Every finding on record at Buffalo Center For Rehabilitation And Nursing

Based on observation, interview, and record review conducted during an Abbreviated Survey (Complaint #2656144), the facility failed to protect residents from verbal and mental abuse by staff for one (1) (Resident #1) of six (6) residents reviewed for abuse. Specifically, on 10/29/2025, it was observed that Certified Nurse Aide #2 yelled at Resident #1 in a harsh, demeaning tone for urinating on themselves and their surroundings. Certified Nurse Aide #2 then verbally threatened the resident they were going to get moved to another floor. After the verbally abusive encounter, Resident #1 was tearful and appeared saddened. Using the reasonable person concept, as referenced in the Centers for Medicare and Medicaid Services Psychosocial Outcome Severity guide, it was determined psychosocial harm occurred that is not Immediate Jeopardy. The finding is:The facility policy titled 'Abuse' revised 07/18/2025 documented the facility prohibits the mistreatment, neglect, and abuse of residents by anyone. Verbal abuse was oral language that willfully incudes disparaging and derogatory terms, to the resident, or within their hearing distance, to describe resident, regardless of their age, ability to comprehend or disability. Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation including but not limited to harassing or yelling, intimidation, threatening or isolation and deprivation of goods and services. 1. Resident #1 had diagnoses including encephalopathy (disease disturbing brain function), obstructive hydrocephalus (fluid buildup in the brain), and intracerebral hemorrhage (bleeding within the brain). The Minimum Data Set (a resident assessment tool) dated 07/18/2025 documented Resident #1 was severely cognitively impaired, was sometimes understood, and sometimes understands others. Resident #1 was frequently incontinent of urine and exhibited no behaviors. The Comprehensive Care Plan initiated 04/21/2025 documented Resident #1 had difficulty communicating with others. The plan documented interventions to anticipate resident needs; monitor for physical/nonverbal indicators of distress, communicate with the resident regarding capabilities; introduce self and explain care; and to use communication techniques to enhance interactions. The Comprehensive Care Plan also documented that Resident #1 was incontinent of bladder and required staff assist with self-care. Review of Kardex (guide used by staff to provide care) Report dated 10/29/2025, documented that Resident #1 be provided peri-care after each incontinent episode; check and provide toileting care every two (2) to four (4) hours as tolerated and was dependent on two (2) or more staff.During an observation on 10/29/2025 from 4:03 PM to 4:12 PM, Certified Nurse Aide #2 was in hallway outside Resident #1's room walking away appearing frustrated and stated loudly, Resident #1 does this all this time, peeing everywhere. This is annoying! They cannot do anything about this. This just makes me want to go home. At this time, Resident #1 was observed in their room laying across their bed facing the window with their legs hanging off the side of the bed. The resident was wearing a hospital gown and an incontinence brief. Their incontinence brief was pushed down from the waist and the resident was observed urinating on themselves, their bed sheets and on the floor. Certified Nurse Aide #2 walked back into Resident #1's room yelling at Resident #1, They are going to send you right to four (4)! Resident #1 was heard to say something (inaudible) to Certified Nurse Aide #2 in which they then replied, I do not want to hear it! Certified Nurse Aide #2's tone of voice was harsh, hostile, impatient and dismissive. Certified Nurse Aide #2 picked the floor mat up from the floor next to the bed and tossed it towards the doorway. Certified Nurse Aide #1 then entered the resident's room to assist Certified Nurse Aide #2 with care and closed the door. While the door to Resident #1's room was closed Certified Nurse Aide #2 was overheard saying, They are going to send you to the fourth floor. During an interview on 10/29/2025 at 4:13 PM, Certified Nurse Aide #2 stated they were frustrated. They stated they had been blamed in the past for Resident #1 peeing everywhere and had been suspended. They stated the second floor was a rehab floor and that they didn't sign up for this. They stated Resident #1 had dementia and did not belong on the rehab floor. Certified Nurse Aide #2 stated they believed Resident #1 had some common sense in their head and should not be peeing everywhere. They further stated, Imagine if you had to deal with that. Certified Nurse Aide #2 stated that was the first time they had raised their voice to Resident #1. The surveyor's observation was reported to Social Worker #1 at 4:15 PM as the social worker was on their way to the Resident #1's room to deliver a message to the resident. During an observation on 10/29/2025 at 4:15 PM, Certified Nurse Aide #2, Social Worker #1 and the Surveyor entered Resident #1's room. Certified Nurse Aide #2 stated to Resident #1, Have I ever yelled at you before? Resident #1 would not look at or speak to Certified Nurse #2. During an interview on 10/29/2025 at 4:24 PM, Registered Nurse Supervisor #1 stated that yelling at a resident was not acceptable. It could be verbal, mental and/or emotional abuse. They stated residents should be treated respectfully. During an observation and interview on 10/29/2025 at 4:30 PM with Registered Nurse Supervisor #1 present, Resident #1 was lying in bed with the television on. Resident #1 became tearful when spoken to and appeared sad. Resident #1 was able to communicate that they did not want or mean to pee everywhere, but they had to go to the bathroom. They stated they did not like being yelled at by staff. During an interview on 10/29/2025 at 4:48 PM, Certified Nurse Aide #1 stated Certified Nurse Aide #2 was upset that Resident #1 was spraying urine everywhere. Certified Nurse Aide #1 stated Certified Nurse Aide #2 was venting to them while they were in Resident #1's room providing care. Certified Nurse Aide #1 stated Certified Nurse Aide #2's attitude and tone was not appropriate, and that Certified Nurse Aide #2 should have walked way. They stated it was not appropriate for Certified Nurse Aide #2 to tell Resident #1 that they were going to get moved to another floor or to discuss their frustrations in front of Resident #1. Certified Nurse Aide #1 stated they did not know how Resident #1 felt hearing Certified Nurse Aide #2 venting to them, but residents should feel safe and be treated like people, not like a job. Certified Nurse Aide #1 stated Resident #1 could not control that they had to go to the bathroom and did not know they were doing something wrong. During an interview on 10/30/2025 at 10:33 AM, Social Worker #1 stated Resident #1 could not control their actions. It was inappropriate and verbal abuse for staff to yell at residents. They stated residents should be treated with respect, dignity and spoken to in a peaceful manner. During an interview on 10/30/2025 at 2:28 PM, Administrator #1 stated it was not appropriate for staff to raise their voices or yell at a resident. Yelling at a