Every finding on record at Buena Vida Rehab And Nursing Center

Based on observation, record review, and interviews, the facility failed to ensure sufficient nursing staff were available to provide nursing and related services to assure resident safety to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, interviews with residents, resident representatives, and staff members indicated that there were staffing concerns in the facility. Additionally, the Payroll Based Journal Staffing Data Report for 01/01/2026-03/31/2026 triggered for Excessively Low Weekend Staffing, and a review of staffing from 01/01/2026-03/31/2026, and 05/01/2026-06/12/2026 indicated multiple dates where the facility did not ensure sufficient nursing staffing based on their facility assessment's staffing levels. The findings include: The facility policy titled Staffing last reviewed 04/31/2026 documented that the facility must have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety. The policy also stated providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. The Facility Assessment last updated 06/01/2026 documented the following par levels for the facility:Day Shift (7:00 AM - 3:00 PM): 2-4 Nurses per unit and 4-5 Certified Nursing Assistants per unitEvening Shift (3:00 PM - 11:00 PM:) 2-3 Nurses per unit and 4-5 Certified Nursing Assistants per unitNight Shift (11:00 PM - 7:00 AM): 2-4 Nurses per unit and 4-5 Certified Nursing Assistants per unit Review of the actual staffing schedules from 01/01/2026 through 06/12/2026 documented the following:On 01/01/2026 on the day shift: the 4th Floor and 6th Floor units were short of 1 Nurse.On 01/01/2026 on the evening shift: 3rd Floor, 4th Floor, 5th Floor, 6th Floor units were short of 1 Nurse and 1 Certified Nursing Assistant, and the 2nd Floor and 7th Floor units were short of 1 Certified Nursing AssistantOn 01/01/2026 on the night shift: 3rd Floor, 4th Floor, 5th Floor, and 6th Floor units were short of 1 Nurse.On 01/02/2026 on the evening shift: the 3rd Floor, 4th Floor Unit, 5th Floor unit were short of 1 Nurse and 1 Certified Nursing Assistant, the 6th Floor unit was short of 1 Nurse, and the 2nd Floor Unit was short of 1 Certified Nursing AssistantOn 01/02/2026 on the night shift: the 3rd Floor, 4th Floor, 5th Floor, and 6th Floor units were short of 1 Nurse.On 01/03/2026 on the day shift: the 3rd Floor, 4th Floor, 5th Floor, and 6th Floor units were short of 1 Nurse.On 01/03/2026 on the evening shift: the 3rd Floor, 4th Floor, and 5th floor units were short of 1 Nurse and 1 Certified Nursing Assistant, the 6th Floor Unit was short of 1 Nurse, and the 2nd Floor Unit was short of 1 Certified Nursing Assistant.On 01/03/2026 on the night shift: the 3rd Floor, 4th Floor, 5th Floor, and 6th Floor units were short of 1 Nurse.On 01/04/2026 on the day shift: the 3rd Floor, 5th Floor, and 6th Floor units were short of 1 Nurse.On 01/04/2026 on the evening shift: the 3rd Floor, 4th Floor, 5th Floor, and 6th Floor units were short of 1 Nurse or 1 Certified Nursing Assistant, and the 2nd Floor and 7th Floor units were short of 1 Certified Nursing AssistantOn 01/04/2026 on the night shift: the 3rd Floor, 5th Floor, and 6th Floor units were short of 1 Nurse.On 01/05/2026 on the evening shift: the 3rd Floor and 5th Floor units were short of 1 Nurse and 1 Certified Nursing Assistant, the 4th Floor and 6th Floor units were short of 1 Nurse, and the 2nd Floor Unit was short of 1 Certified Nursing Assistant,On 01/05/2026 on the night shift: the 2nd, 3rd Floor, 4th Floor, 5th Floor, and 6th Floor units were short of 1 Nurse.On 01/06/2026 on the evening shift: 3rd Floor, 4th Floor, and 5th Floor units were short of 1 Nurse and 1 Certified Nursing Assistant, the 6th Floor Unit was short of 1 Nurse, and the 2nd Floor Unit was short of 1 Certified Nursing Assistant.On 01/06/2026 on the night shift: the 3rd Floor, 4th Floor, 5th Floor, and 6th Floor units were short of 1 Nurse.On 01/07/2026 on the evening shift: the 3rd Floor, 4th Floor, and 5th Floor, and 6th Floor units were short of 1 Nurse and 1 Certified Nursing Assistant Unit, and the 2nd Floor Unit was short of 1 Certified Nursing Assistant,On 01/07/2026 on the night shift: the 3rd Floor, 4th Floor, and 5th Floor units were short of 1 Nurse.On 01/08/2026 on the evening shift: the 3rd Floor, 4th Floor, and 5th Floor, and 6th Floor units were short of 1 Nurse and 1 Certified Nursing Assistant Unit, and the 2nd Floor Unit was short of 1 Certified Nursing Assistant.On 01/08/2026 on the night shift: the 2nd, 3rd Floor, 4th Floor, 5th Floor, and 6th Floor units were short of 1 Nurse.On 01/09/2026 on the evening shift: the 3rd Floor, 4th Floor, and 5th Floor, and 6th Floor units were short of 1 Nurse and 1 Certified Nursing Assistant Unit, and the 2nd Floor Unit was short of 1 Certified Nursing Assistant.On 01/09/2026 on the night shift: the 3rd Floor, 4th Floor, 5th Floor, and 6th Floor units were short of 1 Nurse.On 01/10/2026 on the day shift: the 3rd Floor, 4th Floor, 5th Floor, and 6th Floor units were short of 1 Nurse. On 01/10/2026 on the evening shift: the 3rd Floor, 4th Floor, 5th Floor, and 6th Floor units were short of 1 Nurse.On 01/10/2026 on the night shift: the 3rd Floor, 4th Floor, 5th Floor, and 6th Floor units were short of 1 Nurse.On 01/11/2026 on the day shift: the 3rd Floor, 4th Floor, and 5th Floor units were short of 1 Nurse.On 01/11/2026 on the evening shift: the 3rd Floor, 4th Floor, and 5th Floor units were short of 1 Nurse and 1 Certified Nursing Assistant, the 6th Floor Unit was short of 1 Nurse, and the 2nd Floor Unit was short of 1 Certified Nursing Assistant.On 01/11/2026 on the night shift: the 3rd Floor, 4th Floor, 5th Floor, and 6th Floor units were short of 1 Nurse.On 01/12/2026 on the evening shift: 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 01/12/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 2 Nurses.On 01/13/2026 on the evening shift: 2nd Floor Unit was short 2 Certified Nursing Assistants, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 01/13/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 01/14/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 01/14/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 01/15/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 01/15/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 01/16/2026 on the evening shift: 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 01/16/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 01/17/2026 on the day shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 01/17/2026 on the evening shift: 2nd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse, 7th Floor Unit was short of 1 Certified Nursing Assistant.On 01/17/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 01/18/2026 on the day shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 01/18/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 01/19/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 01/19/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 01/20/2026 on the day shift: 5th Floor Unit was short of 1 Nurse.On 01/20/2026 on the evening shift: 2nd Floor Unit was 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short 1 Certified Nursing Assistant.On 01/20/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse.On 01/21/2026 on the evening shift: 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 01/21/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 01/21/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 01/22/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 01/22/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 01/23/2026 on the evening shift: 2nd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short 1 Nurse.On 01/23/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 01/24/2026 on the day shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 01/24/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant.On 01/24/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 01/25/2026 on the day shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 01/25/2026 on the night shift: 2nd Floor Unit was short of 1 Nurse, 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 01/26/2026 on the day shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Certified Nursing Assistant.On 01/26/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 01/26/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 01/27/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 01/27/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 01/28/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nrusing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 01/28/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 01/29/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 01/30/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 01/30/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 01/31/2026 on the day shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 01/31/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant.On 01/31/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 02/01/2026 on the day shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 02/01/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 02/01/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 02/02/2026 on the day shift: 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant.On 02/02/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 02/02/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 02/03/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 02/03/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 02/04/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Certified Nursing Assistant.On 02/04/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 02/05/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 02/05/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 02/06/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant.On 02/06/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 02/07/2026 on the day shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 02/07/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 02/07/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 02/08/2026 on the day shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 02/08/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 02/08/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 02/09/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 02/09/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 02/10/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 02/10/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 02/11/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 02/11/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 02/12/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant.On 02/12/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 02/13/2026 on the evening shift: 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 02/13/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 02/14/2026 on the day shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 02/14/2026 on the evening shift: 2nd Floor Unit was short of 2 Certified Nursing Assistants, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 02/14/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 02/15/2026 on the day shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 02/15/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant.On 02/15/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 02/16/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 02/16/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse.On 02/17/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 02/17/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse.On 02/18/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 02/18/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse.On 02/19/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 02/19/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse.On 02/20/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant.On 02/20/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 02/21/2026 on the day shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 02/21/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 02/21/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 02/22/2026 on the day shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 02/22/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 02/22/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 02/23/2026 on the day shift: 2nd Floor Unit was short of 3 Certified Nursing Assistants, 3rd Floor Unit was short of 1 Certified Nursing Assistant, 4th Floor Unit was short of 2 Certified Nursing Assistants.On 02/23/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 02/23/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 02/24/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 02/24/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 02/25/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 02/25/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 02/26/2026 on the day shift: 4th Floor Unit was short of 1 Certified Nursing Assistant.On 02/26/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 02/26/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 02/27/2026 on the evening shift: 2nd Floor Unit was short of 1 Certified Nursing Assistant, 3rd Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 6th Floor Unit was short of 1 Nurse.On 02/27/2026 on the night shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse, 5th Floor Unit was short of 1 Nurse, 6th Floor Unit was short of 1 Nurse.On 02/28/2026 on the day shift: 3rd Floor Unit was short of 1 Nurse, 4th Floor Unit was short of 1 Nurse and 1 Certified Nursing Assistant, 5th Floor Un[TRUNCATED]

