbally abusive and needed to be reported immediately.During an interview on 01/16/2026 at 12:57 AM, the Director of Nursing stated they had investigated and interviewed all staff involved in the incident that was reported to them on 01/13/2026. The Director of Nursing stated they did not report the allegation of verbal/mental abuse to the Department of Health until 01/15/2026 because they had initially considered the allegation to be more of a dignity concern. They stated after further investigation and review of the State Operation Manual they concluded verbal abuse had occurred and reported the allegation. The Director of Nursing stated all allegations of abuse were to be reported within two (2) hours of being notified. During an interview on 01/16/2026 at 1:22 PM, the Administrator stated they were made aware of Resident #32's allegation by the Director of Nursing on 01/13/2026. They stated the allegation was not reported to the Department of Health the same day because they were still conducting the investigation. The Administrator stated the investigation concluded verbal abuse occurred and the allegation was reported to the Department of Health on 01/15/2026. They stated technically any allegation of abuse was to be reported within two hours of notification and would consider this to be delayed reporting. 10 NYCRR 415.4 (b) (2)

Based on interview and record review the facility did not ensure that each resident was treated with respect and dignity, cared for in a manner and in an environment that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality for three (3) (Resident #1, #32 and #59) of five (5) residents reviewed for dignity. Specifically, residents were treated disrespectfully and without dignity when a staff member spoke in an unprofessional manner (#32 and #59) while their room. Additionally, Resident #1 did not receive timely assistance with toileting resulting in them having an incontinence episode that was upsetting to them. The findings are: The procedure titled Dignity effective 11/14 documented all residents are to be treated in a manner which enhances/maintains dignity and quality of life with respect to each resident's individuality.New York State Department of Health, Your Rights as a Nursing Home Resident in New York State dated 2022, documented residents have the right to: Be treated with consideration, dignity and respect in full recognition of self-worth; Be cared for in a manner that enhances quality of life, free from humiliation; and receive adequate and appropriate care. 1. Resident #32 had diagnoses that included congested heart failure (chronic condition where the heart cannot pump enough blood), anxiety disorder, and chronic obstructive pulmonary disease (chronic lung disease). The Minimum Data Set (a resident assessment tool) dated 11/04/2025 documented Resident #32 was cognitively intact, understands and was understood by others.The comprehensive care plan dated 11/18/2025 documented that Resident #32 was independent with decision making and had capacity for health care decisions. The Kardex Report (a guide used by staff to provide care) dated 01/12/2026 documented Resident #32 was alert and oriented x3 (person, place and time) and was able to make their needs known. Resident #59 had diagnoses that included parkinsonism (a movement disorder with tremors, stiffness and slow movement), depression, and anxiety. The Minimum Data Set, dated [DATE] documented Resident #59 was cognitively intact, understands and was understood by others. The comprehensive care plan dated 11/25/2025 documented Resident #59 did not have impaired cognitive function/dementia or impaired thought processes. They required modified independence in decision making and had capacity for health care decisions. The Kardex Report dated 01/12/2026 documented Resident #59 was alert and oriented x3 (person, time, and place) and was able to make their needs known. During a resident council meeting conducted on 01/13/2026 at 10:15 AM, Resident #32 reported to the state surveyor that on 01/12/2026 Certified Nurse Aide #2 had been assisting their roommate (Resident #59) when Certified Nurse Aide #1 and Certified Nurse Aide #3 entered their room and began a personal conversation. Resident #32 stated when they asked the staff to leave the room and continue their conversation outside, Certified Nurse Aide #1 responded we wipe your (use of vulgar slang) all day and take care of you and this is how you talk to us. Resident #32 stated this was their home and Certified Nurse Aide #1's comment was rude and unacceptable. The concern was reported to the Assistant Director of Nursing and Director of Nursing immediately by the state surveyor. Review of the Nursing Home Facility Incident Report completed by the Director of Nursing dated 01/15/2026 documented an allegation of verbal/mental abuse that involved Resident #32 and Resident #59. The incident was reported on 01/13/2026 to the Director of Nursing and had documented Resident #32 stated there were three (3) staff members in their room having a personal conversation, they had asked the staff to leave their room when Certified Nurse Aide #1 responded we wipe your (use of vulgar slang) all day and take care of you and this is how you talk to us. The Director of Nursing interviewed and obtained statements from Certified Nurse Aide #1, #2, and #3, Certified Nurse Aide #1 was suspended pending further investigation and terminated on 01/15/2026. Certified Nurse Aide #2 and #3 were provided education on the right to privacy and dignified care. They documented foul language was used during this incident and could have been disparaging to the residents. Review of Social Worker #1's statement in the facility investigation folder dated 01/13/2026 documented Resident #32 reported Certified Nurse Aide #2 was assisting their roommate (Resident #59) when Certified Nurse Aide #1 and Certified Nurse Aide #3 entered their room and were talking loudly, they asked staff to leave the room and Certified Nurse Aide #1 responded to them we wipe your (use of vulgar slang) all day and take care of you and that's how you talk to us. Review of Social Worker #1's statement in the facility investigation folder dated 01/13/2026 documented they met with Resident #59 who reported last evening Certified Nurse Aide #2 was in their room making their bed when Certified Nurse Aide #1 and Certified Nurse Aide #3 entered their room and were talking loudly about their plans outside work. The statement documented Resident #59 stated their roommate (Resident #32) had asked the staff to leave and Certified Nurse Aide #1 made a comment about we wipe your (use of vulgar slang) all day and take care of you. Social Worker #1's statement documented Resident #59 stated the staff conversation was loud and rude. A written statement in the facility investigation folder dated 01/13/2026 and signed by Certified Nurse Aide #1 documented they had entered Resident #32's room to speak to another staff member, Resident #32 made a comment to them, and they responded to the resident stating we are leaving in a second, you do not have to be rude. An undated written statement in the facility investigation folder signed by Certified Nurse Aide #3 documented after Resident #32 asked them to take their conversation outside, Certified Nurse Aide #1 stated you can say it nicer, but we will leave. Certified Nurse Aide #3 documented they could not recall if Certified Nurse Aide #1 used any profanity in the room, they stated the comment was inappropriate and should not have been said, they apologized to both residents and left the room. During an interview on 01/14/2026 at 10:37 AM, Resident #32 stated on 01/12/2026, Certified Nurse Aide #2 was assisting their roommate (Resident #59), the door was opened and Certified Nurse Aide #1 and Certified Nurse Aide #3 entered without knocking and began a personal conversation with Certified Nurse Aide #2. Resident #32 stated when they asked the staff to take their conversation outside, Certified Nurse Aide #1 stated you wipe their (use of vulgar slang) and that is the way they treat us. Resident #32 stated Certified Nurse Aide #1 was rude, lacked manners and their comment was undignified but also stated they did not feel it was verbally abusive. They stated this was their home and they should not be spoken to in that manor. During an interview on 01/15/2026 at 9:31 AM, Resident #59 stated on 01/12/2026 Certified Nurse Aide #2 was making their bed when Certified Nurse Aide #1 and Certified Nurse Aide #3 walked in. They stated the staff members started to have a conversation with themselves, and their roommate (Resident #32) asked them to go out in the hallway to talk. Resident #59 stated Certified Nurse Aide #1 responded, you wipe their (use of vulgar slang) all day and your talked to like this. Resident #59 stated they did not remember the entire conversation, but the comment was rude and uncalled for but did not feel as it was verbally abusive. Resident #59 stated Certified Nurse Aide #1 was not directly speaking to them or Resident #32 but responded loud enough for both of them to hear. During an interview on 01/15/2026 at 11:20 AM, Certified Nurse Aide #3 stated on 01/12/2026 they went into Resident #32's room with Certified Nurse Aide #1 to speak to Certified Nurse Aide #2. They stated when Resident #32 asked them to take their conversation outside Certified Nurse Aide #1 stated you could say that in a nicer way and then left the room. Certified Nurse Aide #3 stated the comment was inappropriate and should not have been made but did not recall Certified Nurse Aide #1 using any profanity in the resident's room. They stated it was disrespectful to have walked into a resident's room and have a personal conversation, it was their home and should have waited outside their room. During an interview on 01/15/2026 at 3:31 PM. Certified Nurse Aide #2 stated on 01/12/2025 they were assisting Resident #59 when Certified Nurse Aide #1 and Certified Nurse Aide #3 entered the room to speak with them. Certified Nurse Aide #2 stated Resident #32 asked them to take their conversation into the hallway and then heard Certified Nurse Aide #1 make a comment we take care of you, and they talk to us however they want. They stated they did not recall Certified Nurse Aide #1 using any foul language towards the residents, did not consider the comment to be verbal abuse but was not appropriate and could have made the residents feel uncomfortable. During an interview on 01/16/2026 at 10:42 AM, Certified Nurse Aide #1 stated they had entered Resident #32's room to speak to another staff member, the resident became upset and yelled at staff to leave. Certified Nurse Aide #1 stated they had said, we were leaving in a second you do not have to be rude. Certified Nurse Aide #1 denied using any profanity towards either resident, they stated their response was inappropriate and should not have made it but did not feel it was verbally abusive. During an interview on 01/16/2026 at 12:57 AM, the Director of Nursing stated they had investigated and interviewed all staff involved in the incident that was reported to them on 01/13/2026. They stated upon interview Certified Nurse Aide #1 denied using any profanity in the resident's room, and their statement documented they had said, do not be rude to us. The Director of Nursing stated using profanities at any time was not an acceptable way to speak to any resident and even a comment of do not be rude was not acceptable. During an interview on 01/16/2026 at 1:22 PM, the Administrator stated they expected staff to treat all residents with dignity and respect. They stated the comments made by Certified Nurse Aide #1 in the presence of Resident #32 and Resident #59 was undignified and not an acceptable way to speak to any resident. 