resident was emotional and verbal abuse that could make a resident feel intimidated and isolated. An Investigation Form completed by Director of Nursing #1 dated 11/04/2025 documented that a review of the investigation involving Resident #1 had been completed and revealed that there was reasonable cause to believe that resident abuse, neglect, exploitation or mistreatment may have occurred. The conclusion of the investigation documented Certified Nurse Aide #2 was verbally inappropriate towards Resident #1. During an interview on 11/04/2025 at 10:30 AM, Licensed Practical Nurse #3 stated it was not the place of nursing staff to tell a resident they were going to get moved. They stated verbal abuse could cause mental or psychological harm depending on the situation and that crying could be a reaction to pain, emotional or mental abuse. During a telephone interview on 11/04/2025 at 12:01 PM, Resident #1's family member stated the facility notified them of a situation where someone became upset with Resident #1 because they were urinating on the floor. Resident #1's family member stated Resident #1 would not have known what they were doing and would be upset if they were being yelled at. During a telephone interview on 11/04/2025 at 12:22 PM, Register Nurse Supervisor #1 stated whether Resident #1 was being defiant, by urinating on floor or not, they should not have been yelled at. Resident #1 could have felt embarrassed or threatened by being yelled at. They stated verbal abuse could cause psychosocial harm. During an interview on 11/04/2025 at 1:08 PM, Director of Nursing #1 stated they investigated the situation as verbal abuse and reported it accordingly. Verbal abuse could have psychosocial effects on a resident, and that Resident #1 was being monitored for any ill effects, and for any changes in their status. During a telephone interview on 11/04/2025 at 1:53 PM, the Medical Director stated it was not appropriate for staff to yell at a resident and would consider it verbal abuse. They stated they were notified about Resident #1's situation on 10/29/2025 and they were pissed off about it. They stated verbal abuse could have psychosocial effects and be harmful, however they saw Resident #1 after the situation on 10/29/2025 and they looked at their baseline without any evidence of lasting psychosocial harm. 10NYCRR 415.3(d)(1)(vii)

Based on interview and record review conducted during an Abbreviated survey (Complaint #2624947) the facility did not ensure that each resident received adequate supervision and assistive devices to prevent accidents for one (1) (Resident #4) of four (4) residents reviewed for accidents. Specifically, Resident #4 was not provided with total assistance of two (2) staff members for bed mobility as per the comprehensive plan of care resulting in the resident falling from their bed, sustaining a multilayered facial laceration (deep gash in multiple tissue layers) to their left cheek and swelling to their left eye. Resident #4 was transferred to the hospital and required surgical repair of the laceration. This resulted in actual harm to Resident #4 that is not Immediate Jeopardy. This finding is: The policy and procedure titled 'Activities of Daily Living (ADL) Care and Support' revised 11/06/2025 documented that activities of daily living (ADL) care and support will be provided for residents who are unable to carry out activities of daily living independently in accordance with the resident's needs, personal preferences, and individualized plan of care that includes but not limited to bed mobility, transfers, and toileting. Resident #4 had diagnoses that included cerebral infarction (stroke), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) of the right side. The Minimum Data Set (a resident assessment tool) dated 07/14/2025 documented Resident #4 was rarely understood, rarely understands others and had severe cognitive impairment. The Comprehensive Care Plan dated 07/07/2025 documented Resident #4 required assistance with self-care and mobility and was at risk for falls. Interventions documented the resident was dependent on two (2) or more staff to roll left and right in bed; dependent on two (2) or more staff for toileting hygiene; and staff were to provide assistance per the resident needs and therapy recommendations. The Kardex Report (a guide used by staff to provide care) dated 08/08/2025 documented Resident #4 was dependent on two (2) or more staff for lying to sitting on the side of bed, rolling left and right, sitting to lying, and toileting hygiene. The Initial Event Documentation V-12 form completed by former Registered Nurse Manager #2 dated 08/08/2025 documented that at 2:40 PM, Resident #4 fell out of bed while they received care which caused an open laceration to their left cheek. Resident #4 was transferred to the hospital for further evaluation and treatment. The Attending Physician and Resident #4's family were notified. The hospital Emergency Department Provider Note dated 08/08/2025 documented Resident #4 required two (2) person assist at the nursing home to help roll them, today they had one (1) staff member roll them and they accidently rolled out of bed. The Provider note documented on physical exam Resident #4 had sustained a large laceration to the left side of their cheek from the left side of nose extending to the superior (upper) portion of the upper lip, they had conjunctival hemorrhage (broken blood vessel on the white part of the eye) present to the lateral (to the side) aspect of left eye. There was evidence of possible corneal (outer clear layer of the eye) abrasion, and mild swelling and erythema (redness of the skin) overlying the left eye. Resident #4 required a Computed Tomography Scan (CT scan -type of imaging test that uses detailed x-rays to detect diseases and injuries) of head, neck, chest, abdomen/pelvis to be completed. A facial trauma consult was required to reconstruct the laceration. The hospital Ear, Nose and Throat (ENT) Provider Consult note dated 08/09/2025 documented Resident #4 had a six (6) centimeter complex laceration to left midface extending from nasal (nose) base inferior(lower) to medial canthus (inner corner where upper and lower eyelids meet near the nose) down through the nasolabial fold (creases that extend from the sides of nose to corner of mouth). The Ear, Nose and Throat Provider Consult note documented that Resident #4's facial laceration was repaired in a multilayered fashion at bedside (deep layer was closed and the skin layer was closed). Recommendations included but were not limited to: treat facial pain symptomatically; apply Polysporin (antibiotic ointment) twice a day to the repaired laceration; Keflex (antibiotic) for 10 days; sutures to be removed in 7-10 days. During a telephone interview on 10/30/2025 at 10:41 AM, Former Registered Nurse Manager #2 stated on 08/08/2025 they were notified by a certified nurse aide (could not recall who) that Resident #4 had fallen from their bed. Former Registered Nurse Manager #2 stated Resident #4 was found to have a laceration to the left side of their face with a large amount of bleeding. They assessed the resident, applied pressure to the wound and called the ambulance. They stated the Medical Provider, Director of Nursing #2 (former), and Resident #4's responsible party were notified. Former Registered Nurse Manager #2 stated they completed the Initial Event Documentation form and Change in Condition form in the medical record and collected staff statements. Former Registered Nurse Manager #2 stated Resident #4 was dependent on staff for all care and required a two (2) person assist for bed mobility. Former Registered Nurse Manager #2 stated they interviewed Certified Nurse Aide #6 and were informed while attempting to turn Resident #4 on their side they had rolled out of the bed onto the floor and there was no additional staff present while care was provided. During a telephone interview on 10/30/2025 at 11:13 AM, Certified Nurse Aide #6 stated on 08/08/2025 they were assigned to Resident #4 on the 7:00 AM - 3:00 PM shift. They stated Resident #4 was incontinent at the end of their shift and needed to be changed. Certified Nurse Aide #6 stated while providing incontinence care, Resident #4 was lying on their left side. Resident #4 slightly bent their right leg upward which made both legs go over the side of the bed. CNA #6 stated they attempted to the hold onto Resident #4's upper and lower part of their body but was unable to stop Resident #4 from rolling out of bed on to the floor. They stated Resident #4 may have hit their face on the bed frame because they had a cut on their face. They stated they immediately notified the nurse and stayed with Resident #4 until the ambulance arrived. Certified Nurse Aide #6 stated they were familiar with Resident #4 and were aware they required a two (2) staff member assist for bed mobility. They stated they did not follow Resident #4's care plan and provided care by themselves. Certified Nurse Aide #6 stated they provided a written statement on the day of the incident to their Registered Nurse Manager #2. During a telephone interview on 10/31/2025 at 10:44 AM, the Former Administrator #2 stated Former Director of Nursing #2 reported to them Resident #4 sustained a fall from bed while care was being provided and was sent to the hospital. During a telephone interview on 10/31/25 at 1:43 PM, the Medical Director stated they were familiar with Resident #4 but could not specially recall the details of the fall. The Medical Director stated a fall with facial laceration that required sutures was considered a significant injury. They stated any fall could cause harm to a resident even if there was no injury. The Medical Director stated they would have expected staff to follow Resident #4's care plan recommendations and stated the care plan was in place for a reason and following the care plan should be a top priority to ensure safety and prevent injuries. During an interview on 10/31/2025 at 2:19 PM, Administrator #1 (current) stated they were unaware of the specifics regarding Resident #4's fall that occurred on 08/08/2025 as it was prior to them working at the facility. The current Administrator #1 stated they expected staff to follow the residents care plan, as it was the safest way to provide care and prevent injuries. They stated they did not consider Resident #4's injury to be significant but stated it did cause harm to Resident #4 because they had to be transferred to the hospital for sutures. During an interview on 10/31/2025 at 2:47 PM, the current Director of Nursing #1 stated staff were expected to review the resident's care plan/Kardex prior to providing care. They stated if a resident was care planned as a two (2) staff member assist, they would expect staff to follow the care plan and provide care with two (2) staff members present to ensure safety and prevent injuries. Director of Nursing #1 stated they considered Resident #4's injury to be significant because it required them to be sent to the hospital for further treatment. 10 NYCRR 415.12 (h)(2)

Based on interview and record review conducted during an Abbreviated survey (Complaint #2587167) the facility did not ensure that all alleged violations of abuse were thoroughly investigated for one (1) (Resident #3) of three (3) residents reviewed. Specifically, the Administrator received an allegation of abuse through an e-mail on 09/30/2025, at 8:08 PM from Resident #3's Health Care Proxy Agent that was not investigated. The finding is: A policy titled Abuse revised 07/18/2025, documented the facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including but not limited to staff, family, friends and residents of the facility. The policy and procedure documented the facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. A policy titled Investigations, How to Conduct revised 11/2019 documented the facility has designed and implemented processes to enable it to come to a resolution, after thoroughly investigating grievances, accidents, incidents. Losses, thefts, allegations or other means in order to determine appropriate actions that can be taken to correct the situation and prevent further recurrences. If an incident occurs on off-hours and is a potential injury or possible abuse, neglect mistreatment or exploitation, notify Director of Nursing and Administrator-on-call immediately upon initiation of investigation. Investigator conducts interviews with people involved in, or who may have witnessed the incident. Resident #3 was admitted to the facility diagnosis include Cerebral Palsy (a group of disorders affecting a person's movement, posture, and muscle tone due to permanent, non-progressive brain damage that occurs before, during or after birth), intellectual disability (a disability characterized by significant limitations in both intellectual functioning and in adaptive behavior, which covers many everyday social and practical skills), and dysphagia (difficulty swallowing, which can involve problems with liquids, solids, or saliva). The Minimum Data Set (a resident assessment tool) dated 09/25/2025 documented Resident #3 was cognitively severely impaired, rarely / never understood by others and rarely / never understands. The undated comprehensive care plan documented that Resident #3 had impaired cognition related to intellectual disability, had limited physical mobility with impaired movements, impulse disorder with intermittent explosive disorder requiring assistance with activities of daily living. Review of e-mails provided by Administrator #1 from Resident #3's Health Care Proxy Agent dated 09/28/2025 through 10/06/2025 revealed the following: -On 09/30/2025 at 08:08 PM an email sent to the Administrator #1 from Resident #3's Health Care Proxy Agent documented the lady who shower (Resident #3) is (Certified Nurse Aide #12) yelled '(Resident #3) you want to puke your getting cold shower this teach you a lesson' and said '(Resident #3) your on my last nerve so maybe you not getting fed will teach you stop puking every time I feed you' and step on (Resident #3's) right foot saying 'I hope it hurts ya' - that's a form of abuse. Review of an undated, untitled document identified by Administrator #1 as their summary of the facility's actions related to the e-mails received from Resident #3's Health Care Proxy Agent, revealed the summary did not document evidence the facility was investigating abuse allegations. During an interview on 11/04/2025 at 11:15 AM, Director of Nursing #1 stated Administrator #1 did not share the e-mail dated 09/30/2025 at 8:08 PM with them or inform them of an allegation of abuse. Director of Nursing #1 read the e-mail dated 09/30/2025 at 8:08 PM and stated they should have been informed of the allegation of abuse and an investigation should have been completed to determine if abuse had occurred. They stated their investigation should have included statements from the accused staff, other potential witnesses/staff, and they would have suspended the accused staff pending their investigation results. During an interview on 11/12/2025 at 11:45 AM, Administrator #1 stated they received multiple e-mails from the Health Care Proxy Agent between 09/28/2025 through 10/01/2025 and they inadvertently missed the allegation of abuse documented in the e-mail dated 09/30/2025 at 8:08 PM. They stated they should have read the e-mails more closely to discern there was an allegation of abuse, and an investigation should have been initiated, and it was not. 10 NYCRR 415.4(b)(3)