Based on observation, record review, and interviews, the facility failed to ensure residents resided in a clean, comfortable, and homelike environment. This was evident in four (Floors 3, 4, 5, and 6) of seven resident care floors. Specifically, during observation, multiple areas throughout the facility were not clean or maintained in good repair, including damaged walls and wallpaper, peeling and chipped paint, stained ceilings, missing floor and shower tiles, damaged resident room fixtures, dirty surfaces, and deteriorated nurses' station furnishings The findings include but are not limited to: The facility's Preventative Maintenance Program policy, last reviewed 12/31/2025, requires the facility to develop and maintain a comprehensive preventive maintenance program to ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and visitors. The facility's Cleaning a Resident's Room policy, last reviewed 12/31/2025, requires resident rooms to be cleaned on a regular basis, including daily cleaning and disinfecting of surfaces, dusting, floor cleaning, garbage removal, and inspection of room furnishings. 1. During observations conducted on 06/07/2026 and 06/12/2026, numerous environmental concerns were identified throughout Unit 3, including: Dirty heating/cooling units, radiators, windowsills, walls, and wall guards with accumulated brown and black debris. Holes and black scuff marks in hallway walls. Chipped and peeling paint on walls, door frames, elevator doors, and bathroom ceilings. Peeling paint on bathroom wall tiles and discolored grout. [NAME] ceiling stains in resident rooms and common areas. Cracked floor tiles. A wall opening above the staff lounge with exposed wiring. A partially detached, non-functioning Rauland call bell without a pull string. [NAME] drip stains on lounge walls and chipped wall borders. On 06/09/2026 at 12:11 PM, Resident #203's overbed light pull cord was observed to be too short for the resident to independently operate the light. The wall behind the resident's bed also contained mismatched paint. Resident #203 stated they wanted the light repaired and the wall repainted. On 06/09/2026 at 12:16 PM, Resident #160's overbed light pull cord was observed to be damaged and repaired with rolled plastic material. Resident #160 stated the pull cord had remained in that condition since admission. On 06/08/2026 at 10:20 AM, Resident #56's spouse stated the facility was frequently dirty and that the resident's fall mat was often soiled. On 06/10/2026 at 11:34 AM, Housekeeper #1, who is the regular Housekeeper for the 3rd Floor, was interviewed and stated that housekeeping staff clean resident rooms and common areas but structural repairs, including damaged paint, walls, tiles, and wallpaper, are the responsibility of the Maintenance Department. On 06/12/2026 at 08:31 AM, Licensed Practical Nurse #3 was interviewed and stated that staff were aware of peeling wallpaper and other environmental concerns and that renovations were planned, although no completion date had been established. On 06/12/2026 at 09:28 AM, the Director of Housekeeping was interviewed and stated that daily environmental rounds were performed. The overbed light pull cords identified during the survey were repaired the same day; however, other concerns would be addressed during future renovations, and no timeline for those renovations was available. On 06/12/2026 at 09:51 AM, the Director of Nursing was interviewed and stated that environmental issues were entered into an electronic maintenance system for review by the Maintenance Department. The Director of Nursing acknowledged that Floors 3 through 6 had not yet been renovated and stated the facility generally deferred non-urgent repairs because those units were scheduled for future renovation, although no renovation timeline had been established. On 06/12/2026 at 02:14 PM, the Administrator was interviewed and stated that renovations had been completed on the 7th floor and were underway on the 2nd floor. Renovations for Floors 3 through 6 were planned but dependent upon ownership approval, and no completion schedule was available. 2. During observations conducted between 06/07/2026 and 06/11/2026, the following concerns were identified in Unit and Unit 5: Unit 4 hallway wallpaper contained food stains, pen marks, torn areas, white painted patches, and extensive discoloration. Unit 5 hallway wallpaper was heavily worn, torn, stained, and discolored throughout high-traffic areas. Resident room floors on Unit 5 contained visible footprints, wheelchair tracks, and accumulated dirt outside multiple resident rooms (Rooms 501, 509, 511, 512, 517, 519, and 521). The shower room on Unit 5 contained nine missing floor tiles near the shower drain. Housekeeper #3 stated on 06/12/2026 that resident room floors should be swept and mopped daily and housekeeping leadership should be notified whenever cleaning could not be completed. The Housekeeping Director stated on 06/11/2026 that one housekeeper is assigned to each floor and is responsible for daily cleaning of resident rooms, including mopping floors. The Housekeeping Director stated they were unaware resident room floors had not been cleaned daily and confirmed wallpaper and baseboards were scheduled for replacement during future renovations. 3. Observations conducted between 06/07/2026 and 06/12/2026 identified multiple maintenance and housekeeping concerns in Unit 6, including: White spackle patches throughout the nurses' station walls. Missing and damaged wood veneer on the nurses' station desk with brown staining. Accumulated brown debris along the desk baseboards. Dirty and peeling nurses' station gates. Torn, stained, and missing wallpaper throughout the unit. Torn wallpaper and exposed wiring adjacent to a wall-mounted computer tablet. room [ROOM NUMBER] nameplate secured with tape. Torn wall covering surrounding resident room nameplates. Stained ceiling tiles. Review of the facility's Maintenance Log for May and June 2026 revealed no work orders documenting these conditions. Housekeeper #2 stated on 06/12/2026 that they had been reassigned to another floor and were unable to complete cleaning of the nurses' station before the observations. Maintenance Staff #1 stated on 06/12/2026 that replacement wallpaper was no longer manufactured, the taped room nameplate did not have an active repair request, and damaged ceiling tiles remained in place while waiting for roof leaks to dry before replacement. Licensed Practical Nurse #4 stated on 06/12/2026 that maintenance concerns are entered into the facility's electronic reporting system and housekeeping concerns are verbally reported but stated they had not noticed the conditions observed during the survey. 10 New York Codes, Rules and Regulations 415.5(h)(2)

Number of residents sampled: 38Number of residents cited: 3Based on observations, record review, and staff interviews, the facility failed to ensure that a person-centered comprehensive care plan was developed and implemented to address the residents' medical, physical, mental, and psychosocial needs. This was evident for one of one resident (Resident #13) reviewed for Dialysis. One of one resident (Resident #56) reviewed for Abuse and 0ne of five residents (Resident # 203) reviewed for Respiratory Care. Specifically, 1). A comprehensive care plan was not developed and implemented for Resident #13 who was receiving dialysis treatment, 2). A comprehensive care plan was not created for Resident #56 who was exhibiting self-injurious behavior, and 3). A comprehensive care plan was not created for Resident #203 who was receiving oxygen treatment. The findings are: The facility's policy and procedure titled Comprehensive Care Plan reviewed 01/05/2026 documented an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment and revised as changes in the resident's condition dictate. 1.Resident #13 was admitted to the facility with diagnoses including End Stage Renal Disease. The Annual Minimum Data Set (a resident assessment tool) dated 05/11/2026 documented Resident #13 had moderately impaired cognition and was receiving dialysis treatment. The Patient Review Instrument dated 05/28/2026 documented Resident has Hemodialysis on Monday, Wednesday and Friday. The admission Nursing Note dated 05/30/2026 documented Resident #13 admitted from hospital, status post two cycles of hemodialysis and plan to resume regular hemodialysis schedule three times a week. The Physician Order initiated 06/05/2026 indicated that Resident #13 to go to Hemodialysis: three times a week and as needed as per dialysis center plan, day shift on every Monday, Wednesday and Saturday for End Stage Renal Disease. The Comprehensive Care Plans initiated 05/30/2026 did not include Resident #13's plan for undergoing dialysis treatment. On 06/11/2026 at 04:14 PM, Registered Nurse #12 stated Resident #13 was readmitted from hospital to the facility on [DATE] and they were responsible for receiving hospital paperwork and entering the admission information in the electronic medical record for admission process. Registered Nurse #12 recalled admitting Resident #13 on 05/30/2026 and checked to ensure all appropriate care plans were initiated. Registered Nurse #12 acknowledged that it was an oversight, and they must have missed the dialysis care plan. On 06/12/2026 at 10:01 AM, the Director of Nursing stated Resident #13's care plan for dialysis was not initiated, which Registered Nurse #12 acknowledged was missed by mistake. The Director of Nursing stated Resident #13 has been in the facility, going to dialysis three times a week; therefore, the care plan should have been implemented upon readmission from hospital. 2. Resident #56 had diagnoses including Alzheimer's Disease, Psychotic Disorder, Depression, and Anxiety Disorder. The Quarterly Minimum Data Set (a resident assessment tool) dated 07/31/2025 documented that Resident #56 had severe cognitive impairments, was rarely/never understood, and was rarely/never able to understand others. The assessment also documented that Resident #56 did not have physical or verbal behavioral symptoms or reject care. The Occurrence Investigation Report dated 08/05/2025 documented that on 08/05/2025 at approximately 04:34 PM, staff observed a bump with yellow discoloration on the left side of Resident #56's forehead. Resident #56 was unable to report what caused the injury and was transported to the hospital and had a CT scan completed with no acute findings. The Occurrence Investigation Report further documented that on 07/22/2025 and 07/24/2025, Resident #56 was noted as being resistive to care, combative during care, and had grabbed and pulled on staff members. The Occurrence Investigation Report documented that the injury was not reported to the Department of Health. The Comprehensive Care Plan with a focus of Resident demonstrates problem behavior of putting himself on the floor mattress last revised 10/17/2025 documented that Resident #56 had a behavior of rolling from side to side in bed on 08/20/2025. This care plan did not address head banging behavior or interventions that were supposed to be in place to assist the resident when exhibiting this behavior. On 06/11/2026 at 10:24 AM, the Director of Nursing was interviewed and stated on 08/05/2025, Resident #56 was observed by staff to have a bump and bruise on their head. The Director of Nursing also stated that the injuries were not reported to the Department of Health because Resident #56 had a habit of banging their head against their headboard in bed. The Director of Nursing further stated that there was no Comprehensive Care Plan related to behaviors of head banging because Resident #56 had a care plan that documented that Resident #56 rolled from side to side in bed, and that that was also supposed to mean that Resident #56 had a behavior of banging their head against the headboard. 3. Resident #203 was re-admitted to the facility with diagnoses that included Acute Respiratory Failure and Pneumonia. The Quarterly Minimum Data Set (a resident assessment tool) dated 05/12/2026 documented Resident #203 was cognitively intact and required assistance of staff to complete Activities of Daily Living. The Quarterly Minimum Data Set also documented that Resident #203 received continuous oxygen therapy. The Physician orders dated 05/08/2026 documented an order for oxygen continuously at 2 liters per minute via nasal canula for shortness of breath. There was no documented evidence that a care plan for oxygen via nasal cannula had been initiated. On 6/11/2026 at 2:24 PM, Registered nurse #3 was interviewed and stated that the admission nurse initiates the care plan based on the resident's diagnoses, medications and needs. Registered Nurse #3 also stated Resident #203 was sent to the hospital for acute respiratory distress and was re-admitted to the facility with an order for oxygen. Registered Nurse #3 further stated that a care plan for oxygen treatment should have been initiated on the day of readmission to the facility. On 6/11/2026 at 5:04 PM, the Director of Nursing was interviewed and stated that the facility has been having a lot of changes in the staffing pattern, especially among the Registered Nurses. The Director of Nursing also stated they have lost six Registered Nurses from the schedule, and the remaining nurses cannot find the time to initiate and update care plans. The Director of Nursing further stated they are aware of the problem, and the shortage of nurses greatly impacts their documentation compliance. 10 New York Code, Rules and Regulations 415.11(c)(1)