2. Resident #1 had diagnoses that included congestive heart failure (heart cannot pump blood as well as it should), cerebral infarction (stroke), and type 2 diabetes mellitus. The Minimum Data Set, dated [DATE] documented Resident #1 was cognitively intact, understands and was understood by others. Resident #1 was dependent for toilet transfers, and toileting hygiene. The Care Plan Report dated 12/06/2026 documented Resident #1 had a self-care deficit related to impaired mobility and physical limitations. Interventions revised 01/09/2026 documented the resident required partial/moderate assist of one (1) staff member; go slow and remind them to push up from the wheelchair armrests. Additionally, the care plan initiated 11/21/2025 documented that Resident #1 was at high risk for falls related to deconditioning, and gait/balance problems. Interventions documented for the call light to be within reach and the resident needed prompt response to all requests for assistance. The Kardex Report dated 01/15/2026 documented Resident #1 toilet transfer was touching assist of one (1), brief use needed. Resident alert and oriented times three (3) and able to make needs known. During an interview on 01/13/2026 at 11:55 AM, Resident #1 stated their call light went unanswered over the weekend for almost an hour. After they waited almost an hour, they wheeled themselves to the nurses' station and reported to staff, sitting at the nurses' station, they needed to use the bathroom. Resident #1 stated nobody came and they had to transfer themselves onto the toilet, even though they knew they were not supposed to. They stated they notified Licensed Practical Nurse #2 in the morning the following day, who stated they reported it to a nurse supervisor. Review of call light system log Group Incident List date range 01/09/2026-01/11/2026, documented Resident #1's room call light on 01/10/2026 was on from 5:32 PM to 6:31 PM. During an interview on 01/14/2026 at 9:39 AM and 01/16/2026 at 8:42 AM, Resident #1 stated the delayed response time to their call light and being ignored at the nurses' station upset them. They stated it made them cry because they needed help, no one came, and they had an incontinent episode. They stated after they had already transferred themselves onto the toilet, an unknown staff member entered the bathroom and threw a pull up and gown on their wheelchair and left. During an interview on 01/16/2026 at 8:31 AM, Licensed Practical Nurse #2 stated Resident #1 was upset and cried when speaking to them while taking their vital signs first thing in the morning over the weekend. They stated that Resident #1 reported that the evening before they were made to wait over an hour for their call light to be answered, then they went in their wheelchair to the nurses' station, informed and asked staff if they could take them to the bathroom and nobody did. Licensed Practical Nurse #2 stated Resident #1 then reported to them that they had to put themselves on the toilet and did not fully make it in time on the toilet and soiled themselves. During a telephone interview on 01/16/2026 at 10:30 AM, Registered Nurse Supervisor #2 stated if resident needs were not being met in a timely manner it could be considered neglectful. During a telephone interview on 01/16/2026 at 10:23 AM, Licensed Practical Nurse #7, per diem Supervisor, stated remembered Licensed Practical Nurse #2 coming into the Supervisors Office at shift change on Sunday, 01/11/2026 (night shift into day shift) telling them about something but could not remember what it was. Licensed Practical Nurse #7, per diem Supervisor stated there were several people in the Supervisors Office and what Licensed Practical Nurse #2 reported was lost in translation. They stated if Licensed Practical Nurse #2 reported a resident concern it should have been addressed. During a telephone interview on 01/16/2026 at 10:30 AM, Registered Nurse Supervisor #2 stated if an allegation of abuse/neglect were brought to their attention, they would interview the resident, look to see what parties were involved and go from there. They stated if resident needs were not being meet in a timely manner it could be neglectful. During a telephone interview on 01/16/2026 at 11:40 AM, Certified Nurse Aide #1 stated they worked evening shift, 2:30 PM-10:30 PM, full time on 4 (four) [NAME] and had worked Saturday evening shift on 01/10/2026. Certified Nurse Aide #1 stated Resident #1 had voiced concerns that staff were not attentive to their needs at times. They did not recall Resident #1 being upset that evening and was not aware there was a delay in their call light being answered. They stated if a resident voiced a complaint, they should report it to a nurse or supervisor. During a telephone interview on 01/16/2026 at 11:40 AM, Certified Nurse Aide #1 stated they worked evening shift, 2:30 PM-10:30 PM, full time on 4 (four) [NAME] and had worked Saturday evening shift on 01/10/2026. Certified Nurse Aide #1 stated Resident #1 had voiced concerns that staff were not attentive to their needs at times but did not elaborate; they had just listened and allowed the resident time to vent. They did not recall Resident #1 being upset that evening and was not aware there was a delay in their call light being answered. During an interview on 01/16/2026 at 11:00 AM, the Director of Nursing (covering Nurse Manager 4 West) stated unit managers, charge nurses were responsible for ensuring the resident's care plan/Kardex was followed. They stated if care was not completed per the care plan/Kardex a resident's dignity may be compromised. During an interview on 01/16/2026 at 12:32 PM, the Director of Nursing stated it was not reasonable for a resident to have to wait an hour to be toileted. They stated they would have expected nursing staff to assist Resident #1, if sitting at the nurses' station whether they were assigned to Resident #1 or not. The Director of Nursing stated the Nursing Supervisor should have acknowledged Licensed Practical Nurse #2, so a conversation with Resident #1 was completed. 10NYCRR 415.3

Based on observation, interview and record the facility did not provide a safe, clean, comfortable and homelike environment for two (2) (3 East and 4 West) of six (6) shower rooms. Specifically, the 3 East and 4 [NAME] shower rooms had issues that involved dirty floors and drains, and standing water on multiple days. Additionally, there were unlabeled personal care items were stored on the shelf in the 4 [NAME] shower room. Resident #223 was involved.The findings are: The procedure titled Cleaning Schedules: Housekeeping dated 04-16 documented a cleaning schedule is followed to control the spread of infection. Shower rooms were to be cleaned daily following the specific infection control directives, and the shower room walls were to be cleaned monthly. The procedure titled Cleaning Shower Rooms/Chairs: Housekeeping dated 11-16 documented shower rooms/chairs are cleaned daily to control the spread of infection. Shower and tub room cleaning included to disinfect and clean walls and doors (spot clean if visibly soiled), make sure floor area was free from dirt and debris and then mop. The procedure titled Infection Control Program dated 11/2024 documented the Infection Control Program establishes guidelines to follow to provide a safe, sanitary and comfortable environment, which helps to prevent the development and transmission of disease and infection. Three East Shower Room: Intermittent observations and interviews revealed the following: During an observation on 01/12/2026 at 11:30 AM a brown substance was observed on the floor in the first shower stall in the 3 East shower room. During an observation on 01/13/2026 at 9:50 AM the same brown substance remained on the shower room floor. During an observation on 01/13/2026 at 3:36 PM the brown substance was no longer visible on shower room floor. During an interview on 01/13/2026 at 3:36 PM, Certified Nurse Aide #15 stated if the substance was a bodily fluid, certified nurse aides, not maintenance, were responsible for cleaning it. They stated they did not provide showers on 01/12/2026 or 01/13/2026. They stated they were uncertain how often the shower room was cleaned but believed it should be disinfected between each resident to prevent cross contamination. During an interview on 1/14/26 at 3:09 PM, Certified Nursing Aide #16 stated it was important to keep the shower clean in between residents. They stated they would not want to take a shower in a dirty environment, and the shower room was part of the resident's home. During an interview on 01/16/2026 at 11:11 AM, Certified Nursing Aide #3 stated they saw the brown substance on the 3 East shower stall floors on 01/13/2026, believed it to be human feces and cleaned and disinfected the area immediately. They stated they did not know how long the substance had been present but stated the shower rooms are hot spots for germs and that some residents have open wounds, increasing the importance of cleanliness. Four [NAME] Shower Room: Intermittent observations and interviews revealed the following: -01/12/2026 at 10:35 AM, 01/14/2026 at 9:21 AM, and 01/15/2026 at 8:49 AM the first shower stall, nearest to hallway had three, eleven-ounce shaving creams opened and unlabeled; one, four-ounce tube of moisturizing body cream and one, four-ounce tube of skin guard unlabeled and used on the corner shelf. The second shower stall floor was wet, had standing water, and hair and a bandage covering the drain. Additionally, two, eight-ounce bottles of shampoo and body wash opened and unlabeled, three, three-ounce antifungal body powders, one, eleven-ounce shaving cream unlabeled were stored on corner shelf in the shower stall. -01/15/2026 at 10:06 AM, Resident #223 was seated in a shower chair in the second stall receiving assist with their shower. Certified Nurse Aide #7 was heard stating there was a flood in here. -01/15/2026 at 10:48 AM, Resident #223 stated that something was not draining right while they were in the shower. When asked how their shower was and they stated, come on, luke warm water, sitting on a stool with this much water on the floor, demonstrating with their fingers that the water was standing approximately a half inch on the shower floor. They stated it was not like taking a shower at home. -01/15/2026 at 10:54 AM, Certified Nurse Aide #7 stated they were responsible for cleaning up what supplies they brought into the shower room and wiping down the shower chair so that it was ready for the next residents' use. They stated they believed it was the housekeeper responsible for cleaning the shower room floors. They stated the floor did not look clean prior to giving Resident #223 a shower. They stated there was hair and a bandage blocking the drain. They stated the floor should have been cleaned prior to giving a shower for infection control purposes. They stated resident care items, shaving cream, powders, shampoo & body wash, creams should be labeled, so they know who they belong to and should not be used for another resident. -01/15/2026 at 11:04 AM, Licensed Practical Nurse #1 stated that the shower stall did not appear clean and sanitary because there was soap scum, hair over the drain, gauze bandage and what appeared to be stool (feces) smeared on the floor. They stated unlabeled personal care items should not be stored in the shower room and did not know who they belonged to. They stated it nobody should be using another resident's stuff. -01/15/2026 at 11:13 AM, Housekeeping/Laundry Supervisor stated it was the responsibility of the housekeeper to wash the shower floors and wipe down shower tiles every- day shift for safety and infection control purposes. They stated the shower floor looked dirty and needed to be scrubbed. They stated the shower room condition was not homelike. They stated residents deserved to take a shower in a clean shower room. Additionally, they stated personal care items should not be kept in the shower room, the aides were responsible for removing them. -01/15/2026 at 12:00 PM, Housekeeper #1 stated 4 [NAME] was their assigned floor. They stated it was their responsibility to check to see if the shower room floors were dirty, sweep, mop, wipe down shelves in the stalls. They stated they completed this as needed, sometimes everyday if needed. They stated the last time they mopped the shower room was last Wednesday (01/07/2026). They stated it was important that the shower room was cleaned because of germs. -01/15/206 at 12:05 PM, Housekeeper #1 observed the 4 [NAME] shower room and stated it needed to be cleaned, there was loose hair, dust bunnies over the drain; the brown tinged water (standing water) should not be there and looked like soap scum. They stated the shower stall was not sanitary and they should have cleaned it since last Wednesday. They stated they did not have a reason why they had not cleaned it and would take care of it. -01/16/2026 at 12:43 PM, the Director of Environmental Services stated they expected housekeepers to mop the shower room floors, spray down the walls to disinfect them daily. They stated it was important to keep the shower rooms clean, and homelike. 10 NYCRR 415.5(h)(2)