Based on interview and record review conducted during an Abbreviated survey (Complaint #2587167) the facility did not ensure that all alleged violations involving abuse and mistreatment are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse, to other officials (including to the State Survey Agency) for one (1) (Resident #3) of three (3) residents reviewed. Specifically, allegations of resident abuse were not reported no later than 2 hours to the New York State Department of Health. The finding is: A policy titled Abuse revised 07/18/2025 documented the facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including but not limited to staff, family, friends and residents of the facility. The Administrator and Director of Nursing are responsible for investigation and reporting. Report to the local law enforcement and appropriate State Agency(s) immediately (no later than two (2) hours after allegation/identification of allegation) by the Agency's designated process after identification of alleged/suspected incident. Resident #3 was admitted to the facility diagnosis include Cerebral Palsy (a group of disorders affecting a person's movement, posture, and muscle tone due to permanent, non-progressive brain damage that occurs before, during or after birth), intellectual disability (a disability characterized by significant limitations in both intellectual functioning and in adaptive behavior, which covers many everyday social and practical skills), and dysphagia (difficulty swallowing, which can involve problems with liquids, solids, or saliva). The Minimum Data Set (a resident assessment tool) dated 09/25/2025 documented Resident #3 was cognitively severely impaired, rarely / never understood by others and rarely / never understands. The undated comprehensive care plan documented that Resident #3 had impaired cognition related to intellectual disability, had limited physical mobility with impaired movements, impulse disorder with intermittent explosive disorder requiring assistance with activities of daily living. Review of e-mails provided by Administrator #1 from Resident #3's Health Care Proxy Agent dated 09/28/2025 through 10/06/2025 revealed the following: -On 09/30/2025 at 08:08 PM an email sent to the Administrator #1 from Resident #3's Health Care Proxy Agent documented the lady who shower (Resident #3) is (Certified Nurse Aide #12) yelled '(Resident #3) you want to puke your getting cold shower this teach you a lesson' and said '(Resident #3) your on my last nerve so maybe you not getting fed will teach you stop puking every time I feed you' and step on (Resident #3's) right foot saying 'I hope it hurts ya' - that's a form of abuse. Review of an undated, untitled document identified by Administrator #1 as their summary of the facility's actions related to the e-mails received from Resident #3's Health Care Proxy Agent, revealed the summary did not document evidence the facility reported the abuse allegations to New York State Department of Health as required. During an interview on 11/04/2025 at 11:15 AM Director of Nursing #1 stated they were not aware of an allegation of abuse documented in an e-mail on 9/30/2025 from the Health Care Proxy Agent to Administrator #1. Director of Nursing #1 read the e-mail dated 09/30/2025 at 8:08 PM and stated the e-mail documented an allegation of verbal, mental, and physical abuse to Resident #3 and it should have been reported to the New York State Department of Health within 2 hours as required and it was not. During an interview on 11/12/2025 at 11:45 AM, Administrator #1 stated they received multiple e-mails from the Resident #3's Health Care Proxy Agent between 09/28/2025 through 10/01/2025 and they inadvertently missed the allegation of abuse documented in the e-mail dated 09/30/2025 at 8:08 PM. They stated they should have read the e-mails more closely to discern there was allegations of abuse and the allegations should have been reported to the New York State Department of Health within 2 hours as required and it was not. 10 NYCRR 415.4(b)(2)

Based on interview, and record review conducted during a Complaint investigation (2606688) completed on 11/12/2025, the facility did not allow the resident and resident's legal representative to obtain a copy of the resident's medical records or any portion thereof upon request and 2 working days advance notice to the facility for one (1) (Resident #2) of three (3) residents reviewed for medical record access. Specifically, Resident #2 submitted a written request for their medical records to be released to their Health Care Proxy on 08/04/2025 and the facility never released their records. The finding is:The policy titled Release of Information, revised 9/2019, documented residents may initiate a request to release information contained in their records and charts to anyone they wish. Such requests will be honored only upon the receipt of a written, signed, and dated request from the resident or representative. A resident has access to their records (excluding weekends or holidays) upon the resident's written or oral request within 24 hours. A resident may obtain photocopies of their records by providing the facility with at least forty-eight (48) hours (excluding weekends and holidays) advanced notice of such request. A fee may be charged for copying services. Resident #2 had diagnoses that included Carbapenem Resistant Enterobacteriaceae infection (CRE- bacterial infection resistant to most antibiotics), malignant neoplasm of rectum (rectal cancer), and colostomy status (surgical connection of the bowel to the skin surface). The Minimum Data Set (a resident assessment tool) dated 08/05/2025 documented Resident #2 understood, understands, and was cognitively intact. Review of the Authorization for Release of Health Information Pursuant to HIPPA (Health Insurance Portability and Accountability Act) revealed Resident #2 completed and dated the form on 08/04/2025. The Authorization for Release of Health Information Pursuant to HIPPA included the release of information to Resident #2's Health Care Proxy.Review of an email correspondence to Medical Records from Risk Management on 08/05/2025 at 1:16 PM, documented ok to release medical record request once the Director of Nursing has reviewed the