Number of residents sampled:38Number of residents cited: 4Based on record review and interview, the facility failed to ensure that a resident's comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This was evident for one of five residents (Resident #8) reviewed for Unnecessary Medications, one of five residents (Resident #191) reviewed for Respiratory Care, one of one resident (Resident #56) reviewed for Abuse, and one of one resident (Resident #29) reviewed for Advance Directives out of a sample of 38 residents. Specifically, 1). The care plan related to Depression for Resident #8, 2). The Respiratory care plan for Resident #191, 3). The Abuse Care Plan for Resident #56, and 4). The Advance Directive care plan for Resident #29 was not reviewed and revised after each assessment. The findings include but are not limited to: The facility policy titled Comprehensive Care Plan dated last reviewed 06/2025 documented the care plans are revised as changes in the resident's condition dictate. Care plans are reviewed at least quarterly. 1. Resident #8 was admitted with diagnosis that included Anxiety Disorder and Depression. The Quarterly Minimum Data Set (a resident assessment tool) dated 01/22/2026 and the Significant Change Minimum Data Set, dated [DATE] documented Resident #8 was cognitively intact and received an antidepressant. The Physician orders last reviewed 6/9/2026 documented an order for Sertraline (Zoloft) 75 milligrams once a day for Depression. Review of Medication Administration record dated March 2026, April 2026, May 2026 and June 2026 documented Resident #8 received medication as ordered. The care plan titled the resident used antidepressant related to Depression created 5/29/2024 and last reviewed 2/28/2026 had interventions which included administer antidepressant medications as ordered by physician, monitor side effects and effectiveness every shift, and monitor document adverse reactions to antidepressants. A Nursing weekly behavior note dated 6/3/2026 documented resident receiving psychotropic medication with no adverse side effects from psychotropic mediations. A Psychology progress note dated 6/1/2026 documented resident missing sibling who died. The goals to improve and adjust to difficult loss. Resident will continue to explore feelings and grief and loss. There was no documented evidence that the Resident #8's care plan for Depression was reviewed or revised after completion of the Significant Minimum Data Set assessment dated [DATE]. 2. Resident #191 had diagnoses that included Coronary Artery Disease (is a common type of heart disease which affects the main blood vessels that supply blood to the heart, called the coronary arteries), Alzheimer's Disease, and Respiratory Failure (serious condition in which the lungs cannot provide enough oxygen to the blood or remove enough carbon dioxide from it). The Annual Minimum Data set (a resident assessment tool) dated 1/21/2026, and the Quarterly Minimum Data Set, dated [DATE] documented Resident #191 had severely cognitive impairment and never/rarely made decisions. The Minimum Data Set assessments further documented Resident #191 was receiving Oxygen therapy. The Physician's orders dated last reviewed 6/6/20206 documented order for Oxygen continuously two (2) liters via nasal canula humified for shortness of breath. Review of Respiratory Administration record dated June 2026, May 2026, April 2026, documented resident receiving Oxygen treatments as ordered. The care plan titled The resident has Oxygen therapy related to Congestive Heart failure, resident is on nebulizer treatments created 5/28/2025 and last reviewed 7/19/2025 included Interventions of changing residents' positions every two hours to facilitate lung secretions, movement and drainage, monitor for signs/symptoms of respiratory distress and report to Medical Doctor as needed. There was no documented evidence that Resident #191's oxygen therapy care plan had been reviewed or revised after the completion of Minimum Data Set assessments on 01/21/2026 and 04/07/2026 and updated to reflect the resident is no longer on nebulizers treatments. On 06/11/2026 at 5:04 PM, during an interview the Director of Nursing stated there were a lot of changes in facility staffing, especially for Registered Nurses. The Director of Nursing also stated the changes included changes in unit assignment, and the facility used to have a Registered Nurse in charge for each floor. The Director of Nursing further stated this change greatly impacted facility documentation compliance. The Director of Nursing stated one year ago, the facility had one unit Manager, one Registered Nurse Charge Nurse, and one Licensed Practical Nurse who gave medication for each floor. The Director of Nursing stated the facility lost six Registered Nurse positions, and the facility cannot get the time to complete care plans. On 06/11/2026 at 2:17 PM, during an interview, Registered Nurse #1 stated care plans are updated quarterly, annually, after a significant change and as needed in the care planning meeting. Registered Nurse #1 also stated during the care planning meeting, if there were no changes then no editing is needed in the care plan. Registered Nurse #1 further stated if there are no changes in the resident care, they will not put in a note or document the care plan was reviewed as there is an assumption that the care plan is still in effect, and there is general signing off by the different departments, but no updating of the individual care plan itself. Registered Nurse #1 someone looking at the care plan would not know if the care plan had been updated by looking at the care plan. Registered Nurse #1 stated the care plans in the facility are updated by discussing the resident during the care planning meetings, and the Social Worker enters a note that the care plan meeting was done. Registered Nurse #1 reviewed the notes in the residents' medical record and were unable to identify any written documentation that showed the care plans were reviewed or revised after each assessment. 3. Resident #56 had diagnoses including Alzheimer's Disease, Psychotic Disorder, Depression, and Anxiety Disorder. The Quarterly Minimum Data Set assessment (a resident assessment tool) dated 03/17/2026 documented that Resident #56 had severe cognitive impairments, was rarely/never understood, and was rarely/never able to understand others. The Quarterly Minimum Data Set assessment also documented that Resident #56 was dependent on others for all areas of care. The Comprehensive Care Plan titled Potential Abuse documented that Resident #56 was at risk of abuse due to re-admission and their Dementia diagnosis. The goals documented that Resident #56's safety would be maintained, and that they would verbalize feeling safe in their environment. The Comprehensive Care Plan for Potential Abuse was last revised on 10/17/2025 and there was no documented evidence that it was reviewed after Resident #56's Minimum Data Set assessment on 03/17/2026. On 06/11/2026 at 01:37 PM, the Director of Social Services was interviewed and stated that they were responsible for updating the Potential Abuse Comprehensive Care Plan for Resident #56 on a quarterly basis within a few days of each Minimum Data Set assessment being completed. The Director of Social Services confirmed that the Potential Abuse care plan had not been updated since 10/17/2025 and that it should have been updated after Resident #56's Minimum Data Set assessment on 03/17/2026. The Director of Social Services stated that they did not know how they had missed updating the care plan. 4. Resident #29 had diagnoses of chronic obstructive pulmonary disease (a chronic lung disease that causes airflow blockage and makes breathing difficult), malnutrition (poor nutrition from not getting enough food or the right nutrients), and hypertension (high blood pressure). The Quarterly Minimum Data Set assessment (a resident assessment tool) dated 04/12/2026 documented Resident #29 had severely impaired cognition and a feeding tube. A comprehensive care plan for Advance Directives with a last reviewed date of 04/11/2026 documented no feeding tube for Resident #29. The physician's orders dated 09/22/2025 with a revision date of 04/10/2026 documented an order for a long-term feeding tube. The April 11, 2026, Medical Orders for Life-Sustaining Treatment form documented long-term feeding tube. On 06/11/2026 at 3:45 PM, the Director of Social Service was interviewed and stated their department reviews care plans during initial assessments, comprehensive assessments, annual assessments, quarterly assessments, and readmissions from hospitals. The Director of Social Service further stated Social Worker #1 reviewed but forgot to update Resident #29's advance directive care plan after the physician placed an order for a long-term feeding tube. On 06/12/2026 at 11:23 AM, Social Worker #1 was interviewed and stated they overlooked updating Resident #29's advanced directives care plan to reflect their changed status to long term feeding tube because they were busy documenting notes in records and visiting people. 10 New York Codes, Rules and Regulations 415.11(c)(2) (i-iii)

Based on observations and interviews, the facility failed to ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. This was evidenced during the Kitchen task. Specifically, prepared and frozen foods were not labeled and dated appropriately. The findings include:The facility's policy and procedure titled Storage of Perishable Goods reviewed 12/31/2025 documented frozen bread products shall be dated after opening and discarded after three months, in-house baked goods shall be dated after preparation and discarded after three days. All other items must be dated when opened and discarded within 72 hours or by the use-by or expiration date, whichever comes first. During the initial kitchen tour on 06/07/2026 from 09:24 AM to 10:02 AM, the following items were observed without a legible labeling and/or dated indicating opened and discard by date.The Walk-in Freezer contained:-18 clam shell containers of cooked item labeled that was partially readable as some type of Pepper dish and had a date that was not legible (could not decipher the handwriting). -Unbaked biscuits in a zippered bag labeled Biscuit dated 2/26/26 and 4/20/26-Individual wrapped bagels in a zippered bag labeled Bagel with a date that was not legible.-Three loaves of cinnamon raisin bread were wrapped with cling wrap dated 5/8/26, 5/8/26, 5/8/26. The Walk-in Refrigerator contained:-Three trays of 36 uncooked eggs were wrapped in cling wrap dated 6/1/26 and 6/5/26-A container of raw meat (unidentifiable) dated 6/6/26-A container of raw meat (unidentifiable) dated 6/6/26 -A container of diced raw meat (unidentifiable) labeled 6/6/26 Don't Touch-A small metal pan containing sliced fresh fruits dated Jun 01 26 and Jun 04 26 The Bread Freezer contained:-Unbaked waffles in two zippered bags labeled each bag with Open 5/3/26 and Open 5/3/26-Opened package of hamburger buns with an illegible date. The Reach-in Freezer contained:-Opened box of meat patties labeled 5/21/26-Three unopened packages of turkey bacon with manufacturer label Use or Freeze by Jan/28/2026 were stored in a zipper bag labeled Turkey Bacon, 3/30/26, 6/5/26. On 06/10/2026 at 12:09 PM, Dietary [NAME] #1 stated frozen food items are opened, wrapped and dated when they were opened and must be used within three days. Dietary [NAME] #1 also stated raw meats found in the walk-in refrigerator are dated when it is prepared and should be used within three days.On 06/10/2026 at 12:26 PM, Dietary [NAME] #2 stated frozen foods are re-wrapped and dated after opening and must be used within two days after opening. Dietary [NAME] #2 also stated prepped meats/fish filets are also dated when prepped in the pan and must be used within two days after storing.On 06/10/2026 at 12:38 PM, Dietary Supervisor stated dietary cooks are responsible for wrapping, dating when opening/prepped/prepared, store and use within 24 hours. Dietary Supervisor stated that stuffed peppers were stored in the freezer for later use, labeled when prepared and was good for three months.On 06/11/2026 at 12:08 PM, the Food Service Director stated all opened items are wrapped, dated with an open date, stored in the freezer, and used within three months. The stuffed cabbage/peppers are dated when produced and used within 14 days. Raw meat is panned and dated when prepared. The Food Service Director also stated boiled eggs are marked with a production date and used within 24 hours. The Food Service Director further stated the unopened turkey bacon packages found in the zipper bag were delivered to the facility on [DATE] and removed from the original box dated 06/05/2026. The Food Service Director stated they contacted the food distributor regarding the frozen turkey bacon received 03/30/2026 that had a manufacturing label indicating to use or freeze by 01/28/2026, and the company confirmed they had frozen the items before 01/28/2026 and kept them frozen until delivery to the facility on [DATE].On 06/12/2026 at 12:45 PM, the Administrator stated they were not aware of any labeling or dating issues found in the freezer and refrigerator in the kitchen. 10 New York Codes, Rules, and Regulations 415.14(h)

Based on observation, record review, and interviews, the facility failed to ensure the designated resident representative was notified of and involved in a significant medication change for one (Resident #56) of one resident reviewed for notification of change. Specifically, the facility decreased Resident #56's Seroquel dose from 25 milligram three times daily to 12.5 milligram three times daily on 01/26/2026 without documented notification to or consultation with the resident's representative. The findings include:The facility policy titled Notification of Medication Changes reviewed on 12/31/2025 states that the resident, family, and/or resident representative has the right to be informed of and participate in treatment decisions. The policy further states that before initiating, discontinuing, increasing, or decreasing a medication, the resident, family, and/or representative must be informed of the benefits, risks, alternatives, and potential adverse effects. The resident has the right to accept or decline medication changes Resident #56 had diagnoses including Alzheimer's Disease, Psychotic Disorder, Depression, and Anxiety Disorder.The Quarterly Minimum Data Set, dated [DATE] documented that Resident #56 had severe cognitive impairment, was rarely or never understood, and rarely or never understood others. The assessment also documented the resident received an antipsychotic medication.A Psychiatry Consultation dated 01/20/2026 documented that Psychiatrist #1 recommended tapering Resident #56's Seroquel from 25 milligram three times daily to 12.5 milligram three times daily. The recommendation was reviewed by Registered Nurse #11 on 01/21/2026 and reviewed and agreed to by Physician Assistant #1 on 01/21/2026.The January 2026 Medication Administration Record documented that Resident #56 received Seroquel 25 milligram three times daily through 01/26/2026, when the order was discontinued. A new order dated 01/26/2026 initiated Seroquel 12.5 milligram three times daily.The facility was unable to provide documentation demonstrating that Resident #56's representative was notified of, consulted regarding, or agreed to the dosage reduction before the medication change was implemented.During an interview on 06/08/2026 at 10:20 AM, Resident #56's representative stated the facility decreased the resident's Seroquel dosage without consulting them. The representative stated they believed the resident needed the medication and would not have agreed to the dosage reduction.During an interview on 06/11/2026 at 10:54 AM, Psychiatrist #1 stated they did not notify Resident #56's representative of the Seroquel dosage reduction because notification was typically the responsibility of nursing staff or the attending medical provider. Psychiatrist #1 stated they were unaware the previous psychiatrist had communicated directly with the representative and believed miscommunication among facility staff resulted in the representative not being notified.During an interview on 06/11/2026 at 11:00 AM, Physician Assistant #1 stated they typically notify resident representatives of medication changes but were unable to locate documentation confirming notification of Resident #56's Seroquel dosage reduction and could not verify that notification occurred.During an interview on 06/10/2026 at 9:43 AM, the Director of Nursing stated that resident representatives are typically included in discussions regarding medication changes and may be notified by nursing staff, the physician, or the psychiatrist. The Director of Nursing stated Resident #56's representative usually communicated directly with the psychiatrist; however, they were unable to locate documentation showing the representative had been notified of the January 2026 dosage reduction and could not confirm notification occurred.10 New York Codes, Rules, Regulations 415.3(f)(2)(ii)(c)