Based on observation, interview, and record review conducted during a Standard survey completed on 1/9/24, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living received the necessary services to maintain good nutrition for one (Resident #118) of four residents reviewed. Specifically, Resident #118 was not provided with continuous supervision or touching assistance (limited assist) with eating in the alcove as planned. The finding is: The policy and procedure titled Feeding Assistance/Tray Labeling revised 7/2020, documented staff members designated the duties of feeding residents are aware of the assistance level needed by referencing the tray ticket placed on each resident's meal tray and the care guide for each resident. The policy and procedure documented that a limited assist is guided maneuvering any hands-on assistance needed to bring utensils or food/drink to mouth. Picking up cups and bringing to lips, hand over hand assist, intermittently assisting with food to mouth. The QRP Pocket Guide (quality reporting program- quick reference guide) provided by the Assistant Director of Nursing documented that supervision or touching assistance, the helper was to provide verbal cues and/or touching/steadying and/or contact guard assistance as the resident completed the activity. Assistance may be provided throughout the activity or intermittently. Resident #118 had diagnoses including dementia, diabetes mellitus type II, and hypertension (high blood pressure). The Minimum Data Set (a resident assessment tool) dated 11/3/23 documented Resident #118 had severe cognitive impairment, was sometimes understood, rarely/never understands, and required supervision/touching assistance for eating. The comprehensive care plan revised 11/20/23 documented Resident #118 had the potential for variable meal acceptance. Interventions included the resident was to eat in the alcove with a continuous supervision or touching assist (limited assist) and encourage adequate intake. The untitled Kardex (a guide used by staff to provide care) dated 1/9/24, documented Resident #118 required continuous supervision or touching assist (limited assist) in the alcove for eating. Review of Resident #118's progress notes dated 10/31/23 through 1/8/24 revealed on 1/8/24 at 2:10 PM, Dietary Technician #1 documented Resident #118 had less well consumed meals in the past few days with recent average of 26-50 percent (%) of meal. There was no documented evidence that Resident #118 had refused supervision or touching assist (limited assist) for meals or refusal to eat in the alcove. During an observation of the lunch meal on 1/3/24 at 11:49 AM, Resident #118 was sitting in their wheelchair in their room attempting to eat their lunch independently. There were no staff member providing continuous supervision. During an observation of the breakfast meal on 1/5/24 at 8:38 AM, Resident #118 had poor positioning and was sitting diagonal in their bed in a half lying/half sitting position. The residents breakfast tray was on the bedside tray table in front of them and they were attempting to independently drink orange juice from a plastic container. The straw was removed from the container and the resident was attempting to replace the straw back into the container independently without success. There were no staff members in the room providing continuous supervision or touching assistance (limited assist). During a continuous observation of the lunch meal on 1/5/24 from 11:40 AM through 11:55 AM, Resident #118 was sitting in their wheelchair in their room by them self with their lunch tray on the bed side table in front of them. Resident #118 was coughing and dropped their fork on the floor. At 11:44 AM an unknown staff member sat in a chair outside of the resident's room to assist another resident eating in the alcove for three minutes and then left the alcove area. At 11:48 AM Certified Nursing Assistant #10 entered Resident #118 room and exited the room without offering assistance to the resident. At 11:50 AM Resident #118 was noted to be coughing again. At 11:55 AM Certified Nursing Assist #11 entered room and removed lunch tray from Resident #118. No staff member provided continuous supervision or touching assist (limited assist) during the meal. During an observation of the breakfast meal on 1/8/24 at 8:33 AM, Resident #118 was in their room, lying in bed with their breakfast meal covered on the bedside table and was not within reach to the resident. At 8:55 AM the resident was still in their room, lying in bed with their breakfast tray in front of them. Resident was independently eating their cereal with a spoon. Milk and cereal had spilled on the tray. There was no staff member in the room to provide continuous supervision or touching assist (limited assist). During an interview on 1/8/24 at 12:32 PM, Certified Nursing Assist #10 stated they were assigned to Resident #118 on 1/5/24 and 1/8/24. Certified Nursing Assist #10 stated that Resident #118 was a continuous supervision or touching assistance for meals in the alcove. Certified Nursing Assist #10 stated that Resident #118 should have been eating in the alcove with a staff member always keeping an eye on them to help the resident when needed. During an interview on 1/8/24 at 12:38 PM, Licensed Practical Nurse #8 stated the importance of Resident #118 eating in the alcove was to be supervised for their safety. During an interview on 1/8/24 at 3:36 PM, Occupational Therapist #2 stated Resident #118 was discharge from occupational therapy program on 12/29/22 at a limited assist for eating. They stated in October 2023 assistance level verbiage changed and Resident #118 was changed to a continuous supervision or touching assist. Occupational Therapist #2 stated that both a limited level of assistance and a supervision or touching assist meant that Resident #118 could feed themselves, but staff needed to supervision and assist. Occupation Therapist #2 stated that Resident #118 had difficulty reaching items, scooping their foods, and would become fatigued at times. During an interview on 1/9/24 at 10:12 AM, Register Nurse #2 (Nurse Manger of the 3 East unit) stated the Resident #118 needed continuous supervision because they often fall asleep during a meal and need to be woken up and assisted. During an interview on 1/9/24 at 11:27 AM, Diet Technician #1 stated Resident #118 had variable intake and needed encouragement and assistance during meals due to their cognitive impairment. During an interview on 1/9/24 at 11:59 AM, the Director of Nursing stated that if a resident was care planned for continuous supervision or touching assist during meals their expectation was for a staff member to observe the resident and assist them when needed. Resident #118 should have been in the alcove for meals as planned unless the resident refused; then a staff member should have remained in the room. 10NYCRR 415.12(a)(3)

Based on observation, interview, and record review conducted during a Standard survey completed on 1/9/24, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, and prevent new ulcers from developing for one (Resident #142) of three residents reviewed. Specifically, the resident developed an unstageable (full thickness skin or tissue loss-depth unknown) pressure ulcer; wound assessments were incomplete. The wound consultants recommendations dated 12/28/23 were not implemented, and the comprehensive care plan was not fully developed to promote wound healing. The finding is: The policy and procedure titled Initial Skin Disruption and Assessment Documentation revised 6/24/19 documented an Initial Skin Disruption and Assessment Record (Non-Pressure Injury) will be initiated at first recognition of a significant skin disruption. Moisture associated skin damage documentation will be initiated upon recognition. Weekly notes will be written in the electronic record wound and skin component thereafter, until the disruption is healed/closed/resolved. The purpose of this directive is to reflect presence and stats of a skin disruption (non-pressure injury), response to nursing care and continuity of care. The policy and procedure titled Initial Pressure Injury Identification and Assessment Documentation revised 6/18/2020 documented to determine the presence of a pressure injury and stage according to the following scale: unstageable/unclassified: full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description: until slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III (3) or IV (4). Preventative measures: include under intervention on the Interdisciplinary Care Plan. This may include but not limited to repositioning, protective devices, cushions, bed mattress, overlays, lubrication of the skin hygiene, hydration, nutritional support, non-compliance, and close observation of pressure areas. The policy and procedure titled Care Planning, Closet Care Plans, Care Guides-Nursing revised 6/2019 documented Closet Care Plans-Skilled Nursing: included on the closet care plan will be any information known to be needed to meet the resident's needs. The resident's formal turning and positioning needs are also listed on the Kardex (guide used by staff to provide care). Resident #142 had diagnoses that included Alzheimer's disease, unspecified protein-calorie malnutrition, and generalized osteoarthritis. The Minimum Data Set (a resident assessment tool) dated 12/15/23 documented Resident #142 was moderately cognitively impaired. Resident #142 was at risk for developing pressure ulcers, had pressure ulcers, and were incontinent of bladder and bowel. Additionally, the Minimum Data Set, dated dated dated [DATE] documented Resident #142 had moisture associated skin damage present. The untitled comprehensive care plan last revised 11/8/23 documented Resident #142 had the potential impairment to skin integrity related to fragile skin. Documented approaches included to cleanse bilateral buttocks with normal saline, pat dry, apply antifungal powder, Medi honey (use to promote wound healing and cover with dry clean dressing every shift until healed dated 10/12/23. Additionally, revised on 2/23/23 Resident #142 had the potential for pressure ulcer development related to decreased mobility with approaches last revised on 7/17/23. There were no new approaches initiated until 1/9/24 which were to turn and position every two hours while in bed. The Kardex as of 1/9/24 did not document formal turning and positioning needs for Resident #142. Review of the Order Recap Report dated 2/1/23-1/31/24 for Resident #142 revealed: - 11/22/23, discontinue cleanse bilateral buttocks with normal saline, pat dry, apply antifungal powder, Medi honey and dry clean dressing to moisture associated skin damage every shift. - 11/22/23-11/30/23, cleanse unstageable pressure ulcer to left buttock with normal saline, pat dry, apply Medi-honey and antifungal powder and cover with dry clean dressing every evening shift and as needed for wound healing, discontinued on 11/30/23 per wound consultant services recommendation. -11/30/23-12/14/23, apply Santyl External Ointment (enzymatic debridement agent) to left sacrum/buttock unstageable pressure ulcer topically every evening shift for wound healing. -12/14/23-12/21/23, cleanse left sacrum/buttock unstageable pressure ulcer with normal saline, pat dry, apply Nystatin powder, Santyl and Flagyl powder and cover with dry clean dressing. -12/21/23-12/28/23, Gentamicin Sulfate (antibiotic) external cream 0.1 percent apply twice a day for wound healing. Cleanse unstageable pressure ulcer to left buttock with normal saline, pat dry, apply Medi-honey, antifungal powder and Gentamicin cream and cover with dry clean dressing twice a day. -12/28/23-1/8/24, apply Santyl external ointment to left buttock/sacrum unstageable pressure ulcer topically once a day for wound healing, cleanse with normal saline, pat dry, cover with dry clean dressing. There were no documented orders for a plain x-ray of sacrum to rule out osteomyelitis (infection of the bone) or for wound culture as recommended on 12/28/23 by Wound Consultant Medical Doctor #2. -1/4/24, order to give 120 milliliters mighty shake twice a day for wound healing/nutrition. Review of Medical Visit notes dated 10/10/23 through 12/12/23 revealed there was no documented evidence of the presence of wound/skin concerns and pressure ulcers. The Skin and Wound Evaluation dated 11/22/23 documented Resident #142 had a new in-house acquired unstageable pressure ulcer, the location was not documented. The wound measured 5.0 centimeter squared area, 2.9 centimeters length by 2.3 centimeters wide. The evaluation documented the resident was to be seen by Wound Consultant Medical this Thursday. Review of the Progress Notes dated 11/22/23 at 2:33 PM by Registered Nurse #5, Nurse Manager revealed the resident was to be put on wound care services for recommendations of treatment. A positioning wedge in place and air overlay to be added to bed for protection. Turn and position as ordered while in bed. Review of the Skin and Evaluation dated 11/30/23 revealed Resident #142 had a new unstageable pressure ulcer to left gluteus with wound measurements of 7.0 centimeters squared area, 3.3 centimeters length by 2.9 centimeters wide. Notes documented Wound Consultant Medical Doctor #2, evaluated Resident #142's unstageable pressure ulcer to