records. Review of an email correspondence from Medical Records to the prior Administrator #2 on 08/12/2025 at 11:14 AM, documented a request to review Resident #2's record. During an interview on 10/30/2025 at 2:28 PM, the Administrator #1 stated they were not aware of any medical record requests from Resident #2. They stated Medical Records should have a record of the request if one was made. They stated they would expect the process of releasing medical records to take less than twenty-four (24) hours. During an interview on 10/31/2025 at 2:56 PM, Medical Records stated that for medical records to be released the resident or resident representative must complete a HIPPA (Health Insurance Portability and Accountability Act) form. Once the form is completed it is sent over to Risk Management to review, prior to release of the requested medical records. They stated communication with the facility's Risk Management is completed via email. Once they received the go ahead from Risk Management, they print copies of the medical record and email them to the Director of Nursing to review prior to them being uploaded to a flash drive or being mailed out to the requestor. Medical Records stated Resident #2 requested the release of their medical records on 08/04/2025; the form was emailed to Risk Management on 08/05/2025; and approved to be released by Risk Management, once the Director of Nursing reviewed the records, on 08/05/2025. Medical Records stated they did not email a copy of the medical records requested to be reviewed for Resident #2 until 8/12/2025 to the Director of Nursing #2 and the prior Administrator #2. Medical Records stated they were not sure why there was a delay in forwarding the medical records for Resident #2, I was off or doing other work. They stated the Director of Nursing #2 was no longer employed at the facility during that time, so they forwarded the email to the prior Administrator #2. They stated once it was emailed to the prior Administrator #2 it was out of their hands until they were told that it was ok to release the medical records as requested by Resident #2. They stated they had no clue if the prior Administrator #2 looked at the medical records forwarded to them, they never got an email back from the Administrator #2 to release the records. Medical Records stated Resident #2's medical records were never released as requested and they did not follow up with the prior Administrator #2 to see if they should send the records. Medical Records stated they were not familiar with the facility's policy on releasing medical records and they should have been. Medical Records stated it was important for medical record requests to be sent as requested so the residents know what is going on, it's their information. Medical Records stated they were unable to locate the invoice for the medical records Resident #2 requested.During a telephone interview on 11/04/2025 at 10:42 AM, prior Administrator #2 stated once requested medical records are reviewed by the Director of Nursing, they would be released via a thumb drive or paper copy once payment is received. They stated they were not aware if residents within the nursing facility who were requesting medical records were charged. They stated usually there was a certain amount charged per page of the medical record being released. Administrator #2 stated if the Director of Nursing was not available to review the medical records requested that they or someone else could review them. They stated they expected there not to be a delay in processing a medical record request. The Administrator #2 stated they would have expected to be notified by Medical Records sooner than 08/12/2025 if a request to release the medical records for Resident #2 was granted on 08/05/2025; so, the medical record could be properly reviewed, processed and released timely. 10NYCRR 415.3 (d)(1)(iv)

Based on observation, interview, and record review conducted during an Abbreviated Partial Extended survey (Complaint #NY00383127), the facility failed to protect residents from sexual and mental abuse by staff for four (4) (Residents #1, #2, #3, and #4) of six (6) residents reviewed for abuse. Specifically, Certified Nurse Aide #1 took personal photographs of heavily soiled incontinent residents in various stages of undress without their consent, including some with their buttocks and genitalia exposed. The photographs were posted on social media along with text messages and descriptions of the lack of resident care. Using the reasonable person concept, as referenced on the Centers for Medicare and Medicaid Services Psychosocial Outcome Severity guide, it was determined psychosocial harm occurred that is Substandard Quality of Care for Residents #1, #2, #3, and #4 that is not immediate jeopardy. The finding is: The policy and procedure titled Abuse, dated 06/2024, documented the facility prohibits the mistreatment, neglect, and abuse of residents/patients by anyone. The facility prohibits any exploitation of the mentally and physically disabled residents in the facility. Mental/emotional abuse is the use of verbal and/or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Mental abuse includes abuse that is facilitated or enabled using technology (smart phones, other personal electronic devices and cameras) that demeans or humiliates the resident, regardless of whether the resident provided consent or the resident's cognitive status. The policy and procedure titled Photography - Still and Video, dated 02/2020, documented in order to ensure resident privacy, to provide optimal resident care, and to foster mutual respect between and among the residents, family and staff, the facility will ban audio or visual recordings of resident encounters, activity of daily living (ADL) assistance, care or procedures by residents, visitors and staff, unless specifically allowed by the applicable procedures or required by state law. The policy and procedure titled Cell Phone Use, dated 10/2019, documented to maintain privacy and confidentiality rights of our residents; to be in compliance with Health Insurance Portability and Accountability Act (HIPAA), use of cellular telephones or any other electronic device is prohibited in resident areas. Protected Health Information should never be stored, shared or accessed on a personal device. Inappropriate use of a cellular device by an employee includes, but is not limited to, photographing or videorecording residents and sharing HIPAA (Health Insurance Portability and Accountability Act) protected information via unsecured networks. Resident #1 had diagnoses including generalized anxiety disorder, major depressive disorder, and selective mutism (a mental health condition where an individual was unable to speak in certain situations due to fear or anxiety). The Minimum Data Set (a resident assessment tool) dated 05/28/2025 documented Resident #1 was usually understood, usually understands, and had moderate cognitive impairment. They were frequently incontinent of both bowel and bladder. Resident #2 had diagnoses including morbid obesity, chronic kidney disease and hypothyroidism (thyroid disease). The Minimum Data Set, dated [DATE] documented Resident #2 was always understood, always understands and was cognitively intact. They