Based on observation, record review, and interviews, the facility failed to ensure a resident was free from physical restraints imposed for purposes other than the treatment of a medical symptom. This was evident in one (Resident #56) of one resident reviewed for physical restraints out of 38 total sampled residents. Specifically, Resident #56 was repeatedly observed sitting in the middle of their bed with legs hanging off the side of the bed between the elevated head and foot sections of the bed while the bed was placed against a wall. The facility lacked documentation supporting the medical necessity, informed consent, assessment, or ongoing reevaluation of the bed's placement against the wall.The findings include:The facility's Use of Restraints policy last reviewed 12/31/2025, states that restraints may only be used to treat a resident's medical symptoms after less restrictive alternatives have been unsuccessful. The policy prohibits restraints for staff convenience, discipline, or fall prevention and requires physician orders, resident or representative consent, documentation of risks, benefits, and alternatives, ongoing reevaluation of continued need, quarterly review for reduction or elimination, and care planning that addresses the resident's underlying medical symptoms.Resident #56 had diagnoses including Alzheimer's disease, psychotic disorder, depression, and anxiety disorder.The Quarterly Minimum Data Set (MDS), dated [DATE], documented that Resident #56 had severe cognitive impairment, was rarely or never understood and rarely or never understood others, was dependent on staff for all activities of daily living, exhibited no physical or verbal behavioral symptoms, did not reject care, and did not use restraints.On 06/08/2026 at 9:42 AM and again on 06/09/2026 at 9:20 AM, Resident #56 was observed seated on the edge of the bed with both the head and foot sections elevated, positioned between the raised sections, with the resident's feet resting on a fall mat located on the right side of the bed. The left side of the bed was positioned directly against the wall. The bed remained positioned against the wall during multiple additional observations conducted between 06/07/2026 and 06/12/2026.The facility was unable to provide documentation demonstrating the medical necessity for positioning the bed against the wall, physician authorization, assessment of restraint use, ongoing reevaluation, or documentation that the resident's representative had been informed of the risks and benefits associated with the bed placement.On 06/08/2026 at 10:20 AM, Resident #56's representative was interviewed and stated they visited the resident daily and frequently found the resident positioned uncomfortably in bed. The representative stated they had previously observed the resident positioned between the elevated head and foot sections of the bed and believed the resident appeared uncomfortable. The representative also stated they preferred the bed remain against the wall because they believed it reduced the risk of the resident falling from bed due to limited staff supervision.On 06/09/2026 at 09:20 AM, Certified Nursing Assistant #4 observed Resident #56 in the same position as the surveyor and stated the resident was unable to operate the bed controls independently. They stated another staff member may have placed the resident in that position while feeding breakfast and stated they did not consider the position to be a restraint. On 06/09/2026 at 09:23 AM, Registered Nurse #6, who was a Registered Nurse Supervisor, observed the resident in the same position and stated Resident #56 should not have been left positioned between the elevated head and foot sections of the bed. They stated a staff member may have placed the resident in that position during feeding. They further stated that placing a bed against a wall could be considered a restraint; however, the resident's representative had requested the bed be positioned against the wall. During a follow-up interview on 06/09/2026 at 10:06 AM, Registered Nurse #6 stated they could not determine when the bed was first positioned against the wall because there was no documentation in the medical record. RN #6 stated documentation regarding the bed placement should have been present but was unsure what specific documentation the facility required.During an interview on 06/10/2026 at 9:43 AM, the Director of Nursing stated Resident #56's representative requested the bed be placed against the wall because of the resident's unpredictable movements and risk of attempting to stand without assistance. The Director of Nursing stated there was no documentation identifying when the bed was placed against the wall and confirmed the facility did not complete assessments or other documentation related to beds positioned against walls because the facility did not consider this practice to be a restraint. The Director of Nursing acknowledged having worked in facilities that did consider wall placement of a bed to be a restraint but was unable to explain why this facility did not. The Director of Nursing further stated Resident #56 should not have been positioned between the elevated head and foot sections of the bed or left in that position unsupervised and could not explain why the surveyor observed the resident in that position on multiple occasions.10 New York Codes, Rules, and Regulations 415.3(d)(1)(vii)

Based on record review and interviews, the facility did not ensure that all alleged violations involving abuse or neglect, including injuries of unknown origin, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than twenty four hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the New York State Department of Health. This was evident in two (Residents #56 and #241) of seven residents investigated for accidents. Specifically, the facility failed to report an unexplained facial injury sustained by Resident #56 on 08/05/2025 and an unwitnessed fall resulting in a left hip fracture sustained by Resident #241 on 10/15/2025, despite both residents being unable to explain how the injuries occurred. The findings include: The facility's Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident's Property policy, reviewed 12/31/2025, stated that all incidents, complaints, and injuries of unknown origin will be investigated and that the New York State Department of Health will be notified whenever abuse cannot be ruled out. 1. Resident #56 had diagnoses including Alzheimer's Disease, Psychotic Disorder, Depression, and Anxiety Disorder. The Quarterly Minimum Data Set, dated [DATE] documented that Resident #56 had severe cognitive impairments, was rarely/never understood, and rarely or never understood others. The assessment also documented that Resident #56 did not have physical or verbal behavioral symptoms or reject care. An Occurrence Investigation Report dated 08/05/2025 documented that staff observed a bump with yellow discoloration on the left side of Resident #56's forehead at approximately 4:34 PM. Resident #56 was unable to explain how the injury occurred. The resident was transferred to the hospital, where a computed tomography scan revealed no acute findings. The investigation concluded the injury was unavoidable, found no probable evidence of abuse, neglect, or mistreatment, and documented that the incident would not be reported to the Department of Health. During an interview on 06/08/2026 at 10:20 AM, Resident #56's representative stated the facility informed them it did not know how the resident sustained the head injury and expressed concern that the resident was being abused. During an interview on 06/11/2026 at 10:24 AM, the Director of Nursing stated the facility believed the injury resulted from the resident striking their head against the bed headboard due to past behaviors. However, the Director of Nursing acknowledged there was no documentation that the resident engaged in head-banging behaviors, no documentation identifying when the injury occurred, and no evidence establishing the cause of the injury. The Director of Nursing stated the behavior should have been documented if it had occurred and acknowledged the injury of unknown origin should have been reported to the Department of Health. During an interview on 06/12/2026, the Administrator stated the facility did not consider the injury to be of unknown origin because staff believed it was consistent with the resident's prior behaviors and therefore did not report the incident. 2. Resident #241 had diagnoses including schizophrenia (a brain disorder that can make it difficult for a person to tell you what is real and to think, feel, or behave normally), cerebral infarction (blood flow to part of the brain is blocked, causing brain cells to die or be damaged), and non-Alzheimer's dementia (a decline in memory, thinking, or reasoning). The Annual MDS dated [DATE] documented that Resident #241 had severe cognitive impairment, was rarely or never understood, and had impaired short- and long-term memory. An Occurrence Investigation Report dated 10/15/2025 documented that staff found Resident #241 on the floor beside the bed at approximately 9:30 AM. The resident complained of hip pain and headache but was unable to recall the event because of baseline confusion. Hip x-rays identified an acute left hip fracture, and the resident was transferred to the hospital for further evaluation. The investigation documented the cause of the injury as undetermined, found no probable evidence of abuse, neglect, or mistreatment, and concluded the incident would not be reported to the Department of Health. During an interview on 06/12/2026 at 12:39 PM, the Director of Nursing stated the unwitnessed fall resulting in the hip fracture had been reviewed with the Administrator. The Director of Nursing stated the resident frequently paced the hallways, occasionally sat on the floor, experienced no delay in treatment, and had no violation of the care plan. Based on those findings, the facility determined the incident did not meet reporting criteria. During an interview on 06/12/2026 at 1:46 PM, the Administrator stated the facility determined the fracture was of known origin following its internal investigation because the resident had a history of falls and interventions were already in place, including frequent monitoring. Therefore, the facility did not report the incident to the Department of Health. 10 New York Codes, Rules, Regulations 415.4

Based on observation, record review, and interviews, the facility failed to ensure that a resident received dental care in a timely manner. This was evident for one of two residents (Resident #128) reviewed for Dental out of a sample of 38 residents. Specifically, a Nursing Note dated 05/08/2026 documented that Resident #128 required a dental consultation, and there was no documented evidence that Resident #128 was seen and evaluated timely by a dentist. The findings include: The facility policy titled Dental Care for Residents reviewed 01/05/2026 stated the facility will provide routine and emergency dental care to all residents. The policy also stated that all residents will have a complete oral examination annually by a licensed dentist, and for emergency dental care, the nurse will inform the dentist, and the dentist will see the resident in the nursing home. Resident #128 had diagnoses including Type 2 Diabetes and Malnutrition.The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #128 had moderate cognitive impairment and required setup assistance when eating and completing oral hygiene. On 06/07/2026 at 11:25 AM, Resident #128 was interviewed and stated that they broke one of their teeth a month ago and still had not been seen by a dentist despite notifying staff of the broken tooth a month ago. Resident #128 stated that the broken tooth caused pain when they ate.The Nursing Progress Note dated 05/08/2026 documented that a Dental Consult was ordered related to Resident #128 experiencing tooth decay on the left molar. The facility was unable to provide documented evidence that Resident #128 was seen by a dentist in a timely manner, or that a dental visit was attempted in a timely manner. On 06/09/2026 at 10:40 AM, Registered Nurse #6 was interviewed and stated that they saw the Nursing Note that documented that a Dental Consult was ordered for Resident #128, but that they were not the regular nurse on this unit and would look into whether the resident had been seen by the dentist following that note. On 06/10/2026 at 09:27 AM, Registered Nurse #6 stated that the Dentist typically came to the facility once every week or once every other week, and they were not sure why Resident #128 had not been seen by the Dentist at some point during the last month. Registered Nurse #6 also stated that a dental visit was conducted on 06/09/2026 and Resident #128 was started on prophylactic antibiotics with a plan that the tooth would be extracted off site in a few weeks. Registered Nurse #6 stated that the Nurse Supervisor for the unit is responsible for following up on consultations to ensure they were completed, and they were not sure why the regular Nurse Supervisor for the floor did not do this. On 06/10/2026 at 10:28 AM, the Director of Nursing was interviewed and stated that residents receive dental examinations on admission, annually, and as needed when complaints or concerns emerge. The Director of Nursing also stated that when a resident is to be seen by the dentist, the nurse notifies the doctor of the resident's concern, the doctor places an order for the consultation, and then every Wednesday, the dentist gets a list of results to see in person. The Director of Nursing further stated that residents should be seen within a week for non-urgent dental complaints, such as Resident #128's broken tooth. The Director of Nursing stated that the dentist stated that they had attempted to visit Resident #128 on 05/20/2026 but they were not in their room, however the dentist had not completed any documentation related to the visit not being completed and had not notified any of the facility staff that they were unable to locate Resident #128 to complete the visit. On 06/11/2026 at 10:40 AM, the Dental Consultant was interviewed and stated that they attempted to see Resident #128 on 05/20/2026 but they were not in their room, and they did not attempt to notify staff to assist them in locating Resident #128 or to document that the visit was missed. The Dental Consultant also stated that they planned on treating the concern symptomatically and reattempting the visit if Resident #128 reported further symptoms. The Dental Consultant further stated that they did not document that they were unable to see Resident #128 on 05/20/2026 but that they should have, and they should have notified the nurse on the unit so the nurse could document and be aware of the missed visit as well. The Dental Consultant stated Resident #128 was assessed on 06/09/2026 and determined to require an off-site tooth extraction. On 06/12/2026 at 02:14 PM, the Administrator was interviewed and stated that the Nurse or Doctor on the unit are responsible for following up on ordered consultations to ensure they are completed. The Administrator also stated that because Resident #128 was not complaining to the staff about ongoing pain, it may have been why staff did not follow up to ensure the consultation was completed. 10 New York Codes, Rules, Regulations 415.17 (a-d)

Based on observations and interviews, the facility failed to ensure garbage and refuse were disposed of properly. This was evident during multiple observations of the garbage disposal area. Specifically, garbage was not properly contained outside of the facility to prevent the harborage and feeding of pests.The findings include:The facility's policy and procedure titled Disposal of Refuse reviewed 12/31/2025 documented outside dumpsters or compactors provided by waste management services will be kept closed and free of surrounding debris. On 06/10/2026 at 12:56 PM, Dietary Worker #1 was observed taking garbage from the kitchen to the garbage disposal area located outside of the building. The 20-yard dumpster was overfilled, exposing piled garbage and multiple flies around the garbage bags. The dumpster was not equipped with a cover/lid.On 06/11/2026 at 03:54 PM, the dumpster was observed uncovered, multiple flies surrounding the dumpster.On 06/10/2026 at 01:13 PM, Dietary Worker #1 stated the dumpster is utilized by both dietary/housekeeping department staff and can get filled up especially if the garbage was not picked up as scheduled. Dietary Worker #1 also stated they have not seen a lid or cover for this dumpster, so they were not able to put a lid on the dumpster after disposing garbage.On 06/11/2026 at 12:08 PM, the Food Service Director stated it has been about two weeks since they changed from a compactor to this 20-yard dumpster, as due to construction, the facility had to remove the compactor and replace it with this dumpster. The Food Service Director also stated this 20-yard dumpster did not come equipped with a cover or lid, so the waste pickup schedule was increased more often to ensure the garbage does not get piled up in the dumpster.On 06/11/2026 at 03:18 PM, the Housekeeping Director stated the dumpster did not come equipped with a cover; therefore, the waste is picked up every other day to ensure it is not overfilled. The Housekeeping Director also stated that on 06/10/2026, the dumpster was overfilled with garbage because waste could not be picked up on the night of 06/09/2026 as the waste company could not access the dumpster due to the driveway entrance being blocked.On 06/12/2026 at 12:45 PM, the Administrator stated the facility needed to place scaffolding in the garbage area due to the ongoing construction, therefore, the compactor was replaced with a 20-yard dumpster for interim. The Administrator also stated the pickup schedule was increased to ensure garbage does not pile up in the 20-yard dumpster. The Administrator further stated the garbage was not picked up as scheduled on 06/09/2026 because of the blocked driveway. The Administrator stated they were not aware that the dumpster was overfilled with waste and exposed to the surroundings, and the 20-yard dumpster did not come with a lid or cover so they will look for alternate options. 10 New York Codes, Rules and Regulations 415.14(h)