left buttock/sacrum and debrided wound on 11/30/23. Additionally, new treatment orders given. Review of the untitled initial wound review note completed by the Wound Consultant Medical Doctor #2 dated 11/30 revealed Resident #142 had a stage 3/unstageable pressure ulcer to their left butt/sacrum, wound size 3.34 centimeters by 2.91 centimeters with sharp wound debridement procedure was performed. Review of the Skin and Evaluation dated 12/28/23 revealed Resident #142 had a new unstageable pressure ulcer to left gluteus and there were no wound measurements documented. Treatment documented sharp debridement. Review of the untitled wound review note completed by Wound Consultant Medical Doctor #2 dated 12/28/23 revealed Resident #142 had an unstageable pressure ulcer to their left butt/sacrum, wound size 4.10 centimeters by 2.67 centimeters. Wound status noted to be worse and sharp debridement procedure was performed. Recommendations included a plain x-ray of sacrum to rule out osteomyelitis, a wound culture, and a treatment daily to the pressure ulcer. Review of the Skin and Evaluation dated 1/4/24 revealed Resident #142 had a new unstageable pressure ulcer to left gluteus and measured 7.9-centimeter squared area, 3.8 centimeters length by 2.9 centimeters wide. Depth, undermining tunneling not applicable. Review of the untitled wound review note completed by Wound Consultant Medical Doctor #2 dated 1/4/23 revealed Resident #142 had an unstageable pressure ulcer to their left butt/sacrum, wound size 3.77 centimeters by 2.88 centimeters. There was no wound status documented. During an observation on 1/5/24 at 8:43 AM, Resident #142 was lying on their back in bed, with head of bed elevated, on a standard pressure relieving mattress. There was no air overlay or positioning wedge observed to be utilized on bed. During an observation on 1/8/24 at 7:48 AM and 9:20 AM, Resident #142 was lying on their back on a standard pressure relieving mattress in bed. There was a positioning wedge observed at foot end of bed. During an observation on 1/8/24 at 9:25 AM, morning care was completed on Resident #142 by Certified Nurse Aide #3 and #4. The dressing covering the sacrum/left buttock pressure ulcer was bunched up, loose and the pressure ulcer was uncovered and exposed. The dressing fell off during care and was noted to be saturated with serosanguinous drainage (yellow/blood-tinged fluid). Certified Nurse Aide #4 exited room, and stated they were going to inform the nurse about the dressing. After care was provided, Certified Nurse Aide's #3 and #4 boosted Resident #142 in bed, positioned on their back. The positioning wedge remained at foot of bed. During an interview on 1/8/24 at 10:04 AM, Licensed Practical Nurse #3 stated Resident #142's treatment was completed every day on the evening shift. Licensed Practical Nurse #3 stated an aide reported to them that Resident #142's dressing came off, but they did not have an as needed treatment order to complete treatment at that time. During an observation and interview on 1/8/24 at 10:54 AM, Licensed Practical Nurses #3, #5, and Registered Nurse/Inservice Instructor #2 were all present to complete treatment to the pressure ulcer on the left buttock/sacrum. Resident #142 was rolled onto their left side in bed by Licensed Practical Nurse #5. Resident #142's pressure ulcer was exposed, and small amount of serosanguinous drainage was observed on incontinent brief. Licensed Practical Nurse #5 stated they could smell an odor from the pressure wound. Licensed Practical Nurse #3 stated it was documented as an unstageable pressure ulcer. Licensed Practical Nurse #3 stated the pressure ulcer had depth, looks like it is tunneled and was about 1.5 inches wide. Wound bed was deep maroon/red in color with some granulation tissue and raised areas noted in wound bed. Light yellow slough noted at distal edge of pressure ulcer. Licensed Practical Nurse #3 completed Resident #142's treatment as ordered and placed Resident #142 after care on their back in bed. The positioning wedge remained at the foot of bed. During an interview on 1/8/24 at 3:55 PM, Certified Nurse Aide #6 stated that if a resident needed turning and positioning or had an air mattress/air overlay it would be on the residents' care plan. During an interview on 1/9/24 at 9:53 AM, Unit Manager Registered Nurse #5 Registered Nurse #5 stated turning and positioning should have been implemented for Resident #142 to promote pressure ulcer healing and prevent pressure ulcer from getting worse. Registered Nurse #5 stated they just added turning and positioning to the care plan on 1/9/24. Additionally, Registered Nurse #5 stated Registered Nurse assessments were not done on moisture associated skin damage and pressure ulcer measurements were only done when a resident was seen by the Wound Consultant. During an interview on 1/9/24 at 10:44 AM, Licensed Practical Nurse #5 stated prior to 1/8/24 the last time they saw Resident #142 buttocks was 2 to 3 months ago before Resident #142 was moved downstairs to another unit. Licensed Practical Nurse #5 stated that the area to Resident #142's left buttock/sacrum was opened, and they spoke to Registered Nurse #4 Unit Manager regarding the treatment at that time. During an interview on 1/9/24 at 10:53 AM, Unit Manager Registered Nurse #4 stated they do not complete Skin and Wound evaluations for moisture associated skin damage. Registered Nurse #4 stated they did not take measurements or track Resident #142's moisture associated skin damage because they have time frame to clear it up and was hoping to heal it. Registered Nurse #4 stated that after a couple of weeks of the wound deteriorating and not showing signs of improvement with treatment, they should have tracked it and placed Resident #142 on the Wound Consultant, Medical Doctor #2 list to be seen. During an interview on 1/9/24 at 11:04 AM, Registered Nurse Inservice Instructor #1 stated turning and positioning should be on the residents Kardex, so staff know individualized needs on how to take care of any resident. During an interview on 1/9/24 at 11:47 AM, Unit Manager Registered Nurse #5 stated they were responsible for reviewing Wound Consultant Medical Doctor #2 recommendations and getting orders. Upon review of the 12/28/23 Wound Consultant Medical Doctor #2 recommendations, Registered Nurse #5 stated they did not see those recommendations at that time and should have. During an interview on 1/9/24 at 12:18 PM, Medical Doctor/Director #1 and Nurse Practitioner #1, stated they would expect to be made aware of all Wound Consultant Medical Doctor #2's recommendations within 12 hours to make sure the recommendations were ordered. Medical Doctor/Director #1 and Nurse Practitioner #1 stated the Wound Consultants recommendations from 12/28/23 should have been reviewed with them so that osteomyelitis, infection, and worsening of wound could be ruled out. Additionally, Nurse Practitioner #1 viewed Resident #142's most recent pressure ulcer picture in the electronic medical record and stated they would stage Resident #142's pressure ulcer as a Stage IV based on the depth and wound bed. During an interview on 1/9/24 at 12:53 PM-1:05 PM, Director of Nursing stated while viewing Resident #142's comprehensive care plan in the electronic record there should be a care plan for their unstageable pressure ulcer, as it is part of their care and treatment. The Director of Nursing stated turning and positioning, use of a positioning wedge should have been on Resident #142's care plan; and an overlay or air mattress should have been being used to promote wound healing of an unstageable pressure ulcer. The Director of Nursing stated the Unit Managers were responsible for reviewing Wound Consultant Medical Doctor #2 recommendations and should be followed up on them within the week of getting the recommendations. The Unit Managers should be reviewing recommendations with the medical provider within a week, so the medical provider knows exactly what was going on with the resident. Director of Nursing stated anytime a skin issue has been identified they should be seen by the wound team and if any open areas develop resident's get added to the Wound Consultants list to be seen the following week. During a telephone interview on 1/9/24 at 12:56 PM, Wound Consultant Medical Doctor #2 stated an unstageable pressure ulcer should be restaged after they debrided the unstageable pressure ulcer and if the wound base could be seen it would be a Stage 3 pressure ulcer and if muscle can be seen it would be restaged as a Stage 4. Additionally, Wound Consultant Medical Doctor #2 stated they expected their wound recommendations to be reviewed with the primary care physician and done within a few days. 10 NYCRR 415.12 (c)(1)(2)

Based on observation, interview, and record review conducted during a Standard survey completed on 1/9/24, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #8) of 5 residents reviewed. Specifically, the facility did not implement effective interventions to prevent falls for Resident #8, who had over 60 falls since their admission to the facility in August of 2023. The finding is: The policy and procedure titled Fall Prevention Plan revised 5/19 documented the facility will implement a fall prevention plan on every resident to maximize resident safety and identify those at risk for falls. The Certified Nurse Aide will ensure all equipment, including alarms is present and functioning. All departments are required to note which residents had a fall and share this information with their staff so all staff can work together to prevent falls, this includes therapy, environmental services, volunteers, activities, spiritual care, dietary, and social workers. Resident #8 had diagnoses including cerebral infarction (stroke), aphasia (absence or difficulty with speech), and dementia. The Minimum Data Set (a resident assessment tool) dated 11/15/23 documented the resident had severe cognitive impairment and had two or more falls since admission. During an observation on 1/3/24 at 12:23 PM, Resident #8 was seated in their wheelchair in the alcove area. The resident had a dark bruise on the left side of their face and forehead. Review of the comprehensive care plan dated 10/4/23 documented the resident was at risk for falls related to confusion, psychoactive medication use, and self-transfers. The Kardex Report (guide used by staff to provide care) dated 1/9/24 documented safety interventions included do not leave unattended on the toilet, encourage a body pillow on both sides of the bed, encourage nonskid socks to both feet when in bed, a floor mat to both sides of bed, falling star program, Velcro seatbelt in wheelchair, and a wide low boy bed. Wheelchair equipment included a wedged hemi wheelchair, pummel gel cushion, dycem (non-slip, self-adhesive mat) for all layers, anti-rollback brakes, and rear anti-tippers. Review of the Risk Management historical incidents report dated from 8/17/23 at 12:40 PM to 1/6/24 at 10:40 PM documented the resident had 100 falls. Review of the Therapy Screen dated 1/4/24 documented Resident #8 was found on the floor out of their wheelchair in the alcove area on 1/4/23. The resident had a history of 66 falls in 2023. The nurse Progress Note dated 10/30/23 at 5:30 PM, written by Registered Nurse Manager #2, documented the Accident/Incident Committee met on 10/25/23 and reviewed Resident #8's fall history. All current care plan interventions were reviewed. A recommendation was made to try melatonin (sleep aid) medication, however upon further review, it was noted the resident had an allergy to this medication. There were no further interventions documented as being discussed. During an interview on 1/5/24 at 8:58 AM, Registered Nurse Manager #2 stated Resident #8 had probably fallen daily since they were admitted to the facility. The resident had bruising on their face from falls on Christmas Eve when they sustained a hematoma on their left forehead. The Registered Nurse Manager #2 stated based on the number of falls the resident has had, their interventions were not doing the best they'd like them to. During an interview on 1/8/24 at 11:57 AM, Resident #8's healthcare proxy stated what the facility was doing for the resident's falls wasn't working because there have been multiple falls and it was sad that they were damaging themselves this way at this point in their life. During an interview on 1/8/24 at 10:42 AM, Certified Nurse Aide #1 stated the resident has had falls, and couldn't express how they felt, so maybe that was the reason. Certified Nurse Aide #1 stated they'd never seen Resident #8 have combative behaviors and falling was their main behavior. Certified Nurse Aide #1 stated the resident wanted staff to pay attention to them, but