were frequently incontinent of bowel and bladder.Resident #3 had diagnoses including encephalopathy (a disease of the brain), polyneuropathy (a disease process involving nerves), and anemia (a condition where the blood doesn't have enough healthy red blood cells or hemoglobin to carry adequate oxygen to the body's tissues). The Minimum Data Set, dated [DATE] documented Resident #3 was always understood, always understands and had severe cognitive impairment. They were frequently incontinent of bowel and bladder.Resident #4 had diagnoses including cerebral infarction (stroke), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body). The Minimum Data Set, dated [DATE] documented Resident #4 was usually understood, usually understands and had severe cognitive impairment. They were frequently incontinent of bowel and bladder. Review of the Complaints/Incidents Tracking System ACTS/Investigative Report received on 06/10/2025 at 10:52 AM revealed photographs were posted on social media by Certified Nurse Aide #1, as well as a text message that was sent to the Administrator. The photographs attached to the report revealed heavily soiled, incontinent residents in various stages of undress, with their buttocks and genitalia exposed. The social media post indicated it was publicly shared 825 times. Review of the social media pictures/posts revealed residents lying in bed in various stages of undress, some with their genitals and buttocks exposed; some with their torso, chest and legs exposed. Medical devices, equipment and skin conditions could also be visualized in some of the photos. The residents could be seen lying on heavily soiled linens and briefs. Some of the pictures were labeled with a day and time. The residents' faces could not be visualized. There were also text messages from the employee to the Administrator posted, documenting the residents were covered in black feces and soaked in urine and looked like they had not been changed in at least two shifts, describing the condition of residents' skin as fire red.The facility investigation dated 06/11/2025 documented on 06/9/2025, social media posts alleged that Resident #1, Resident #2, and Resident #3 did not receive care from 05/25/2025 to 05/26/2025. The social media posts showed photos of facility residents in various stages of incontinence. The investigation did not include Resident #4. Review of Certified Nurse Aide #1's employee file revealed the last day they worked at the facility was 06/1/2025. During a telephone interview on 06/12/2025 at 9:00 AM, Certified Nurse Aide #1 stated they had sent text messages and written statements to the Administrator on many occasions to report that care was not being completed on the previous shift. Certified Nurse Aide #1 stated they were a mandated reporter, and they were following the chain of command by reporting to the facility first. They stated they felt filing a complaint with the New York State Department of Health would not help so, they posted the pictures on their personal social media account. The pictures had people in them, but there were no faces, names or identification, so they felt the Health Insurance Portability and Accountability Act (HIPAA) privacy of the residents was not an issue. The pictures showed that the residents were lying in feces and the linens needed to be changed. During an interview on 06/12/2025 at 9:42 AM, Certified Nurse Aide #2 stated staff were not supposed to have their cell phones in the halls or resident rooms because it could impact a resident's privacy. They stated that they saw the social media post and the pictures contained residents' exposed backsides, including their buttocks. They stated the pictures should never have been taken and posted on social media. It was a Health Insurance Portability and Accountability Act (HIPAA) violation and was considered abuse. It was just wrong to take a picture of residents like that. If the residents knew that their picture was taken in that way and shared online, they could be upset or feel violated. Certified Nurse Aide #2 identified Resident #4 as one of the residents in the pictures/posts on social media. They stated Resident #4 was sometimes confused and this was something they would not want posted online.During an interview on 06/12/2025 at 9:48 AM, Certified Nurse Aide #3 stated out of respect for the residents and because there could be a HIPAA (Health Insurance Portability and Accountability Act) violation, cell phones were not supposed to be used while on the unit or in resident rooms and definitely should never be used while giving care. Certified Nurse Aide #3 stated they saw the social media post, noting there were pictures of residents, some with their backs and buttocks exposed, and their sheets were soiled with urine/feces. Certified Nurse Aide #3 stated Resident #4 was pictured in the post on social media. During an interview on 06/12/2025 at 9:59 AM, Certified Nurse Aide #4 stated that they did not see the post on social media but heard about it from other staff. Certified Nurse Aide #4 stated it was messed up for Certified Nurse Aide #1 to exploit the residents on social media. They stated it was possible the community and the families of the residents saw the social media posts. They stated they felt the pictures and social media posts were a HIPAA (Health Insurance Portability and Accountability Act) violation and a form of abuse. During an observation and interview on 06/12/2025 at 10:05 AM, Resident #4 was lying in their bed in their room. Resident #4 was unable to answer simple questions. During an interview on 06/12/2025 at 11:15 AM, Resident #2 stated they would not like it if a staff member took a picture of their buttocks and posted it on social media. Resident #2 stated, Who would want to see my ass? and stated they would be pissed off if they found out that there was a picture of their buttocks posted on social media. They stated that was a dignity issue and crossed a line into abuse that should never be crossed. During an interview on 06/12/2025 at 11:19 AM, Licensed Practical Nurse #1 stated they were aware of Certified Nurse Aide #1's social media posts because somebody had shared them, and it contained pictures of people's body parts. Licensed Practical Nurse #1 stated the pictures on social media were a HIPAA (Health Insurance Portability and Accountability Act) violation, a dignity issue, could be considered mental abuse and were sexually inappropriate. They stated private body parts were visible in the pictures. Licensed Practical Nurse #1 stated they did not think any of the residents in the pictures would have been able to speak for themselves, and they probably would not want those pictures on social media. During an interview on 06/12/2025 at 11:35 AM, Licensed Practical Nurse #2 stated it was never ok to record or take pictures of residents and they should never be posted on social media. Any pictures that contain buttocks and/or genitals would be considered nudity. Licensed Practical Nurse #2 stated if the residents were aware that pictures of them were posted, they might feel embarrassed or violated. They stated the situation was a dignity issue and a form of abuse. It could be mental abuse but also could be a form of sexual abuse. Licensed Practical