Based on observation, interviews, and record reviews conducted during an Abbreviated Survey (NY00317501), the facility failed to ensure that a resident who is fed by enteral means receives the appropriate care and services to prevent complications of enteral feeding. This was evident for one out of four residents (Resident #1) sampled for nutrition. Specifically, Resident #1 experienced persisting diarrhea from March 2023 to October 2023 while receiving tube feedings and experienced a significant weight loss of over 20 percent. There was no documented evidence that additional medical follow-up was attempted when the facility was unable to identify a cause for the persistent diarrhea or that increased weight monitoring was implemented when Resident #1 experienced a significant weight loss. The findings are: The facility's Policy and Procedure Nutrition and Hydration reviewed September 2023 states that residents within the facility will maintain adequate parameters of nutritional and hydration status, to the extent possible, to ensure each resident is able to maintain the highest practicable level of well-being. The facility's Policy and Procedure, Weight Loss reviewed September 2023 states that the nursing staff and the Dietitian will cooperate to prevent, monitor, and intervene for undesirable weight loss for the residents. The Policy further states nursing staff will measure the resident weight on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. Resident #1 was admitted to the facility with diagnoses including Cerebral Infarction, Aphasia, Dysphagia, and Hemiplegia and Hemiparesis. Resident #1 had a feeding tube. The Minimum Data Set with an assessment reference date of 03/03/2023, revealed that Resident #1 had severely impaired cognition and weighed 138.0 pounds. The Comprehensive Care plan for nutritional problem was initiated on 02/27/2023 and documented that Resident #1 had nutritional problem related to reliance on enteral route to meet 100 percent of nutritional needs and had a feeding tube. The Documentation Survey Report (completed by the Certified Nursing Assistant) documented the following: 03/01/23 to 03/31/23-26 bouts of loose stool. 04/01/23 to 04/31/23-18 bouts of loose stool. 05/01/23 to 05/31/23 -34 bouts of loose stool. 06/01/23 to 06/31/23 -18 bouts of loose stool. 07/01/23 to 07/31/23 -22 bouts of loose stool. 08/01/23 to 08/31/23- 26 bouts of loose stool. 09/01/23 to 09/31/23 -16 bouts of loose stool. 10/01/23 to 10/31/23 -18 bouts of loose stool. The Weight and Vitals sheet documented the following: 02/24/23 -138.0 pounds - admission weight. There were no weights documented for March 2023 04/10/23 -130.4 pounds (7.6 pounds weight loss from 02/24/23) 05/18/23- 121.2 pounds (16.8 pounds weight loss from 02/24/23) (12.2 percent significant weight loss) 06/05/23- 118.6 pounds (19.4 pounds weight loss from 02/24/23) 07/07/23 -113.6 pounds (24.4 pounds weight loss from 02/24/23) 08/10/23- 108.0 pounds (30.0 pounds weight loss from 02/24/23) (21.7 percent significant weight loss) 09/29/23 -100.0 pounds (38.0 pounds weight loss from 02/24/23) 10/04/23 -108.0 pounds (30.0 pounds weight loss from 02/24/23) 10/05/23 -105.2 pounds (33.0 pounds weight loss from 02/24/23) 10/11/23- 100.0 pounds (38.0 pounds weight loss from 02/24/23) 10/17/23 -103.0 pounds (35.0 pounds weight loss from 02/24/23) 11/06/23- 103.5 pounds (34.5 pounds weight loss from 02/24/23) The Order Summary Report from 02/24/23 to 05/30/23 documented the following: Monthly weights ordered 02/24/23. Imodium A-D Oral Liquid 1mg/7.5ml give 15ml via feeding tube every 12 hours as needed for loose motion for 7 days ordered on 03/22/23. Toxin A&B stool for clostridium difficile ordered on 05/08/23. Acidophilus Lactobacillus Oral Capsule (Lactobacillus) give 1 capsule via gastrostomy tube one time a day for change in bowel movement for 14 days ordered on 05/11/23. A complete blood count (measures red blood cells and white blood cells) and complete metabolic panel (measures several important aspects of your blood) ordered again on 05/17/23. Imodium A-D Oral Tablet 2mg 1 tablet via feeding tube one time only for diarrhea for 1 day ordered on 06/01/23. The Medical Progress Notes dated 03/22/23 through 10/2023, revealed periodic documentations regarding Resident #1's loose stools and weight loss. The Medical Progress notes dated 03/22/2023 showed that Imodium 1 tablet was ordered STAT and as needed for loose bowel movement. A Medical Note dated 09/12/23 at 11:50am documented that a weight meeting was held for significant weight loss and tube feeding will be evaluated (correct formula and rate), and training floor nurses. A Medical Note dated 10/03/23 revealed that Resident #1 presented with a significant weight loss times 30 days. Unplanned and unfavorable weight loss likely related to noncompliance with feeding regimen. Resident #1 was not receiving the full amount of ordered feeding when on replacement formula fiber source. Resident #1 has difficulty tolerating certain formulas often experiencing gastrointestinal distress and loose stools. Isosource is back in stock and Resident tolerating well. Dietary notes dated 03/22/23 and 03/23/23 documented that Resident #1's feeding was changed three times. However, Resident #1 continued to have loose bowel movements. A Dietary Note dated 03/23/2023 recommended to change tube feeding to Diabeticisource 6 cans bolus feed via pump with 50 milliliters before and after fluids. A Dietary Note dated 05/18/23 at 1:59pm documented Resident #1 presented with significant weight loss times 30 x 90 days and that the weight loss was unplanned and unfavorable. Etiology likely related to recent gastrointestinal distress. Also documented 30 days: 130.4 pounds (4/10) 7.1% significant weight loss. 90 days:138 pounds (2/24)-12.2% weight loss. A Dietary Note dated 08/22/23 documented significant weight change assessment. Resident #1's Body Mass Index:18 underweight for age. Documented 30 days: 113.6 pounds (7/7) - 4.9% insignificant. 90 days: 121.2 pounds (5/17)-10.9% significant, and 180 days: 138 pounds (2/24) = 21.7% significant. Tube feeding regimen estimated 100% nutritional needs. There was no documented evidence that Resident #1 was referred for additional evaluation when diarrhea persisted, and a cause could not be identified. There was no documented evidence that there was increased monitoring of weight for Resident #1 following admission or when Resident #1 was identified has having a significant weight loss. On 02/09/24 at 12:20pm, the Director of Nursing was interviewed and stated that they were not in employment at the time Resident #1 resided in the facility. Additionally, the nurses and dietitian who were assigned to Resident #1's unit are no longer in employment. During an interview on 02/09/24 at 4:30pm, the Medical Doctor stated that Resident #1 was admitted to the facility with multiple comorbidities including a stroke and a new gastrostomy tube placement. The Medical Doctor stated that Resident #1 was seen and evaluated by the speech department. The Medical Doctor stated Resident #1 was having diarrhea and that it was a side effect of the tube feeding. The Medical Doctor also stated that they ordered labs to see if there were any underlying medical disease and that the lab results were negative for any form infection. The Medical Doctor stated that they were aware of Resident #1's weight loss and that the Dietician changed Resident #1's feeding multiple times to see which feeding would be most appropriate. The Doctor stated there was a national shortage on tube feeding just like in other industry where everyone was having issue with food shortages. During a follow up telephone interview on 04/03/24 at 9:38am, the Medical Doctor stated that they did not order a gastrointestinal consult for Resident #1 because they did not believe Resident #1 had gastrointestinal problem. The Medical Doctor went on to say that staff only notify them that Resident #1 was having diarrhea during March and April 2023. The Medical Doctor stated that Resident #1's tube feeding was changed from Glucerna to [NAME] Farm. The Medical Doctor stated that after the [NAME] farm formula was changed, Resident #1 was still having some gastrointestinal issues and they spoke with Resident #1's spouse who confirmed that Resident #1 had lactose intolerance. The Medical Doctor stated that the formula was changed again to Isosource formula. The Medical Doctor stated that Resident #1 was doing well with this formula until there was a nationwide shortage. The Medical Doctor stated that Resident #1 may have loose stool, but staff did not consider it as diarrhea and maybe this was why the staff did not notify them. The Medical Doctor stated labs were done to ensure that Resident #1 had no underlying issues. The Medical Doctor also stated that Resident #1 had a surgical wound on their left knee that was not healing well, had developed a wound infection three times and was on antibiotics that contributed to the diarrhea. The Medical Doctor further stated Resident #1 was sent to the hospital (11/15/23) to address the wound infection and the non-healing of the wound. The Medical Doctor stated that Resident #1 had a stroke and was not moving which led to muscle wasting and bone density loss that contributed to the weight loss. 10 CNYCRR 415.12(g) (1-7)

Based on interviews and record review conducted during the recertification and complaint (NY00310615) survey from 2/21/2024 to 2/28/2024, the facility did not ensure all alleged violations involving injuries of unknown source, were reported immediately to the New York State Department of Health, but not later than 2 hours after the allegation is made. This was evident for 1 (Resident #24) out of 4 residents reviewed for Abuse out of 35 total sampled residents. Specifically, the facility did not report Resident #24's dislocated right shoulder of unknown origin within 2 hours of the occurrence. The findings include: The facility policy titled Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Residents' Property last dated 1/2024 documented the facility will report any incident and/or violation where abuse, neglect, mistreatment, or misappropriation of property is suspected to the New York State Department of Health. Resident #24 had diagnoses of Osteoarthritis, Dementia and Hypertension. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #24 was severely cognitively impaired and required the assistance of 2 people to complete activities of daily living. The Nursing Note dated 2/11/2023 documented Certified Nursing Assistant #6 heard Resident #24 screaming in pain from the hallway, entered the resident's room, and observed Resident #24 in bed with right shoulder pain. The Medical Doctor Note dated 2/11/2023 documented Resident #24 was transferred to the hospital after bedside examination and X-ray report of a right shoulder dislocation. The Aspen Complaint Tracking System report documented the facility report of Resident #24's injury of unknown origin was dated 2/13/2023 at 9:34 AM, more than 2 hours after occurrence. There was no documented evidence the facility reported Resident #24's injury of unknown origin within 2 hours of occurrence on 2/11/2023 at 6:45 AM. On 02/27/2024 at 02:16 PM, an interview was conducted with the Director of Nursing who stated that they were employed by the facility in 9/2023 and was unaware of the reporting of Resident #24's injury of unknown origin to the New York State Department of Health. After reviewing the facility investigation, the Director of Nursing stated the facility was not in compliance with the reporting requirements that an injury of unknown origin must be reported within 2 hours of occurrence. On 02/27/2024 at 02:30 PM, an interview was conducted with the Administrator who stated they were hired by the facility 1/2024 and were unaware of the incident and reporting of Resident #24's injury of unknown origin. 10 NYCRR 415.4(b)(2)

Based on observation, record review and interviews conducted during an abbreviated survey (NY00318019), the facility failed to develop and implement a comprehensive person-centered care plan for a resident that includes measurable objectives and timeframes to meet a resident ' s medical, nursing, and mental and psychosocial needs. This was evidence for 1 out of 3 residents sampled (Resident #1) Specifically, Resident #1 had a Physician ' s Order dated 05/19/23 for Insulin Glargine Solution (Lantus, long acting), 100u/ml, inject 30 units subcutaneously at bedtime, for Diabetes. The instructions also documented to hold for blood sugar 120 and below. A person-centered care plan was not developed with interventions for Resident #1 with diagnosis of Diabetes. The findings are: The Policy and Procedure titled Care Plans, Comprehensive Person-Centered revised 12/2016 documented a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident. Resident #1 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Schizophrenia of Bipolar type, and Dementia. The Minimum Data Set Assessment (MDS) dated [DATE], documented that Resident #1 had severely impaired cognition. A Physician ' s Order dated 05/19/2023 documented Insulin Glargine Solution (Lantus, long acting), 100u/ml, inject 30 units subcutaneously at bedtime for Diabetes. Hold for blood sugar 120 and below. Review of the Medication Administration Record (MAR) dated 06/01/23 - 06/07/23, revealed that Resident #1 was receiving the Insulin as per the Physician ' s Order. Review of the comprehensive care plans revealed that Resident #1 did not have a person-centered care plan with interventions implemented for diagnosis of Diabetes. During an interview on 06/14/23 at 1:19 pm, the Director of Nursing (DON) stated that the care plans for new admissions are initiated on the 3:00pm-11:00pm shift by the Registered Nurse Supervisor (RNS) who admitted the resident. The DON said that it is the responsible of the unit manager to ensure that all the care plans are initiated, implemented, and updated to meet resident ' s goal and that a care plan should have been implemented for Resident #1. 10 NYCRR 415.11(1)