that was hard to do while taking care of other residents. During an interview on 1/8/24 at 10:59 AM, Registered Nurse #1 stated the resident has had many falls and they can't figure it out. They try to meet the resident's needs, but it seems like there's no contentment. The resident's family said the resident was a busy person and very active. Registered Nurse #1 stated the resident couldn't communicate their needs as they were mostly nonverbal and maybe they were bored. The Registered Nurse #1 stated they didn't trust the resident to be alone and that somebody usually sits with the resident. During an interview on 1/8/24 at 4:18 PM, Registered Nurse Supervisor #3 stated Resident #8 has had many falls, sometimes multiple times per shift. Registered Nurse #3 stated they felt the resident just wanted a friend and didn't like to be left alone. Registered Nurse Supervisor #3 stated their goal was to keep the resident from falling and to do this, someone needed to be with them or keep an eye on them. This was an everyday occurrence for this resident. During an interview on 1/9/24 at 9:34 AM, Registered Nurse Manager #2 stated the fall committee meeting reviewed the resident in October. They were not sure if they discussed any additional interventions other than the melatonin (which the resident was allergic to), they might have discussed using a different medication. During an interview on 1/9/24 at 9:59 AM, Occupational Therapist Registered #1 stated they participated in the fall committee meetings, and they meet quarterly. Occupational Therapist Registered #1 stated this resident was a challenge, and thought the resident deliberately slides themselves from their chair. To keep the resident safe, they monitor to ensure all the equipment in place is the ideal equipment for them and the resident gets a lot of attention from the staff. During an interview on 1/9/24 at 12:12 PM, the Director of Nursing stated the interdisciplinary team knew about Resident #8's falls and that they have exceeded 50 since they were admitted to the facility. The Director of Nursing stated it was almost impossible to prevent the resident's falls and they felt they were keeping the resident as safe as they possibly could. The Director of Nursing stated they have not been able to pinpoint any type of pattern with the falls. The Director of Nursing stated obviously not that their interventions weren't working to prevent falls. NYCRR 10 415.12 (h)(2)

Based on observation, interview, and record review conducted during a Standard survey completed on 1/9/2024, the facility did not provide separately locked, permanently affixed compartments for the storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse for one (Unit 4 East) of three resident units observed for medication storage. Specifically, there were three bottles of liquid Lorazepam (Ativan, Schedule IV controlled substance - sedative/antianxiety medication) in a locked box that was not permanently affixed in small refrigerator located in the medication room. Residents #14 and #478 were involved. The finding is: The facility policy and procedure titled, Controlled Substances Administration and Storage revised on 2/2017 documented, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility in accordance with Federal and State laws and regulations. Controlled substances are stored under double lock in a fixed cabinet designated for that purpose in the medication room, separate from other medications. During an medication storage observation on 1/8/2024 at 9:39 AM, Licensed Practical Nurse (LPN) #7 unlocked a small refrigerator in the medication room and removed a small locked metal box. The small metal box, contained three bottles of Lorazepam intensol oral concentrate 2 milligrams (mg) per milliliter (ml). Bottle #1 for Resident #14 had 28.25 milliliters (ml) remaining with a pharmacy fill date of 12/1/23; bottle #2 for Resident #14 had 30 milliliters (ml) remaining with a pharmacy fill date of 12/29/23; bottle #3 for Resident #478 had 30 milliliters (ml) remaining with a pharmacy fill date of 12/29/23. During an interview on 1/8/2024 at 9:39 AM, Licensed Practical Nurse (LPN) #7 stated the metal locked box was newer and had not been affixed to the inside of the refrigerator and did not know if it was required. During an interview on 1/8/2024 at 9:47 AM, Unit Manager Registered Nurse (RN) #6 stated the locked box was not affixed to the refrigerator, and that they believed controlled substances needed to be double locked. RN #6 stated they were not sure if the locked box needed to be affixed to the refrigerator. During an interview on 1/8/2024 at 3:09 PM, the Director of Nursing stated the refrigerator on the Four East Unit was only about two to three months old and they could not affix a locked box to the inside of the refrigerator. Therefore, the Lorazepam should not have been stored in that refrigerator. The Director of Nursing stated it was important to ensure that the control substances were stored in a locked control box that was affixed to the refrigerator to ensure that the no one could take the box out of the refrigerator. The Lorazepam (controlled substance) was not securely stored. 10 NYCRR 415.18(e)(2)

Based on observation, interview, and record review conducted during a Standard survey completed on 1/9/24, residents have the right to a safe, clean, comfortable, and homelike environment and the facility did not provide housekeeping and maintenance services necessary to maintain a clean and comfortable interior. Specifically, five units (2 East, 2 West, 3 East, 3 [NAME] and 4 West) of six units had issues with dirty wall heaters. The findings are: The policy and procedure titled, Cleaning Resident Rooms: Housekeeping revised on 6/16 documented Resident rooms are cleaned to control the spread of infection. Vertical and horizontal room cleaning/ disinfecting: using the appropriate disinfectant solution and wearing gloves, damp clean and disinfect windowsills and heater. Review of untiled report, identified as the maintenance work orders by the Director of Plant Operations, dated 11/9/2023 through 1/8/2024, revealed there were no work orders to clean heating registers. Observations of the 2 East Unit electric of the wall heaters had debris located on top of the heater beneath the plexiglass protective cover with vent holes on the top revealed the following: -1/3/24 at 2:59 PM and 1/8/24 at 12:20 PM Resident room [ROOM NUMBER] wall heater had plant leaves and debris. -1/3/24 at 3:00 PM and 1/8/24 at 12:25 PM side 2, end of the hallway, the wall heater had two dead bugs, dried plant leaves, dust debris and a candy wrapper. -1/4/24 at 2:25 PM Resident room [ROOM NUMBER] the wall heater had dried plant leaves. -1/4/24 at 2:27 PM Resident room [ROOM NUMBER] the wall heater had dried plant leaves. -1/4/24 at 2:32 PM Resident room [ROOM NUMBER] the wall heater had two facial tissues. -1/4/24 at 2:38 PM Resident room [ROOM NUMBER] the wall heater had a toothbrush. Observations of the 2 [NAME] Unit wall heaters had debris located on top of the heater beneath the plexiglass protective cover with vent holes on the top revealed the following: -1/3/24 at 9:29 AM, 1/4/24 at 10:24 AM, 1/5/24 at 8:40 AM and 1/8/24 at 12:12 PM Resident room [ROOM NUMBER] the wall heater had thick grey dust build up, and paper debris. -1/4/24 at 9:20 AM and 1/8/24 at 10:13 AM Resident room [ROOM NUMBER] the wall heater had thick grey dust build up, dried flower petals, candy wrappers, laminated prayer card and a three-leaf clover decoration. -1/4/24 at 10:38 AM, Resident room [ROOM NUMBER] the wall heater had thick dust and dried plant leaves. -1/8/24 at 9:25 AM and 1/9/24 at 9:38 AM, Resident room [ROOM NUMBER] the wall heater had grey dust debris, a straw wrapper, toothpaste cap, and dried plant leaves. -1/4/24 at 2:45 PM Resident room [ROOM NUMBER] the wall heater had two red arm bracelets and a disposable drinking straw. -1/8/24 4:15 PM, resident room [ROOM NUMBER] the wall heater had dried flower petals, dust and peeling white paint from the wall. Observations of the 3 East Unit wall heaters had debris located on top of the heater beneath the plexiglass protective cover with vent holes on the top revealed the following: -1/4/24 at 10:31 AM, Resident room [ROOM NUMBER] the wall heater had dead plant leaves, flower petals, dust, pearl bead and scattered paper debris. -1/4/24 at 10:33 AM Resident room [ROOM NUMBER] the wall heater had dead flower petals and a lot of dust build up. -1/4/24 at 11:34 AM and on 1/8/24 at 8:51 AM, Resident #room [ROOM NUMBER] the wall heater had thick dust and dried plant leaves and flower petals. -1/4/24 at 10:37 AM, the end of hall, side 2 the wall heater had a soiled paper napkin, a soiled tissue, dust, and smaller paper debris scattered along the top, white and brown dried spill stains on the clear plastic cover and down the front of the heating register. Observation on 1/4/24 at 11:35 AM, Resident room [ROOM NUMBER] the wall heater had thick dust and dried leaves on top. -1/4/24 at 12:35 PM Resident room [ROOM NUMBER] wall heater had dried plant leaves and a disposable drinking straw. Observations on the 3 [NAME] Unit of wall heaters that had debris located on top of the heater beneath the plexiglass protective cover with vent holes on the top revealed the following: -1/3/24 at 3:23 PM Resident room [ROOM NUMBER] the wall heater had thick dust and several dried leaves scattered on it. -1/4/24 at 9:48 AM Resident room [ROOM NUMBER] the wall heater had thick dust, several small pieces of crumpled paper, a paper covered straw and several dried plant leaves. -1/4/24 at 9:49 AM Resident room [ROOM NUMBER] the wall heater had thick dust, several small pieces of crumpled paper and several dried plant leaves scattered on top of it. -1/4/24 at 9:51 AM Resident room [ROOM NUMBER] the wall heater had thick dust, several small pieces of crumpled paper, and several dried plant leaves scattered on it. -1/4/24 at 10:16 AM Resident room [ROOM NUMBER] the wall heater had several small pieces of crumpled paper, a white plastic bottle cap and several scattered dried plant leaves. During multiple observations on 3 [NAME] Unit on 1/8/24 between 9:00 AM and 11:00 AM, there were no changes to the condition of the wall heaters mentioned above. -1/9/24 at 10:03 AM, Resident room [ROOM NUMBER] wall heater had thick dust, paper debris and dried leaves. Observations made on the 4 [NAME] Unit the wall heaters that had debris located on top of the heater beneath the plexiglass protective cover with vent holes on the top revealed the following: -1/4/24 at 11:36 AM Resident room [ROOM NUMBER] wall heater had a salt packet. -1/4/24 at 11:50 AM Resident room [ROOM NUMBER] wall heater had dried plant leaves. -1/4/24 at 12:00 PM Resident room [ROOM NUMBER] wall heater had dried plant leaves. During an interview on 1/8/24 at 10:23 AM, Housekeeper # 2, stated they do not have the ability to clean under the covers of the heating units in residents' rooms and the maintenance department maintains them. Housekeeper #2 stated they know there was debris from plants, and dust gets under the covers of the registers, but they can't get it out. Housekeeper # 2 stated they didn't know who to report it to, hasn't reported it, and stated that they could have reported it to their boss, the Housekeeping Director. During an interview on 1/8/24 at 10:43 AM, a resident that resides in room [ROOM NUMBER] stated that the dried leaves and debris on the heating registers made them nervous. They thought that because it was a heating unit, it could be a fire hazard. They thought that maintenance would have to remove the clear plastic for them to clean under it. They stated that housekeeping kept their room very clean, but they couldn't clean under the clear plexiglass that covered the top of the heating register. During an observation and interview with Housekeeper #1 on 1/8/24 at 10:54 AM on side 2 hall of the 3 East Unit the heaters remained with a soiled napkin, soiled tissue, paper debris, dust, and dried spills. Housekeeper #1 stated the heating register did not look clean or homelike, and that they wiped down the heating registers as part of their duties, but maintenance had the vacuum to get under the clear plastic cover to clean the registers. During an interview on 1/8/24 at 11:06 AM, the Housekeeping Director stated they would expect staff to complete a work order, so maintenance was aware of the need for the heating units to be cleaned. Maintenance had a vacuum with a special attachment to clean them with. Housekeeping Director stated they would expect housekeepers to report concerns to them. Housekeeping Director stated dried leaves and stuff like tissues, paper get in there and they wouldn't want it to overheat. During an interview