Nurse #2 stated that they doubted any residents on the unit would be ok with having those pictures taken or posted on social media. During an interview on 06/12/2025 at 12:07 PM, Resident #1 stated they would not want staff taking a picture of their undressed buttocks because it was their private area; they were not sure if any staff had taken their picture. They stated it would be upsetting if their picture was taken and posted on social media. During an interview on 06/12/2025 at 12:13 PM, Registered Nurse Unit Manager #1 stated the pictures that were taken of residents and posted on social media could be considered abuse. During an interview on 06/12/2025 at 1:25 PM, the Administrator stated within an hour of Certified Nurse Aide #1's social media posting, several staff members informed them of the posts. The social media posts had occurred on 06/9/2025 around 3:00 PM and Certified Nurse Aide #1 was a former employee. The Administrator stated there were pictures of residents lying in their beds, but there were no faces, and they were unable to identify any of the residents by the pictures. Prior to posting the pictures on social media, Certified Nurse Aide #1 wanted to change their schedule, which could not be accommodated, so they resigned. Approximately an hour later, the social media post was made. The Administrator stated that Certified Nurse Aide #1 would sometimes text them about the care at the facility, and each time they were asked to provide a written statement regarding their concerns, however never did. The Administrator stated this was the resident's home and posting anything on a public forum, including social media was the opposite of what the facility was striving to do. They stated they did not think of the pictures and social media post to be a form of abuse. During a telephone interview on 06/12/2025 at 4:00 PM, Resident #4's Responsible Party stated Resident #4 was at the facility because they had a stroke; they believed they had dementia and were at times confused. The Responsible Party stated Resident #4 would never be okay with a picture of their exposed buttocks/genitals being posted on social media. They stated this was something they would not be happy about and it would be shameful. During a telephone interview on 06/17/2025 at 8:15 AM, Resident #3's Responsible Party stated Resident #3 was becoming more and more confused and at times was unable to speak for themselves. The Responsible Party stated Resident #3 would definitely not be okay with anyone taking pictures of their undressed buttocks and/or genitalia and they would be appalled if those pictures were posted on social media. During an interview on 06/17/2025 at 8:49 AM, Certified Nurse Aide #6 stated they were aware of the pictures and social media posts. In the pictures, a resident was turned on their side, their entire backside was exposed, and they had been lying in filth. Certified Nurse Aide #6 stated the social media post was public, which means that anybody who had access to the internet had the ability to see the full post, including photos of residents. Certified Nurse Aide #6 stated when they saw the post, it had been shared at least 700 times. They stated the pictures contained private areas of residents and even though their faces were not in the picture, it was still a violation of their dignity and could be abuse. During an interview on 06/17/2025 at 9:22 AM, Licensed Practical Nurse Unit Manager #4 stated they were supervising on the day of the social media post and reported the post to the Director of Nursing and Administrator because it was inappropriate, and it was undignified for the residents. They stated they looked at the post quickly, and were able to see residents, their backs and their buttocks and the conditions they were left in. Licensed Practical Nurse Unit Manager #4 stated the buttocks were considered a private area and the pictures were a breach of residents' privacy and dignity even if their faces were not in the picture. Licensed Practical Nurse Unit Manager #4 stated if they found out someone took these types of pictures of them and posted on social media for the world to see, they would be upset and embarrassed. During a telephone interview on 06/17/2025 at 10:14 AM, the Medical Director stated they were not aware pictures of residents had been taken and posted on social media. The Medical Director stated the facility was the residents' home and even though their physical safety was not affected, their mental safety was intruded on. During an interview on 06/18/2025 at 9:00 AM, Social Worker #1 stated taking pictures without residents' consent was just wrong. Taking the pictures was completely disregarding how the resident would feel and who they were. Social Worker #1 stated the pictures in the social media post were potentially humiliating and degrading for the residents involved. During an interview on 06/18/2025 at 11:10 AM, the Director of Nursing stated the pictures were of elderly people in various stages of undress and as if they were in the process of care being provided to them. In some of the pictures, there was a visible buttock, and the residents were in a vulnerable position. The Director of Nursing stated they felt firmly the pictures and social media posts would not be considered abuse. An example of mental/emotional abuse would include making a resident feel humiliation, shame, or embarrassment. During an interview on 06/18/2025 at 11:35 AM, the Administrator stated the residents in the pictures were unable to be identified and because of that, they treated the investigation as a dignity concern. They stated they were able to identify for their investigation Residents #1, #2 and #3 from the original text messages sent from Certified Nurse Aide #1. Mental/Psychosocial abuse would include anything demeaning or humiliating to a specific individual. The Administrator stated the pictures of the exposed buttocks and genitalia could be demeaning and humiliating, but since the residents were not aware of the pictures being taken, they would not be able to be humiliated. 10 NYCRR 415.4(b)(1)(i)

Based on observation, interview, and record review conducted during an Abbreviated Partial Extended survey (Complaint #NY00383127) the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws and regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; and the governing body is responsible and accountable for the Quality Assurance and Performance Improvement program. Specifically, the administration did not ensure implementation of abuse policies and recognize abuse when Certified Nurse Aide #1 took personal photographs of heavily soiled incontinent residents in various stages of undress without their consent, including some with their buttocks and genitalia exposed. The photographs were posted on social media along with text messages and descriptions of the lack of resident care. The findings are:REFER TO: F 600 - Free from Abuse and Neglect F 609 - Reporting Alleged ViolationsF 610 - Investigate/Prevent/Correct Alleged ViolationThe policy and procedure titled Abuse, dated 6/2024, documented the facility prohibits the mistreatment, neglect, and abuse of residents/patients by anyone. The facility prohibits any exploitation of the mentally and physically