Based on observation, record review and interviews conducted during an abbreviated survey (NY 886), the facility did not ensure that an injury of unknown origin was reported to New York State Department of Health (NYS DOH). This was evident for 1 out of 3 residents sampled (Resident #1). Specifically, Resident #1's family member notified Registered Nurse Supervisor (RNS) #1 on 06/13/2021, that Resident #1 was found with a linear scratch mark to their left cheek. RNS #1 reported the allegation to the Director of Nursing (DON) one week after Resident #1's family made the allegation. The facility did not report the injury of unknown origin to NYS DOH. The findings are: The facility Policy entitled Abuse Prevention Policy & Procedure dated 02/03/2022 documented All allegations involving mistreatment, neglect, or abuse, including injuries of unknown etiology, are immediately reported to the Director of Nursing and Administration; thoroughly investigated and effective corrective action implemented. Report all alleged violations and all substantiated incidents to the State agency and to all other agencies as required and after a thorough internal investigation. Resident # 1 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #1 had long- and short-term memory impairments and was not able to complete a Brief Interview of Mental Status. Review of a Nurse's Progress Note (late note by RNS #1) dated 06/16/2022, documented that Resident #1 was observed with a linear scratch mark to the left cheek (same self-inflicted). The medical Doctor was made aware, and [MEDICATION(S)] was applied. During a follow up interview on 08/03/2022 at 3:00 PM, RNS #1 stated that Resident #1's family reported that Resident #1 had a linear scratch mark to their left cheek. RNS #1 stated that he/she did not recall when he/she reported the allegation to the DON. During a follow up interview on 08/03/2022 at 2:45 PM, the DON stated that RNS #1 reported the scratch mark to him/her one week after the Resident #1's family reported the incident to RNS #1. The DON stated that he/she should have reported the alleged abuse to NYS DOH. 415.4.(b)(2)

Based on interviews and records review conducted during an abbreviated survey (NY 886), the facility did not ensure that an allegation of injury of unknown was investigated. This was evident for 1 out of 3 residents sampled (Resident #1). Specifically, Resident #1's family member notified Registered Nurse Supervisor (RNS) #1 that Resident #1 was found to have a linear scratch mark to their left cheek. An incident report was not initiated immediately, and the incident was not investigated to rule out abuse. The findings were: The facility Policy entitled Abuse Prevention Policy & Procedure dated 02/03/2022 documented All allegations involving mistreatment, neglect, or abuse, including injuries of unknown etiology, are immediately reported to the Director of Nursing and Administration; thoroughly investigated and effective corrective action implemented. Resident # 1 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #1 had long- and short-term memory impairments and was not able to complete a Brief Interview of Mental Status. Review of a Nurse's Progress Note (late note by RNS #1) dated 06/16/2022, documented that Resident #1 was observed with a linear scratch mark to the left cheek (same self-inflicted). The medical Doctor was made aware, and [MEDICATION(S)] was applied. During an interview on 07/05/2022 at 11:00 AM, RNS #1 stated that on 06/13/2022 Resident #1's family informed him/her that Resident #1 had a scratch mark on their cheek. RNS #1 stated that he/she did not assess Resident #1's because he/she was afraid that Resident #1 would punch him/her. RNS #1 stated that he/she assumed that the injury was self-inflicted. RNS #1 stated that he/she was supposed to assessed Resident #1's scratch mark and initiated an incident report. During an interview on 6/30/2022 at 2:00 PM, the Director of Nursing (DON) that an investigation includes identifying and interviewing of all involved persons that might have knowledge of the alleged abuse. The DON stated that an incident report was not initiated, and the injury of unknown origin was not investigated. 415.4(b)(1)(i)

Based on interviews and records review conducted during an abbreviated survey (NY 886), the facility did not ensure that a resident receive treatment and care in accordance with professional standards of practice. This was evident for 1 out of 3 residents sampled (Resident #1). Specifically, Resident #1's family member notified Registered Nurse Supervisor (RNS) #1 on 06/13/2021, that Resident #1 was found with a linear scratch mark to their left cheek. RNS #1 did not assess Resident #1 to ascertain the origin and severity of the injury. The findings are: The facility Policy entitled Accidents and Incidents originated November 2013 and updated in July 2017 documented: the Nursing Supervisor/Charge Nurse, Unit manager and or the department Director or Supervisor shall promptly be notified and then responsible for assessing, reviewing, documenting, and reporting of the incident and or accident. The supervisor must assess resident for any injury and determine if it is of known or unknown origin. Resident #1 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #1 had long- and short-term memory impairments and was not able to complete a Brief Interview of Mental Status. Review of a Nurse's Progress Note (late note by RNS #1) dated 06/16/2022, documented that Resident #1 was observed with a linear scratch mark to the left cheek (same self-inflicted). The medical Doctor was made aware, and [MEDICATION(S)] was applied. Record review of Resident #1's medical record revealed there was no order for [MEDICATION(S)] Ointment. During an interview on 07/05/2022 at 11:00 AM, Registered Nurse Supervisor (RNS) #1 stated that on 06/13/2022 Resident #1's family informed him/her that Resident #1 had a scratch mark on their cheek. RNS #1 stated that he/she did not assess Resident #1 to see the scratch as he/she was afraid that Resident #1 would punch him/her. RNS #1 stated that he/she should have assessed Resident #1's scratch mark. During a follow up interview on 08/03/2022 at 3:00 PM, RNS #1 stated that they called and informed the Medical Doctor about the allegation on the same day (06/13/2022) after the allegation was made by Resident #1's family. During an interview on 6/30/2022 at 2:00 PM, the Director of Nursing (DON) stated that the procedure for an alleged abuse includes examining the alleged victim for any sign of injury. During an interview on 08/04/2022 at 12:00 PM, the Medical Doctor (MD) stated that he/she did not recall the exact date when RNS #1 called and informed him/her that Resident #1 had a scratch mark. MD stated that RNS #1 reported that the scratch mark was self-inflicted. MD stated that RNS #1 did not report any skin opening and that he/she did not order [MEDICATION(S)] Ointment. MD stated he/she did not write a note because when he/she saw Resident #1 (does not remember date) the resident did not have any scratch marks. 415.12

Based on observations, interviews, and record review conducted during an abbreviated survey (NY 180) on 12/09/2021, the facility did not ensure that a resident was treated with respect and dignity. This was evident in 1 of 3 residents sampled (Resident #1). 1) Specifically, on 11/05/2021, two interns witnessed Certified Nursing Assistant (CNA) #1 roughly removed hoarded items from inside Resident #1's clothes. CNA #1 partially pulled down Resident #1's clothes, exposing the resident's buttock and disposable diaper, to remove the items. This was done in the dining room in the presence of staff and other residents who were in the dining room for activity program. Resident #1 was observed crying in the dining room. The findings are: Review of the facility's policy and procedure entitled Resident Rights and Responsibilities effective in 11/2020 documented: The facility will protect and promote the rights of each resident and will assist and encourage each resident to exercise their rights and responsibilities. The facility will comply with the State Nursing Home Code and recognize and support the rights of residents to a dignified existence, self-determination, respect, consideration and privacy in treatment, care of personal needs, and in communication with and access to persons and services within the facility and community. Staff will assist residents in exercising their rights and will assure that the resident is always treated with respect, kindness, and dignity. Resident #1 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 10/04/2021 documented Resident #1 with short term and long term memory problems and moderately impaired decision making ability. Review of the facility's undated Investigative Summary documented that on 11/08/2021, the Director of Recreation (DOR) reported to the Director of Nursing (DON) and the Administrator that there was an incident during recreation activities on 11/05/2021. CNA #1 was observed yelling at Resident #1 for sticking napkins in/under their clothes. CNA #1 was forceful when reaching in Resident #1's clothes to remove the tissues. The surveillance camera showed CNA #1 arguing with Resident #1 in an attempt to remove napkins from under Resident #1's clothes. The camera also showed CNA #1 swat away Resident #1's hand with a lack of sensitivity as Resident #1 tried to object the removal of the items. A Cognitive Impairment related to Dementia Care Plan was initiated on 07/10/2021. The interventions included: ask yes and no questions in order to determine the resident's needs, identify yourself on each interaction, provide the resident necessary cues and stop and return if agitated. The Point of Care Audit Report of the Certified Nursing Assistant Accountability Record dated 11/01/2021-11/05/2021 contained no instructions for or documentation regarding Resident #1's hoarding behavior. The facility's surveillance video revealed that on 11/05/2021 at 1:52 PM, Resident #1 entered the Dining Room and Recreation Intern (RI) #1 directed Resident #1 to sit in a regular chair at 1:53 PM. At 1:53 PM, CNA #1 walked from the far corner of the dining room and went towards Resident #1. CNA #1 was seen showing Resident #1 a sandwich. CNA #1 then pulled Resident #1's clothes (top) forward, placed his/her hands inside Resident #1's top and pulled out plastic cups, papers, and other items. At 1:54 PM, CNA #1 took out a dark colored item from inside Resident #1's clothes and Resident #1 stretched out him/her left hand to grab the item from CNA #1. CNA #1 used the back of CNA #1's right hand and slapped away Resident #1's hand. Resident #1 then began to resist. CNA #1 held on to the front of Resident #1's top and pulled more items out from inside Resident #1's clothes. CNA #1 took out a hairbrush, more papers, and other items from Resident #1's clothes. At 1:57 PM, CNA #1 stood Resident #1 up, placed his/her (CNA #1) hands inside all corners of Resident #1's clothes and took out more items from out of Resident #1's clothes. At 1:58 PM, the Recreation Therapist (RT) was seen with his/her (RT) arms around Resident #1. Eleven other residents were observed seated in the dining room. On 12/09/2021 at 2:27 PM, an interview was conducted with RI #1 who stated that on 11/05/2021 around 1:30 PM- 2:00 PM, he/she witnessed emotional, psychological, and physical abuse towards Resident #1 in the dining room. RI #1 said that he/she observed that CNA #1 was aggressive towards Resident #1. CNA #1 repeatedly told Resident #1 that Resident #1 was disgusting. CNA #1 stuffed his/her hand in Resident #1's clothes and aggressively pulled out items. RI #1 stated that CNA #1 forced Resident #1 to stand up and pulled Resident #1's clothes down. RI #1 stated that Resident #1's buttocks and disposable brief were exposed. RI #1 stated that Resident #1 was observed crying. On 12/22/2021 at 10:15 AM, an interview was conducted with Certified Nursing Assistant (CNA) #1 who stated that they were assigned to Resident #1 on 11/05/2021. CNA #1 stated that he/she made the biggest mistake when he/she placed his/her hands in Resident #1's clothes and removed the items in the dining room, while other residents and staff members were around. CNA #1 stated that he/she went to Resident #1 and informed the resident that he/she (CNA #1) would remove the items. CNA #1 stated that he/she removed about 20 cups, papers, combs and other items from inside Resident #1's clothes. On 12/22/2021 at 12:59 PM, an interview was conducted with the Recreation Therapist (RT) who stated that on 11/05/2021, while setting up the dining room and residents for dance movement therapy, he/she observed CNA #1 approached Resident #1 who was seated in the dining room. CNA #1 began pulling items out of Resident #1's clothes. The RT stated that he/she heard CNA #1 yelled at Resident #1 and tell Resident #1 that the resident was disgusting. The RT stated that Resident #1 was visibly weeping, and RT went to comfort Resident #1. On 01/10/2022 at 11:58 AM, an interview was conducted with the Registered Nurse Supervisor (RNS). The RNS stated that he/she was the nursing supervisor of Resident #1's unit. The RNS stated that Resident #1 was a hoarder and Resident #1 was not cooperative with staff to remove the hoarded items. CNAs were instructed to check Resident #1, every shift, in the resident's room and remove hoarded items. RNS stated that Resident #1 was often resistive but assigned staff would let Resident #1 calm down and remove the items later. The RNS said that he/she was not sure if there were any instructions for the CNAs to follow regarding Resident #1's hoarding but said that the CNAs were reminded verbally. The RNS also said that he/she could not recall if there was a care plan for Resident #1's hoarding prior to the incident of 11/05/2021. On 01/11/2022 at 4:20 PM, an interview was conducted with the current Director of Nursing (DON) who stated that for residents with hoarding behavior, staff should ensure that the resident's room is safe. If the resident is alert, the staff should coordinate with the resident. The family should be included in the resident's plan of care. The current DON further said that for cognitively impaired residents, the staff should explain to the resident and ask his/her permission before removing any hoarded items from the resident. The current DON also said that staff should remove the items from a resident's body when the resident is in his/her room. 415.3(c)(1)(iii)