on 1/8/24 at 11:22 AM, Housekeeper #3 stated that they wiped down the outside of the clear plexiglass on the wall heaters whenever it was dusty, but they had to call maintenance when there was debris under the plexiglass and housekeepers did not have access to a vacuum. Housekeeper #3 stated that paper and dead leaves sitting directly on the heaters could be a fire hazard. During an observation interview and with Certified Nursing Assistant #8 on 1/8/24 at 12:33 PM, Certified Nursing Assistant #8 stated there was dried flowers and dust on the wall heater in Resident room [ROOM NUMBER], and two dead bugs, plant debris, dust, and a candy wrapper on the wall heater on side 2 at the end of the hall. They stated they believed maintenance department was responsible to clean the wall heaters because of the plexiglass covering. During an interview and observation on 1/8/24 at 12:50 PM Unit Manager Licensed Practical Nurse #6, stated there was dried flower plant debris and dust on the wall heater in resident #oom 260 and two dead bugs, plant debris, dust, and a candy wrapper on the wall heater on side 2 at the end of the hall and believed maintenance department is responsible to clean the wall heaters because of the plexiglass covering. During an observation and interview on 1/8/24 from 1:16 PM to 1:20 PM, Resident Rooms #346, 353, and 351 heating registers were observed with Housekeeper #1. The register had dust, paper debris, and dried leaves/flower petals the top of the heating registers under the clear plastic cover. Housekeeper #1 stated that the registers were dusty, and they didn't know if maintenance staff routinely cleaned them. During observation and interview on 1/8/24 at 1:44 PM, Resident room [ROOM NUMBER] heating register was observed with Housekeeper #1 (Housekeeper of 3 East Unit) and continued to have thick dust and dried leaves/flowers. Housekeeper #1 stated they did not have access to clean the heating registers due to the clear plastic cover and that the maintenance department cleans the registers. Housekeeper #1 stated that they would tell their supervisor and their supervisor would put a work order into maintenance to have them cleaned. They stated they have told their supervisor a couple times about the dirty heating registers. During an interview and observation on 1/8/24 at 02:45 PM the Director of Plant Operations stated wall heaters are cleaned as needed with an adaptive device on the vacuum to clean out the debris through the holes of the clear plastic cover. In addition, they stated they do not have a schedule when to clean the wall heaters and expect any staff member, such as nursing or a housekeeper to have noticed the garbage debris on the wall heaters and have requested them to be cleaned by putting in a work order. During an observation and interview on 1/8/24 at 2:52 PM with the Director of Plant Operations, the following was observed on top of the heating registers, Resident Rooms #202, 216, 225 and 342 had dust and dried plant debris noted. Resident room [ROOM NUMBER] had an unknown blue colored material, dust, and dried plant debris. The Director of Plant Operations stated that the maintenance department was responsible for vacuuming the tops of the heating registers when a work order was placed. In interview on 1/8/23 at 4:02 PM, the Director of Plant Operations stated that they do not have any work order reports for the last 30 days to clean any of the heating registers within the facility. During an interview on 1/8/24 at 2:53 PM, Unit Clerk #1 stated they had completed work orders for several wall heaters in resident's rooms in the past 30 days because they were disgusting but does not recall room numbers and was unable to review the information on the computerized work order system. During an interview on 1/9/24 at 9:42 AM, Rehab Aide/Certified Nursing Assistant #7 stated the overall appearance of the wall heaters didn't look homelike in Resident room [ROOM NUMBER]. Certified Nursing Assistant #7 stated they needed to be cleaned. Certified Nursing Assistant #7 stated if the heat gets too hot the debris could smell or even smoke. During an interview on 1/9/24 at 10:00 AM, the Administrator stated the wall heaters were not on a set cleaning schedule and expected staff to notice debris on wall heaters and report it to maintenance for cleaning. The Administrator stated the wall heaters should be cleaned and maintained for cleanliness to create a homelike environment within the facility. An observation and interview on 1/9/24 at 10:22 AM, Registered Nurse #2 (3 East Unit Manager), observed Resident room [ROOM NUMBER]'s heating register which continued to have thick dust and dried leaves/flowers debris under the clear plastic cover. Registered Nurse #2 stated that many residents on their floor had cognitive deficits issues and cannot state if they minded the dust and debris. Registered Nurse #2 stated, It is gross, and their rooms should be clean and presentable. During an interview on 1/9/24 at 10:40 AM, Registered Nurse/Inservice Instructor stated they saw dust and leaf debris under the clear protective plastic cover of the heating register in Resident room [ROOM NUMBER]. Registered Nurse/Inservice Instructor stated a work order needed to be completed, and that it wasn't homelike. Registered Nurse/Inservice Instructor stated the debris would probably be a concern if the heat register got to hot, it could stink but didn't think it could get hot enough to be a fire hazard. 10 NYCRR 415.5(h)(2)

Based on observation, interview, and record review conducted during the Focused Infection Control Survey (Complaint #NY 368) completed on 8/18/20, it was determined the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for the facility for one (Unit 3 East) of six units reviewed. Specifically, the facility did not practice social distancing (at least six feet apart) during a small group activity. This involved Residents #1, 2 and 3. The findings are: Review of a CMS (Centers for Medicare and Medicaid Services) memorandum dated April 24, 2020, with Reference ID QSO-20-28-NH, provided: Residents may still eat in dining rooms, however, nursing homes should adhere to social distancing, such as being seated at separate tables at least six feet apart. We note that social distancing should be practiced at all times not just while dining. Review of the facility policy and procedure (P&P) titled: Activities/Psychosocial Needs dated 8/20 documented social distancing and mask use should be observed when a resident is outside their room for any reason if they can tolerate mask use. During an observation on 8/18/20 at 9:35 AM Resident #1 and #3 were sitting next to one another at a 2.5 foot by 6-foot table in the Unit 3 East alcove, 3 feet apart. Resident #1 was working on a puzzle which was initiated by the Activity Aide #1. Activity Aide #1 transported Resident #2 and positioned them across from Resident #1, next to Resident #3, which was 3 feet away from both residents. Resident # 2 was 3 feet from both Resident #1 and Resident #3. Resident #2 actively engaged working on the same puzzle with Resident #1, who was observed multiple times raising their left hand, touching their fingers to their lips, then touching the pieces of the puzzle. Residents #1, 2 and 3 were not wearing face masks while sitting at the table while engaged in the puzzle activity. The Activity Aide did not provide or encourage the residents to wear a mask or attempt social distancing. During interview on 8/18/20 at 9:42 AM, Activity Aide #1 stated they try to keep everyone separated six feet apart most of the time. Activity Aide #1 stated they seated Resident #2 at the table across from Resident #1 and next to Resident #3. Residents should be encouraged to wear a face mask and socially distance. Activity Aide #1 stated the nursing staff were responsible to provide residents with masks, and anyone can encourage them to wear a face mask. Activity Aide #1 stated they did not encourage Residents #1, 2, and 3 to wear a face mask and did not keep them socially distant. During an observation on 8/18/20 at 10:33 AM Residents #1, 2 and 3 were still positioned at the table in the Unit 3 East alcove. Residents #1 and 2 were actively working on a puzzle. Resident #2 raised their fingers on left hand to their lips multiple times and then resumed touching the pieces of the puzzle. Resident's #1, 2 and 3 were not wearing face masks and were not six feet apart. During interview on 8/18/20 at 11:25 AM, the Director of Activities stated residents were expected to be socially distanced six feet apart when unable to tolerate wearing masks. The residents should have been placed at separate tables six feet apart with their own puzzle. During interview on 8/18/20 at 12:29 PM, the Assistant Director of Nursing (ADON) stated maintaining social distancing of six feet apart was expected during small group activities. Staff are expected to provide frequent hand hygiene for dementia residents and should encourage residents to wear masks. The puzzle pieces should have been sanitized to reduce the potential spread of infection. During interview on 8/18/20 at 2:02 PM, the Administrator stated dementia residents do not understand when to wear masks or the need to be socially distanced. Staff are expected to socially distance residents six feet apart during activities. Hand hygiene with alcohol-based hand rub or hand wipes should be provided more frequently for our dementia residents to reduce the potential risk of infection. The staff must redirect dementia residents constantly. 415.19(a)(1)

Based on observation, interviews, and record review conducted during the Standard survey, completed on 7/15/19, the facility did not ensure that a resident who is fed by enteral means (method of feeding that uses the gastrointestinal (GI) tract to deliver part or all of a person's caloric requirements) receives the appropriate treatment and services to prevent possible complications for one (Resident #145) of one resident reviewed for feeding tubes. Specifically, the facility did not provide tube feed formula as ordered by the physician. In addition, the nursing staff documented the formula was administered as ordered. The finding is: The facility policy titled Enteral Tube Feeding: General Guideline with a revision date of 9/17 documented tube feedings, using gastrostomy tube ( [DEVICE], a feeding tube that is inserted through the abdomen or mouth into the stomach wall to feed patients who cannot eat normally) as ordered, will be considered based on comprehensive assessment where there is demonstrated medical need to prevent or reverse malnutrition or dehydration. Tube feedings will be provided according to prevailing standards of professional practice and in compliance with Federal and New York State regulations. 1. Resident #145 was admitted [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment tool) dated 5/22/19 documented the resident was cognitively intact, usually understands and was usually understood. Additionally, the MDS documented the resident received 51% (percent) or more of total calories and 501 cc (cubic centimeters) per day or more fluid intake through [MEDICATION NAME] or tube feeding. During an observation on 07/12/19 at 12:08 PM with the Assistant Director of Nursing (ADON) Registered Nurse (RN) #1 present; Licensed Practical Nurse (LPN) #1 provided the resident with the bolus feed (a type of feeding method using a syringe to deliver formula through a feeding tube allowing formula to flow down using gravity). LPN #1 checked for [DEVICE] placement and then for residuals (the volume of fluid remaining in the stomach). LPN #1 attached a large syringe (tumi) to the [DEVICE] and placed 150 cc of water into the syringe to flush the [DEVICE]. LPN #1 then placed the 237 cc of [MEDICATION NAME] 1.5 (tube feed formula) into the syringe until it all ran through the tube. LPN #1 once again administered 150 cc of water via the syringe to flush the tube. The physician's orders [REDACTED].@ 237 cc QID (four times a day) via the [DEVICE]. Flush with 175 cc water before and after the bolus feed. On 6/11/19 the water flush before and after bolus feed was changed to 150 cc. Review of the Medication Administration Record [REDACTED]. Review of the physician's orders [REDACTED]. Review of untitled Comprehensive Care Plan dated 6/11/19 revealed the problem for potential weight fluctuations due to order for PEG tube feedings, the goal was that the resident will maintain weight no higher than 128 to 136 pounds (lbs.) Review of Medication Incident/Error/Adverse Reaction Report dated 7/12/19 revealed resident received PEG feed of [MEDICATION NAME] 1.5 instead of [MEDICATION NAME] 1.2 and the Registered Dietitian (RD) #1 notified. Additionally, company sent incorrect feed packaged in box (package slip stated [MEDICATION NAME] 1.2). Review of Delivery Ticket dated and signed 7/3/19 revealed the facility received 56 8-ounce (oz.) cartons of [MEDICATION NAME] 1.2. During an interview on 7/12/19 at 12:24 PM LPN #1 stated, The bolus feed order reads [MEDICATION NAME] 1.2. The one I gave the resident reads [MEDICATION NAME] 1.5. I gave the wrong feed. The feed that I gave at 8:00 AM was also the wrong feed as I gave the [MEDICATION NAME] 1.5 that is in the box in the medication room. We do not have any [MEDICATION NAME] 1.2 on hand. I did not read the label close enough. I say it read [MEDICATION NAME] but did not notice the 1.5 on the box. I should be reading the order first and them checking the product I am administering before giving it to the resident. During an interview on 7/12/19 at 12:32 PM, ADON RN #1 stated, the box of feed LPN #1 administered reads [MEDICATION NAME] 1.5. I reviewed the orders from the physician and it reads the bolus feed should be [MEDICATION NAME] 1.2. There is no order for the feeding to have been changed to [MEDICATION NAME] 1.5. The wrong feed was given. When the order comes in the nurse is to check the order and they sign it off. Before administering the feed, the nurse should be checking the order and then the feed product. We only fax new orders to the company, otherwise they continue to send the product that was originally ordered. The company calls once a week to verify the order. During an interview on 7/12/19 at 12:36 PM, RD #1 stated, The resident is to be receiving [MEDICATION NAME] 1.2, not [MEDICATION NAME] 1.5. The feed she received is the wrong feed. The nurses should be checking the product received when it comes and before administering the feed to the physician's orders [REDACTED]. The goal for this resident is to have the weights remain stable. I will be calling the company immediately to get in the correct product, as all that is here is [MEDICATION NAME] 1.5. At 1:30 PM RD#1 stated, I spoke to the representative at the company and they stated that sometimes the wrong product is sent, and it happens due to human error. 415.12(g)(2)

Based on observations, interviews, and record review conducted during the Standard survey completed on 6/5/18, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #40) of four residents observed for pressure sores. Specifically, the lack of accurately staging a pressure ulcer, and the resident's physician had not evaluated the resident's left lateral heel pressure ulcer. The finding is: Review of the facility's policy and procedure 04.221 entitled Pressure Injury Assessment, Prevention, treatment of [REDACTED]. If slough and eschar obscures the extent of the tissue loss this is an unstageable pressure injury. Review of the facility's policy and procedure 04.222 entitled Initial Pressure Injury (ulcer) Identification and Assessment Documentation dated 11/1/16 and identified as current revealed the Stage II Pressure Injury documented that granulation tissue, slough and eschar are not present. 1. Resident #40 was admitted on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS, a resident assessment tool) dated 4/19/18 revealed the resident had severe cognitive impairment, usually understands and is usually understood. The resident required staff assistance for bed mobility, transfers, dressing, and personal hygiene. The resident had one Stage II pressure ulcer, and it was facility acquired. Review of the Care Plan revealed that on 1/14/18 the resident's shoes were noted too tight and the resident developed a Stage II to the left lateral heel due to ill-fitting shoes and a contracture of the left lower extremity. Planned approaches included to complete weekly skin assessments of the pressure ulcer and to document the assessment. On 4/24/18 a new treatment to apply Santyl ointment (used to remove dead tissue), cover with a [MEDICATION NAME] (non-adherent dressing) and wrap with kerlix daily and as needed. The treatment to the left heel was changed on 5/22/18 to [MEDICATION NAME] (antiseptic solution) twice a day and cover with a light dry clean dressing, and on 5/29/18 the treatment again changed to paint the left lateral heel with [MEDICATION NAME] and leave open to air. Review of Nursing Departmental Notes completed by Registered Nurses (RN) revealed the following: - 1/16/18 1:12 PM, revealed the resident had a Stage II open blister of the left lateral heel that measured 2.5 centimeters (cm) in length (L) x 1.9 cm in width (W) with a superficial depth. There was no drainage and documented the pressure ulcer had a white wound base. - 4/2/18 1:19 PM, Stage II left lateral heel measured 1.8 cm (L) x 1.8 cm (W), with a superficial depth and documented the wound base had 98 percent (%) granulation, and 2% slough. - 4/24/18 1:54 PM, Stage II left lateral heel measured 2 cm (L) x 1 cm (W) x 0.1 cm depth (D), with 50% yellow slough, 50% was beefy red. There was no drainage. - 5/1/18 11:18 AM, Stage II left lateral heel measured 2 cm (L) x 1 cm (W) 0.1 cm (D), and documented the wound base had 100% yellow slough. There was no drainage. - 5/8/18 2:42 PM, Stage II left lateral heel measured 0.8 cm (L) x 0.8 cm (W), with a superficial depth and documented the wound base had 50% yellow slough, and 50% pink to red tissue. There was no drainage. - 5/15/18 4:54 PM, Stage II left lateral heel measured 0.6 cm (L) x 0.4 cm (W), with a superficial depth and documented the wound base had 75% slough, and 25 % pink tissue. There was no drainage. - 5/22/18 5:43 PM, Stage II left lateral heel measured 1 cm (L) x 0.4 cm (W), with a superficial depth, and documented a yellow to white wound base, with macerated edges (occurs when the area of skin surrounding a wound has an excessive amount of moisture). - 5/29/18 11:43 AM, Stage II left lateral heel 1 cm (L) x 1 cm (W), superficial depth no drainage with a plan to change the treatment to paint with [MEDICATION NAME] twice a day and do not cover. Review of physician progress notes [REDACTED]. - 2/12/18, the MD (medical doctor) documented the resident had a Stage II pressure ulcer and to continue the current wound care. - 4/8/18, the MD documented the resident developed a Stage II pressure ulcer of left heel and to continue wound care per RN protocol. Observation on 6/1/18 at 9:54 AM revealed LPN #1 applied [MEDICATION NAME] to the left lateral heel. Upon inspection the wound had a noticeable depth/ depression to the naked eye on the heel. The wound bed was white with a scant serosanguinous (blood and serum) drainage; there no granulation tissue present. During an interview on 6/1/18 at 10:00 AM, RN #1 stated the wound was evaluated by the wound team consisting of RN #2, 3, and 4 (2 RN Unit Managers and the Assistant Director of Nurses (ADON). RN #1 reviewed the documentation and stated the left lateral heel pressure ulcer began as a Stage II blister from a shoe that was too tight. RN#1 stated the slough began in (MONTH) and the wound team all agreed the wound was still a Stage II based on the facility's policy and the treatment was changed to Santyl. RN#1 stated since the wound looked better last week, the treatment was changed to [MEDICATION NAME]. During an additional observation on 6/1/18 at 11:55 AM, the Skin Team was in the room evaluating the resident's left lateral heel pressure ulcer with two surveyors present. During the observation, RN #1 measured the depth noticed of the wound with a cotton tipped applicator, using her fingers to approximate the skin surface and stated the wound had a depth of 0.2 cm. RN #1 stated she always measures the depth in the same manner. This surveyor asked the RN to use the flat edge of the paper to approximate the depth on the applicator and re-measure. RN #1 stated it was 0.2 to 0.3 cm deep. RN #1 stated during the observation, that the wound looks different than it did on Tuesday (5/29/18); on Tuesday there was no slough. Review of the Nursing Departmental Note dated 6/1/18 at 12:09 PM by RN #1 documented the left lateral heel wound was re-evaluated by the Skin Team. The team agreed that the wound had declined, and was currently staged as a Stage III. The pressure ulcer measured 1.5 cm (L) x 0.8 cm (W) X 0.2 cm (D). The wound bed was described as having yellow slough from approximately 3 to 9 o'clock, and the remaining area of the wound bed was pink to red in color. There was no drainage. During an interview on 6/4/18 at 7:50 AM, the Director of Nursing (DON) stated the Skin Team RN's informed her the resident's pressure injury had some slough but there was still some healthy tissue present on the wound bed, thus it was assessed as a Stage II. The DON stated, currently there were no RN's in the building that were wound certified. However, the Medical Director was wound certified. During an interview on 6/4/18 at 9:05 AM, the resident's MD (Medical Doctor) stated he did not look at the resident's pressure ulcer because the resident was a hospice resident. He did not want to cause the resident any additional pain or discomfort, since the goal of the resident's care was palliative care. During an additional interview on 6/4/18 at 9:10 AM, the DON stated the 04.221 policy had a typo in it, and that a Stage II pressure ulcer does not contain slough which is consistent with the MDS Pressure Ulcer Staging criteria. Thus, the assessments were incorrect. The MDS 3.0 manual documents the definition of a Stage 2 pressure ulcer as partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. (MONTH) also present as an intact or open/ ruptured blister. 415.12(c)(2)

Based on observation, interview, and record review conducted during a Standard survey completed on 2/7/17, the facility did not ensure that the resident environment remained as free of accident hazards as possible. Six (2 East, 2 West, 3 East, 3 West, 4 East, 4 West) of six resident units observed for a safe environment had an issue involving electric heating units in resident rooms with metal surfaces that were extremely hot to the touch and not shielded from resident access. Residents #12, 49, and 111 were involved. The findings are: 1. Observations on Units 2 East, 2 West, 3 East, 3 West, 4 East, and 4 West on 2/3/17 from approximately 1:30 PM until 4:45 PM revealed resident rooms had wall-mounted electric heating units installed along the entire length of the exterior wall in each resident sleeping room. The metal grate at the top of the electric heating units, where the heat was expelled, was approximately five inches deep and located approximately three feet above the floor. Continued observations during this time revealed the electric heating units in 20 of 34 resident sleeping rooms had metal surfaces that were extremely hot to touch. Additionally, all of the heaters were easily accessible to residents, families and staff and had no shielding from the metal. During this time period, the following surface temperatures of electric heating units were measured by the Director of Plant Operations, the Lead Maintenance Supervisor, and the General Manager using the facility's two laser type infra-red thermometers in the following rooms: UNIT 2 EAST Resident Room # 253 - Top Grate 141 F (degrees Fahrenheit), Rear Ledge (closest to wall) 108 F Resident Room # 256 - Top Grate ranged from 123 to (-) 151 F, Rear Ledge ranged from 108 - 116 F UNIT 2 WEST Resident Room # 231 - Top Grate 149 F, Rear Ledge 112 F UNIT 3 EAST Resident Room # 339 - Top Grate ranged from 157 - 176 F, Rear Ledge ranged from 130 - 138 F Resident Room # 348 - Top Grate ranged from 161 - 189 F, Rear Ledge 138 F Resident Room # 352 - Top Grate ranged from 109 - 150 F, Rear Ledge ranged from 110 - 116 F Resident Room # 356 - Top Grate ranged from 135 - 205 F, Rear Ledge ranged from 141 - 170 F UNIT 3 WEST Resident Room # 308 - Top Grate 142 F, Rear Ledge 118 F Resident Room # 325 - Top Grate 190 F, Rear Ledge 115 F Resident Room # 334 - Top Grate 232 F, Rear Ledge 133 F UNIT 4 EAST Resident Room # 443 - Top Grate 199 F, Rear Ledge 120 F Resident Room # 447 - Top Grate 145 F, Rear Ledge ranged from 103 - 123 F Resident Room # 450 - Top Grate 180 F, Rear Ledge 99 F Resident Room # 460 - Top Grate 179 F, Rear Ledge ranged from 104 - 163 F UNIT 4 WEST Resident Room # 411 - Top Grate 203 F, Rear Ledge 130 F Resident Room # 412 - Top Grate 215 F, Rear Ledge 154 F Resident Room # 414 - Top Grate 151 F, Rear Ledge 135 F Resident Room # 431 - Top Grate 137 - 189 F, ranged from Rear Ledge 113 - 122 F Resident Room # 433 - Top Grate 137 - 175 F, ranged from Rear Ledge 123 - 135 F Resident Room # 434 - Top Grate 135 - 138 F, ranged from Rear Ledge 122 - 150 F Interview with the Director of Plant Operations on 2/3/17 at approximately 3:50 PM revealed a sample of room air temperatures are taken daily during each shift, but surface temperatures of the metal casing of the electric heating units are not monitored. Interview with the Director of Plant Operations on 2/3/17 at approximately 4:10 PM revealed the primary source of heat for the building is gas-heated forced air and the electric heat radiators (electric heating units) provide supplemental heat. Interview with the Director of Plant Operations on 2/6/17 at approximately 10:40 AM revealed the building is equipped with a computer-based energy management system, which controls the primary and secondary sources of heat together. Continued interview revealed the energy management system sheds and loads the electric heating units as needed, starting with the coldest parts of the building. This system can only be adjusted by the Director of Plant Operations, and is inaccessible to residents, staff members, and visitors. 