Based on observations, interviews, and record review conducted during an abbreviated survey (NY 180) on 12/09/2021, the facility did not ensure that a resident was free from abuse. This was evident in 1 of 3 residents sampled (Resident #1). Specifically, on 11/05/2021, multiple staff witnessed Certified Nursing Assistant (CNA) #1 physically and verbally abused Resident #1 in the dining room. CNA #1 continued to work on the unit until his/her shift ended at 3:00PM. The findings are: Review of the facility's policy and procedure entitled Resident Abuse Prohibition Program effective on 09/09/2011 documented: The facility ensures that each resident's right to be free from abuse, physical and/or mental corporal punishment, and involuntary seclusion are maintained. Residents shall not be subjected to abuse, physical and/or mental by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff from other agencies, family members or legal guardians, friends or other individuals. If witnessed, staff should stop the abuse and immediately report the incident to their supervisor who will notify his/her department head. Resident #1 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 10/04/2021 documented Resident #1 with short/long-term memory problems and moderately impaired decision-making ability. The facility's undated Investigative Summary documented that on 11/08/2021, the Director of Recreation (DOR) reported to the Director of Nursing (DON) and the Administrator that there was an incident during recreation activities on 11/05/2021. CNA #1 was observed yelling at Resident #1 for sticking napkins in/under their clothes. CNA #1 was forceful when reaching in Resident #1's pants to remove the tissues. The surveillance camera showed CNA #1 arguing with Resident #1 in an attempt to remove napkins from under Resident #1's clothes. The camera also showed CNA #1 swat away Resident #1's hand with a lack of sensitivity as Resident #1 tried to object to the removal of the items. A Risk for Abuse Care Plan was initiated on 01/29/2019 and was updated on 04/14/2021. The interventions included: assess/monitor for possible medical/psychologic conditions that may cause behaviors, encourage participation and attendance in therapeutic recreational programs, monitor behaviors to identify patterns/causes, monitor peer interaction and intervene and redirect as needed and provide emotional support. The Point of Care Audit Report of the Certified Nursing Assistant Accountability Record dated 11/01/2021-11/05/2021 contained no instructions for or documentation regarding Resident #1's hoarding behavior. The facility's surveillance video revealed that on 11/05/2021 at 1:52 PM, Resident #1 entered the Dining Room and Recreation Intern (RI) #1 directed Resident #1 to sit in a regular chair at 1:53 PM. At 1:53 PM, CNA #1 walked from the far corner of the dining room and went towards Resident #1. CNA #1 was seen showing Resident #1 a sandwich. CNA #1 then pulled Resident #1's top forward, placed their hands inside Resident #1's top and pulled out plastic cups, papers, and other items. At 1:54 PM, CNA #1 took out a dark colored item from inside Resident #1's top and Resident #1 stretched out their left hand to grab the item from CNA #1. CNA #1 used the back of their (CNA #1) right hand and slapped away Resident #1's hand. Resident #1 then began to resist. CNA #1 held unto the front of Resident #1's top and pulled out more items from inside Resident #1's top. RI #1 went towards Resident #1 and stood behind Resident #1 briefly then stepped away. CNA #1 took out a hair brush, more papers, and other items from inside Resident #1's pants. At 1:57 PM, CNA #1 stood Resident #1 up, placed hands inside all corners of Resident #1's pants and took out items from Resident #1's pants. At 1:58 PM, the Recreation Therapist (RT) was seen with their arms around Resident #1. Eleven other residents were observed seated in the dining room at that time. Another CNA entered and removed a resident from the dining room. On 12/09/2021 at 2:27 PM, an interview was conducted with RI #1 who stated that on 11/05/2021 around 1:30 PM- 2:00 PM, they witnessed emotional, psychological, and physical abuse towards Resident #1 in the dining room. RI #1 said that they observed that CNA #1 was aggressive towards Resident #1. CNA #1 repeatedly told Resident #1 that Resident #1 was disgusting. CNA #1 stuffed their hand in Resident #1's top and pants and aggressively pulled out items. RI #1 said that Resident #1 tried to push CNA #1's hand away and CNA #1 hit Resident #1's hand. RI #1 also said that CNA #1 forced Resident #1 to stand and pulled Resident #1's pants down. RI #1 stated that Resident #1's buttocks and disposable brief were exposed. RI #1 stated that Resident #1 was observed crying. On 12/22/2021 at 10:15 AM, an interview was conducted with Certified Nursing Assistant #1(CNA #1) who stated that they were assigned to Resident #1 on 11/05/2021. CNA #1 stated that they made the biggest mistake when they placed their hands in Resident #1's top and pants and removed the items in the dining room while other residents and staff members were around. CNA #1 also stated they went to Resident #1 and informed them that they would remove the items and removed about 20 cups, papers, combs and other items from inside Resident #1's top and pants. CNA #1 further stated that they did not hit Resident #1's hand or yell at Resident #1. CNA #1 stated that they recalled that Resident #1 held the CNA's hand and CNA #1 moved their hand away. CNA #1 stated that if it appeared that they hit Resident #1, it may have been a reflex action. On 12/22/2021 at 12:59 PM, an interview was conducted the Recreation Therapist (RT) who stated that on 11/05/2021, while setting up the dining room and residents for dance movement therapy they observed CNA #1 approach Resident #1 who was seated in the dining room and begin to pull items out of Resident #1's top and pants. The RT also stated that they heard CNA #1 yell at Resident #1 and tell Resident #1 that they were disgusting. CNA #1 also asked Resident #1 why they were putting items in their clothes. The RT stated that they approached CNA #1 and told CNA #1 that was how Resident #1 felt safe. CNA #1 continued to remove the items from Resident #1. The RT also stated that Resident #1 was visibly weeping, and they went to comfort Resident #1. The RT stated that they did not see CNA #1 hit Resident #1. RI #1 and RI #2 informed them that they observed CNA #1 hit Resident #1. The RT also stated they tried to reach their supervisor but the supervisor had already left work on the Friday (11/05/2021). The RT verbalized that they informed their supervisor on the following Monday (11/08/2021). The RT further stated that their supervisor informed them that they should have reported the matter to Administration immediately. During an interview on 12/30/2021 at 12:16 PM, the Administrator stated that they were informed by the Recreation Director of the incident that occurred on 11/05/2021 on 11/08/2021 at 5:06 PM. The facility investigation concluded that CNA #1 was a little rough with Resident #1 but it was more like tough love with CNA #1 trying to remove the hoarded items from Resident #1. The Administrator stated that CNA #1 admitted that they made a big mistake. During an interview on 01/10/2022 at 11:58 AM, the Registered Nurse Supervisor (RNS) assigned to Resident #1's unit stated that Resident #1 hoarded items and was not cooperative with staff to remove the hoarded items. CNAs were instructed to check Resident #1 every shift in their room and remove hoarded items. Resident #1 was often resistive, then the assigned staff would let Resident #1 calm down and attempt later. The RNS also stated that they were not sure if there were any instructions for the CNAs to follow regarding Resident #1's hoarding but said the CNAs were reminded verbally. The RNS further stated that they could not recall if there was a care plan for Resident #1's hoarding prior to the incident on 11/05/2021. During an interview on 01/11/2022 at 4:20 PM, the current DON stated that CNA #1 worked on the unit with Resident #1 until his/her shift ended on 11/05/2021 at 3:00 PM. CNA #1 was off on 11/06/2021 and 11/07/2021 then CNA #1 returned to work on 11/08/2021 and was suspended when the facility management became aware on 11/08/2021. 415.4(b)(1)(i)

Based on observations, interviews and record reviews conducted during an abbreviated survey (NY 180) on 12/09/2021, the facility did not ensure that all alleged violations involving abuse was reported immediately but no later than 2 hours to the Administrator of the facility and to other officials including New York State Department of Health (NYS DOH). This was evident in 1 out of 3 residents sampled (Resident #1). 1) Specifically, on 11/05/2021 two interns and a Recreation Therapist (RT) witnessed Certified Nursing Assistant (CNA) #1 physically and verbally abused Resident #1 in the dining room. 2) The incident was not immediately reported to the facility Administrator or Director of Nursing (DNS) and CNA #1 continued working on the unit with Resident #1 until his/her shift ended at 3:00PM. The incident was reported to the facility Administrator and DNS three days (11/08/2021) after the incident was witnessed and four days after to NYS DOH. The findings are: Review of the facility's policy and procedure titled Resident Abuse Prohibition Program effective on 09/09/2011 documented: The facility ensures that each resident's right to be free from abuse, physical and/or mental corporal punishment, and involuntary seclusion are maintained. Residents shall not be subjected to abuse, physical and/or mental by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff from other agencies, family members or legal guardians, friends or other individuals. If witnessed, staff should stop the abuse and immediately report the incident to their supervisor who will notify his/her department head. All allegations, violations and all substantiated incidents are reported to the State Agency and to all other Agencies as required and after a thorough internal investigation. Resident #1 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 10/04/2021 documented Resident #1 with short term and long term memory problems and moderately impaired decision making ability. Review of the undated Investigative Summary documented that on 11/08/2021, the Director of Recreation (DOR) reported to the Director of Nursing (DON) and the Administrator that there was an incident during recreation activities on 11/05/2021. CNA #1 was observed yelling at Resident #1 for sticking napkins in/under their clothes and CNA #1 was forceful when reaching in Resident #1's pants to remove the tissues. The surveillance camera showed CNA #1 arguing with Resident #1 in an attempt to remove napkins from under Resident #1's clothes. The camera also showed CNA #1 swat away Resident #1's hand with a lack of sensitivity as Resident #1 tried to object the removal of the items. The facility investigation summary concluded that CNA #1 was not abusive since there was no harmful intent and CNA #1 was trying to help Resident #1. The facility's surveillance video revealed that on 11/05/2021 at 1:52 PM, Resident #1 entered the Dining Room and Recreation Intern (RI) #1 directed Resident #1 to sit in a regular chair at 1:53 PM. At 1:53 PM, CNA #1 walked from the far corner of the dining room and went towards Resident #1. CNA #1 was seen showing Resident #1 a sandwich. CNA #1 then pulled Resident #1's top forward, placed their hands inside Resident #1's top and pulled out plastic cups, papers, and other items. At 1:54 PM, CNA #1 took out a dark colored item from inside Resident #1's top and Resident #1 stretched out their left hand to grab the item from CNA #1. CNA #1 used the back of their (CNA #1) right hand and slapped away Resident #1's hand. Resident #1 then began to resist. CNA #1 held unto the front of Resident #1's top and pulled out more items from inside Resident #1's top. RI #1 went towards Resident #1 and stood behind Resident #1 briefly then stepped away. CNA #1 took out a hair brush, more papers, and other items from inside Resident #1's pants. At 1:57 PM, CNA #1 stood Resident #1 up, placed hands inside all corners of Resident #1's pants and took out items from Resident #1's pants. At 1:58 PM, the Recreation Therapist (RT) was seen with their arms around Resident #1. On 12/09/2021 at 2:27 PM, an interview was conducted with RI #1 who stated that on 11/05/2021 around 1:30 PM- 2:00 PM, they witnessed emotional, psychological, and physical abuse towards Resident #1 in the dining room. RI #1 said that they observed that CNA #1 was aggressive towards Resident #1. CNA #1 repeatedly told Resident #1 that Resident #1 was disgusting. CNA #1 stuffed their hand in Resident #1's top and pants and aggressively pulled out items. RI #1 said that Resident #1 tried to push CNA #1's hand away and CNA #1 hit Resident #1's hand. RI #1 also said that CNA #1 forced Resident #1 to stand and pulled Resident #1's pants down. RI #1 stated that Resident #1's buttocks and disposable brief were exposed. RI #1 stated that Resident #1 was observed crying. RI #1 stated that RI reported the abuse towards Resident #1 to the RT just after RI #1 witnessed the incident on 11/05/2021. On 12/22/2021 at 12:59 PM, an interview was conducted the Recreation Therapist (RT) who stated that on 11/05/2021, while setting up the dining room and residents for dance movement therapy they observed CNA #1 approach Resident #1 who was seated in the dining room and begin to pull items out of Resident #1's top and pants. The RT also stated that they heard CNA #1 yell at Resident #1 and tell Resident #1 that they were disgusting. CNA #1 also asked Resident #1 why they were putting items in their clothes. The RT stated that they approached CNA #1 and told CNA #1 that was how Resident #1 felt safe. CNA #1 continued to remove the items from Resident #1. The RT also stated that Resident #1 was visibly weeping, and they went to comfort Resident #1. The RT stated that they did not see CNA #1 hit Resident #1. RI #1 and RI #2 informed them that they observed CNA #1 hit Resident #1. The RT stated that he/she tried to reach his/her supervisor, but the supervisor had already left work on the Friday (11/05/2021). The RT verbalized that he/she informed their supervisor on the following Monday (11/08/2021). The RT stated that his/her supervisor informed them that they should have reported the matter to Administration immediately. During interviews on 12/30/2021 at 12:16 PM and 01/19/2022 at 1:35 PM, the Administrator stated that he/she was made aware of the incident on 11/08/2021 at 5:06 PM from the Recreation Director. The facility investigation concluded that CNA #1 was a little rough with Resident #1, but it was more like tough love with CNA #1 trying to remove the hoarded items from Resident #1. The Administrator stated that CNA #1 admitted that he/she made a big mistake. The Administrator stated that if staff to resident abuse is identified, the staff member is suspended immediately. The Administrator also stated that staff should report abuse allegations right away and the RT, RI #1 and RI #2 had prior in-services on abuse reporting. The Administrator verbalized that they reported the alleged abuse allegation to the NYS DOH as soon as they found out. During an interview on 12/30/2021 at 1:52 PM, the former Director of Nursing (DON) was interviewed and stated that they became aware of the incident on 11/08/2021 sometime after 5:00 PM and immediately went to the Administrator. The DON also stated that the Administrator conducted the investigation, and that CNA #1 was taken off the schedule from 11/08/2021. The DON said that the alleged abuse was not reported to the NYS DOH within the required timeframe because the RT did not report it to their supervisor immediately. 415.4 (b) (1)(i)