2. a.) Resident #49, admitted [DATE], has [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan (CCP) dated 1/30/17 revealed that the resident is at risk for elopement due to confusion and has the ability to self-propel the wheelchair, requires supervision and redirection, and the resident lacks knowledge related to safety and safe home environment. The resident is a fall risk and had a fall on 1/7/17 going to the bathroom, with planned interventions for the use of a bed alarm and chair alarm. Observation of Resident #49's room, a semi-private room located on the 3 East Unit on 2/3/17 at 1:38 PM revealed the resident's bed was approximately 8 to 10 inches from the electric heating unit and the metal casing of the top grate was hot to the touch. The temperature of the top grate of the electric heater's metal casing was 184 to 198 degrees Fahrenheit and the metal rear ledge was 165 degrees Fahrenheit. During the observation, the surveyor needed to remove their hand within one second due to excessive heat from the top of the heater casing. In addition, the Director of Plant Operations put his hand on the metal grate and pulled his hand off within one second and stated, it's hot. During an interview on 2/3/17 at approximately 1:30 PM, Resident #49's responsible party stated that the resident wheels all over in the her room, is not often cognizant of what she is doing, and often requires constant redirection or supervision. 2. b.) Resident #12, admitted on [DATE], has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed that the resident has severe cognitive impairment and understands and is usually understood. Review of a Closet Care Plan (guide used by staff to provide care) dated 1/18/17 revealed the resident requires a total mechanical lift with the assistance of two people for transfers, and requires contact assist of two staff members for bed mobility. Review of the CCP dated 1/30/17 revealed that the resident has a potential for falls related to cognitive deficits, wandering, and independent transfer attempts with plans for the use of a bed and chair alarm. Observation of Resident #12's room, a semi-private room located on the 3 East Unit, on 2/3/17 at approximately 1:52 PM revealed the top grate of the electric heater's metal casing was hot to the touch and measured 161 to 189 degrees Fahrenheit. 2. c.) Resident #111, admitted on [DATE], has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severe cognitive impairment and usually understands and is understood. Review of the CCP dated 12/29/16 revealed that the resident has a lack of knowledge related to safety and the ability to perform functional mobility, is an elopement risk due to wheelchair mobility, confusion, and is a fall risk. Observation of Resident #111's room, a semi-private room located on the 4 East Unit, on 2/3/17 at approximately 3:52 PM revealed the top grate of the electric heater's metal casing was hot to the touch and measured 145 degrees Fahrenheit. 415.12(h)(1)

Based on interview and record review conducted during a Complaint investigation (NY# 211) during a Standard Survey completed on 2/7/17, the facility did not ensure that each resident has the right to refuse treatment, participate in experimental research, and formulate an advanced directive. One (Resident #399) of three residents reviewed for advance directives had issues involving the facility did not honor the health care proxy (HCP) wishes acting on behalf of the resident. Specifically, the facility did not send the resident to the hospital despite requests by the HCP. 1. Resident #399 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 3/10/16 revealed that the resident was admitted to the facility on [DATE]. The resident was cognitively impaired, understood, and understands. The resident required supervision of one person for eating. Interview with the HCP on 1/31/17 at approximately 1:30 PM revealed that they had requested the resident be sent to the hospital to be examined due to a fall the resident had at the facility. The HCP also stated that they asked the facility staff several times from 6/11/16 to 6/13/16 to please have their father sent to the emergency room to be examined as the facility did not have the equipment to do so. Review of a Determination of Capacity form dated 3/9/16 revealed that the resident lacks the capacity to make health care decisions. The lack of capacity is due to dementia. The form is signed by two physicians. Review of the Medical Orders for Life Sustaining Treatment (MOLST) form dated 3/16/16 revealed that the resident wished to be sent to the hospital. Review of a letter written and signed by the resident's daughter dated 4/18/16 revealed that the resident completed a health care proxy and living will on 12/18/1996. The health care proxy named the resident's daughter as his proxy to make health care decisions for him in case he is incapacitated. Review of a nursing progress note dated 6/9/16 revealed that the resident had an unwitnessed fall out of bed at 11:45 PM. The resident had no apparent injuries such as bruising, bleeding, or cuts. Neurological checks were initiated (several different checks to see if there was a [MEDICAL CONDITION] sustained during a fall or another type of trauma) which included blood pressure, temperature, respirations, pulse, hand and foot strength checks. Review of the nursing progress notes on 6/10/16 revealed the following: - 11:19 AM revealed that the resident's HCP was notified that day of the resident's fall the night before. - 3:28 PM revealed that the resident slept the majority of the shift. - 8:16 PM revealed that the resident complained of a headache at 4:45 PM. The resident received 650 (mg) milligrams of Tylenol with a positive effect. -10:23 PM revealed that the resident had several incidence's of agitation and was found lying on his bed with the lower half of his body hanging out. The resident was also yelling out but did not have an answer for staff when he was asked what was wrong. Review of nursing progress notes dated 6/11/16 revealed the following: - 9:57 PM revealed that the resident's daughter was in to visit and was concerned about the resident. The daughter stated to staff that the resident was complaining about pain in his ears and throat. Registered Nurse (RN) #4 examined the resident and noted that there was no drainage or redness in throat or ears. - 10:02 PM revealed that the resident stayed in bed all shift, refused supper, and refused medications. The resident also complained of pain to his back, neck, and complained of headache. - 10:07 PM revealed that the daughter requested that the resident go to the hospital for the pain in his ears, throat, neck, and head. Licensed Practical Nurse (LPN #2) stated to the daughter that she did not feel that the resident going to the hospital was warranted at this time. The daughter then stated to LPN #2 that the resident had a missing tooth and she was concerned about a mouth infection. She requested that the resident go to the hospital to the emergency department so he could be examined. LPN #2 stated to the daughter that the resident's vital signs are within normal limits (WNL), stable, and had no fever. LPN #2 then evaluated resident's mouth and throat with a flash light, tissue wnl. LPN #2 called the physician and the physician instructed to monitor resident for 24 hours and take vital signs if any changes. Review of the nursing progress notes dated 6/12/16 revealed the following: - 2:15 AM complained of neck pain. - 2:43 PM revealed that the resident was totally fed by the certified nurse aide (CNA) during breakfast, at lunch, and the resident would not feed himself or open his eyes. - 2:51 PM revealed that the resident complained of a backache at 8:00 AM and was medicated with pain medication. - 8:10 PM revealed that the resident did not feed himself supper and he was sleepy but easily aroused. A progress note dated 6/12/16 at 9:53 PM revealed that at 8:55 PM staff spoke to the resident's daughter. The resident's daughter stated if my dad doesn't get STAT (now) labs done, then I am coming in there and taking him to the hospital myself. At 9:05 PM the staff notified the RN supervisor. The resident was assessed and had low blood oxygen level of 77 % (percent) (normal 94 - 99 %) , his skin was cool and dusky, and his nail beds were bluish in color. Oxygen was applied and abnormal lung sounds were noted in his left lungs. Physician orders [REDACTED].(a laboratory test to see the amount and levels of blood cells in the blood). Review of the nursing progress notes dated 6/13/16 that the physician was notified of the results of the chest x-ray at 12:50 AM. The physician did not have any new orders and that the resident should be monitored. A progress note dated 6/13/16 by the Speech Pathologist at 9:05 AM revealed that the staff reported the resident was experiencing a change in the ability to eat and swallow. An evaluation was done and the resident was able to accept thin liquids by spoon, chewing was prolonged, and mild oral residue was cleared with alternation small amounts of thin liquids and soft foods. Recommendations by the Speech Pathologist included downgraded the resident to mechanically soft foods, liquids with no straws, a total feed, and alternating liquids with soft foods. Continue review of the nursing progress notes dated 6/13/16 revealed the following: - 1:25 PM revealed that the physician was on the unit speaking with the daughter and reviewed the laboratory results. - 1:48 PM the physician ordered an x-ray for the spine related to the fall. - 3:39 PM revealed that the resident's daughter asked the facility if they could do a magnetic resonance image (MRI) or an electroencephalogram (EEG) and was told that they could not perform one at the facility. The daughter stated that they needed to figure out what was going on with the resident and requested that the resident receive an MRI or EEG. A message was left with the physician. - 4:24 PM revealed the x-ray revealed no fractures of the resident's spine. - 4:32 PM revealed that the resident complained of neck and back pain. - 5:52 PM revealed that the Nurse Practitioner (NP) and was updated on the resident's medical status including his current complaints of pain. The NP ordered that the resident be transferred to the emergency room due to MOLST form indicating that if pain or severe symptoms cannot be controlled that the resident be sent to the hospital. - 6:10 PM revealed that resident was transferred to the local hospital. Interview with the Director of Nursing (DON) on 2/3/17 at approximately 1:47 PM revealed that she expects her staff to call the physician and notify them of the resident's daughter's concerns. The DON also stated that she would have sent the resident to the hospital if the resident's daughter is asking her to do that. Interview with the Medical Director on 2/3/17 at approximately 2:06 PM revealed that the Medical Director would expect the staff to call her about the HCP wanting the resident to be sent to the hospital. She also stated that if the HCP is pushing for the resident to be sent to the hospital then the resident should be sent to the hospital. Interview with the Nurse Practitioner (NP) on 2/7/17 at approximately 11:56 AM revealed that they would try to do the interventions at the facility before sending them to the hospital. The NP stated that she sent the resident to the hospital because of his neck pain and per his daughter's request. Review of a policy and procedure entitled Health Care Proxy dated 04/13 revealed that all residents may appoint an agent to make health care decisions in the event that they lose decision making capacity. Review of a policy and procedure entitled MOLST/Do Not Resuscitate (DNR) (withhold cardiopulmonary resuscitation) dated 09/16 revealed that if the resident is unable to make his or her own decision due to lacking capacity, the designated surrogate or primary HCP agent will be responsible. 415.3(e)(1)(i)