Based on observations, interviews, and record review conducted during a recertification survey, the facility did not ensure that infection control practices were maintained. Specifically, 1) oxygen tubing was observed touching the floor; 2) a catheter bag was observed on the floor; 3) Alcohol Based Hand Sanitizers (ABHR) were used after expiration date; and 4) staff did not ensure residents' hands were sanitized prior to meals. This was evident for 2 of 4 residents reviewed for Respiratory Care (Resident # 33 and Resident # 52), 1 of 3 residents reviewed for Urinary Catheter (Resident # 52), 5 of 6 units observed for Infection Control (Unit #2, 3, 4, 5, & 7) and 1 of 6 units observed for Dining (Unit #7). The findings are: 1) The facility policy on Oxygen Administration effective [DATE] documented During use, if nasal cannula/mask tubing touches the floor, discards and replaces with new nasal cannula/mask set-up. (a)Resident #33 was admitted to facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #33 required extensive assistance of 1 person for activities of daily living. On [DATE] at 10:45 AM, on [DATE] at 10:19 AM, on [DATE] at 10:18 AM and on [DATE] at 10:04 AM, Resident #33 was observed in bed with oxygen in use. The oxygen tubing connecting the resident to the oxygen concentrator was on the floor. On [DATE] at 10:19 AM, Certified Nursing Assistant (CNA) was observed in the resident's room while the oxygen tubing was on the floor. An interview was conducted on [DATE] at 10:36 AM with CNA # 1 who stated they ensure Resident #33 receives oxygen therapy by making sure the oxygen concentrator is on and the oxygen tubing is connected to the resident. CNA #1 also checks to ensure oxygen tubing is not touching the floor. An interview was conducted on [DATE] at 10:43 AM with the Licensed Practical Nurse (LPN #1) who stated they check to ensure oxygen tubing is off the floor whenever they go to Resident #33's room. The oxygen tubing is very long and the excess tubing should be placed in a plastic bag to promote infection control by ensuring the tubing does not touch the ground. An interview was conducted on [DATE] at 11:01 AM with the Registered Nurse (RN #1) who stated rounds are done several times a day to ensure oxygen tubing remains off the floor for each resident receiving oxygen therapy. If oxygen tubing is observed on the floor, it should be changed. Long oxygen tubing should be maintained in a way to ensure it does not touch the floor. An interview was conducted on [DATE] at 03:05 PM with the Infection Control Preventionist (ICP) who stated facility staff are educated that oxygen tubing should be kept off the floor to promote infection control. (b) Resident #52 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] at 12:00PM, [DATE] at 08:28 AM, 11:59 AM, 04:14 PM, [DATE] at 09:14AM and 11:52 AM, [DATE] at 09:58AM and 05:37 PM, and [DATE] at 11:49 AM oxygen tubing for nasal cannula was observed touching the floor. On [DATE] between 11:56AM and 12:07 PM, RN #3 was observed entering and exiting Resident #52's room and did not address the oxygen tubing on the floor. On [DATE] at 06:04 PM, LPN # 3, was interviewed and stated oxygen tubing should not be touching the floor. DON gloves with alcohol swab clean tubing. The floor is a big problem carry a lot of germs and want to keep thing off the floor. On [DATE] at 03:19 PM, the Infection Control Preventionist (ICP) was interviewed. The IP stated that oxygen tubing has to be changed immediately when it falls on the floor as the tube would be considered contaminated. The ICP also stated that oxygen goes to the lungs and microorganisms from the dirt on the floor can get into the tubing and enter the nose. On [DATE] at 04:07 PM, the Director of Nursing (DON) was interviewed. The DON stated that oxygen tubing has to be changed when visibly soiled, should not be touching floor and should be discarded and replaced immediately. The DON also stated that this would be is an infection control issue so the tubing should be discarded. 2. Resident #52 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS dated [DATE] documented resident was severely cognitively impaired, always incontinent of bowel, and had an indwelling catheter. Physicians' orders as of [DATE] documented [MEDICATION(S)] order as of 100mg (1 tablet via PEG for [CONDITION(S)]/[CONDITION(S)] for 28 days). On [DATE] at 11:59 AM, and 03:39 PM, [DATE] at 08:28 AM and 03:30PM and [DATE] at 9:14AM and 03:18PM, the resident's urinary catheter tubing was observed touching the floor. On [DATE] at 03:19 PM, the Infection Control Preventionist (ICP) was interviewed. The ICP stated that the urinary catheter tubing should be secured. The ICP also stated that if the catheter bag is dropped on the floor the connection should be changed right away as it can contaminate the whole set and place the resident at high risk of getting an infection. On [DATE] at 04:07 PM, the Director of Nursing (DON) was interviewed. The DON stated that if a urine catheter touches the ground it is considered contaminated. The DON also stated that the nurse has to be informed and the team would have to consider whether tubing should be changed or catheter reinserted. 3. The facility policy on Handwashing/Hand Hygiene effective [DATE] documented Hand Hygiene products and supplies (sinks, soaps, towels, alcohol-based hand rub, etc) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following before and after eating or handling food, before and after handling an invasive device (e.g., urinary catheters, IV access sites), before donning sterile gloves, after removing gloves. Hand hygiene is the final step after removing and disposing of personal protective equipment. The facility policy on Infection Control- COVID-19 also known as [CONDITION(S)]-CoV-2 (CORONAVIRUS) effective [DATE] documented Adequate supply of alcohol-based gel dispensers will be available for use by residents, staff, and visitors throughout the facility. Provide supplies for hand hygiene to include >/= 60% alcohol-based hand sanitizer, tissues, no touch receptacles for disposal, face masks at entrances. On [DATE] at 11:55AM-03:25PM, [DATE] at 10:01AM- 04:32 PM, [DATE] at 11:45 AM-04:38 PM, [DATE] at 10:,d+[DATE] AM, three wall hand sanitizer dispensers on the 7th Floor in hallway corridor in front of room [ROOM NUMBER], 720 and 721 were observed to contain sanitizer with an expiry date of ,d+[DATE] and ,d+[DATE]. On [DATE] at 10:40 AM and [DATE] at 04:58 PM, one wall hand sanitizer dispenser between room [ROOM NUMBER] and 207 observed to contain sanitizer with an expiry date of ,d+[DATE]. On [DATE] at 10:50 AM and 02:32 PM, [DATE] at 11:35 AM, 04:51 PM-4:55PM, three wall hand sanitizer dispensers between rooms 319, 320, 321 and 322 near the 3rd floor dining room by elevator side of wall were observed to contain sanitizers with an expiry date of ,d+[DATE], ,d+[DATE] and ,d+[DATE]. On [DATE] at 01:54 PM-01:58 PM, [DATE] at 04:42 PM, [DATE] at 11:51 AM, on the three wall hand sanitizer dispensers located in the 5th floor dining room and between room [ROOM NUMBER], 514, 521 and 522 were observed to contain sanitizer with an expiry date of ,d+[DATE]. On [DATE] at 04:47 PM and [DATE] at 11:49PM, one wall hand sanitizer dispenser in the 4th floor dining room observed to contain sanitizer with an expiry date of ,d+[DATE]. On [DATE] at 11:13 AM, Housekeeper (HK) #1 was interviewed. HK #1 stated the wall hand sanitizer is changed weekly on Fridays and they think it was done last Friday. On Fridays and I stock up for next weeks. HK #1 also stated that we are now in [DATE], so sanitizer is expired. HK#1 further stated hand sanitizers is delivered in a box which should have right expiration date on it. On [DATE] at 11:32 AM, HK # 2 was interviewed. HK#2 stated the sanitizer expired in ,d+[DATE], and we have to change it. HK #2 also stated new staff make little mistakes here and there. HK#2 further stated expired sanitizer would not be as effective and may not kill germs right away. On [DATE] at 11:49 AM, HK#3 was interviewed. HK #3 stated they are new, and the hand sanitizer is changed by the manager as they do not have the keys to change the hand sanitizer dispenser. HK #3 also stated that if they notice it was expired, they would notify the manager. HK #3 further stated that if it is expired, it would not have the same effect and this is the reason it has an expiration date. On [DATE] at 11:55AM, HK #4 was interviewed and stated they noticed the hand sanitizer dispenser solution by room [ROOM NUMBER] was expired ,d+[DATE] and they would have to inform their supervisor so it could be changed. On [DATE] at 3:00PM, the Director of Housekeeping (DOH) was interviewed. The DOH stated that they distribute PPE supplies to the unit to include hand sanitizer for the dispensers. The DOH also stated that they did not notice that the hand sanitizers were expired as they started working at the facility recently. The DOH further stated that it is important that the hand sanitizer dispensers are not expired and if they are expired, they will not be as effective. On [DATE] at 04:00 PM, the Director of Nursing (DON) was interviewed and stated that they do rounds a minimum 3 times daily. DON stated that before they used to assess sanitizer on the unit and last time assess them 1 and ,d+[DATE] months ago to look for their usage, functionality, and they have not looked at the dates recently. The DON stated that the last time they looked at date on hand sanitizer dispenser was 6 months ago. On [DATE] at 03:19 PM, the Infection Control Preventionist (ICP) was interviewed. The ICP stated they do rounds daily or once every 2 days. The ICP stated that they had not checked the hand sanitizer dispensers today and could not remember the last time they checked it. When I check the hand sanitizer dispenser, I check to see if it is full, working, and if in good condition. The ICP further stated that part of their check should include expiry dates but they had not been doing this. 4. The facility policy on Meal Service during COVID-19 Pandemic and implementing social distancing during meal services effective [DATE] documented the facility will promote a safe and comfortable meal service for residents to minimize the potential spread of infection and promote quality of meal service to residents. Provide in-room meal service to residents, assessed capable of feeding themselves without supervision or assistance. Hand hygiene and clothing protectors should be offered/provided to these residents. On [DATE] at 04:39 PM, during a dinner meal observation on the 7th floor the CNA (CNA # 2) was observed serving the dinner meal to residents # 401 and # 400. Neither resident was provided with a Sani cloth to clean their hands until after they started to eat their dinner. On [DATE] at 04:46 PM, LPN #3 brought Sani wipes for resident hands after trays had already been distributed. On [DATE] at 05:12PM, the Certified Nursing Assistant (CNA)# 2 was interviewed. CNA#2 stated hand hygiene was important because we can transmit infection. CNA #2 also stated that the normal practice is to have residents clean their hands before they eat meals. On [DATE] at 05:58 PM, LPN # 3 was interviewed. LPN #3 stated hand hygiene should be provided before eating to prevent germs from hands getting into the mouth. LPN#3 stated they realized that residents had not cleaned hands so they went to get hand wipes. LPN #3 also stated that the normal procedure when they come into the resident's room with the tray is to provide resident with a hand wipe and if they cannot do it for themselves, don gloves and assist resident prior to the meal. On [DATE] at 03:19 PM, the Infection Control Preventionist (ICP) was interviewed. The ICP stated that with every other tray staff should sanitize hands and use hand wipes or sanitizer. The ICP also stated that the resident hands should be sanitized and cleaned prior to mealtime for protection, prevention, and infection control issue. 415.19(a)(b) (,d+[DATE])