disabled residents in the facility. Mental/emotional abuse is the use of verbal and/or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Mental abuse includes abuse that is facilitated or enabled using technology (smart phones, other personal electronic devices and cameras) that demeans or humiliates the resident, regardless of whether the resident provided consent or the resident's cognitive status. The policy and procedure titled Photography - Still and Video, dated 2/2020, documented in order to ensure resident privacy, to provide optimal resident care, and to foster mutual respect between and among the residents, family and staff, the facility will ban audio or visual recordings of resident encounters, activity of daily living (ADL) assistance, care or procedures by residents, visitors and staff, unless specifically allowed by the applicable procedures or required by state law. The policy and procedure titled Cell Phone Use, dated 10/2019, documented to maintain privacy and confidentiality rights of our residents; to be in compliance with Health Insurance Portability and Accountability Act (HIPAA), use of cellular telephones or any other electronic device is prohibited in resident areas. Protected Health Information should never be stored, shared or accessed on a personal device. Inappropriate use of a cellular device by an employee includes, but is not limited to, photographing or videorecording residents and sharing HIPAA (Health Insurance Portability and Accountability Act) protected information via unsecured networks. Review of a Counseling Memo dated 5/7/25 documented the Director of Nursing was provided counseling that all incidents must be thoroughly investigated to rule out abuse and all investigations must include factual data including witness statements and resident interviews to reach a reason able conclusion. The Counseling Memo was signed by the Director of Nursing. The Director of Clinical Operations signed as the instructor. During an interview on 6/12/25 at 1:25 PM, the Administrator stated they were aware within an hour of the post on social media that included allegations against the facility as well as pictures of residents laying in their beds. They began an investigation immediately but did not think about the possibility of abuse at the time, only dignity. During a telephone interview on 6/17/2025 at 10:14 AM, the Medical Director stated the facility was the residents' home and even though their physical safety was not affected, their mental safety was intruded on. During an interview on 6/18/25 at 11:10 AM, the Director of Nursing stated the incident that occurred was investigated focused on dignity because it was a dignity concern and not abuse. The Director of Nursing stated an example of mental/emotional abuse would include making a resident feel humiliation shame, or embarrassment. During an interview on 6/18/25 at 11:35 AM, the Administrator stated the day that the incident happened on 6/9/25, the incident was not seen as suspected abuse but was viewed a dignity concern and was investigated as a dignity concern. Any suspected abuse should be reported within two (2) hours to the State Agency. The incident on 6/9/25 was reported to the State Agency on 6/12/25. During an interview on 6/18/2025 at 9:00 AM, Social Worker #1 stated the pictures in the social media post were potentially humiliating and degrading for the residents involved. During an interview on 6/18/25 at 11:55 AM, the Director of Clinical Operations stated the pictures that were posted on social media certainly could be humiliating and degrading, the incident should have been reported to the State Agency.10 NYCRR 415.26

Based on observation, interview, and record review conducted during an Abbreviated survey (Complaint #NY00383127) the facility did not ensure that all alleged violations involving abuse and mistreatment are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse, to other officials (including to the State Survey Agency) for four (4) (Resident #1, #2, #3, and #4) of four (4) residents reviewed. Specifically, allegations of resident abuse were not reported within 2 hours to the New York State Department of Health and law enforcement agencies. The finding is: The policy and procedure titled Abuse dated 6/2024 documented the facility prohibits the mistreatment, neglect, and abuse of residents/patients by anyone including but not limited to staff, family, friends, and residents of the facility. The Administrator and Director of Nursing are responsible for investigation and reporting. Report to the local law enforcement and appropriate State Agency(s) immediately (no later than two (2) hours after allegation/identification of allegation) by the Agency's designated process after identification of alleged/suspected incident. The local law enforcement authorities are to be notified of any instance of resident: abuse, exploitation, mistreatment, neglect, involuntary seclusion or misappropriation of personal property which is a criminal act. Resident #1 had diagnoses including generalized anxiety disorder, major depressive disorder, and selective mutism (a mental health condition where an individual was unable to speak in certain situations due to fear or anxiety). The Social Service Assessment and Documentation dated 5/23/25 documented Resident #1 was usually understood, usually understands and had moderate cognitive impairment. Resident #2 had diagnoses including morbid obesity, chronic kidney disease and hypothyroidism. The Minimum Data Set (a resident assessment tool) dated 4/1/2025 documented Resident #2 was always understood, always understands and was cognitively intact. Resident #3 had diagnoses including encephalopathy (a disease in which the functioning of the brain was affected), polyneuropathy (a disease process involving a number of nerves), and anemia. The Minimum Data Set, dated [DATE] documented Resident #3 was always understood, always understands and had severe cognitive impairment. Resident #4 had diagnoses including cerebral infarction (stroke), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body). The Minimum Data Set, dated [DATE] documented Resident #4 was usually understood, usually understands and had severe cognitive impairment. Review of the New York State Complaints/Incidents Tracking System Investigative Report received on 6/10/25 at 10:52 AM revealed photographs that were posted on social media sites by Certified Nurse Aide #1, as well as a text message that was sent to the Administrator. The photographs attached to the report revealed heavily soiled, incontinent residents in various stages of undress, with their buttocks and genitalia exposed. The social media post indicated the post was publicly shared 825 times. The report documented that the incident was not submitted by the facility. Review of the facility investigation dated 6/11/25 revealed on 6/9/25 social media posts alleged that Resident #1, Resident #2, and Resident #3 did not receive care on 5/25/25 to 5/26/25. The social media posts also showed photographs of facility residents in various states of care. The facility investigation documented the incident was reported to the Buffalo Police Department on 6/12/25, to the State Agency on 6/12/25 and the Office of Professions on 6/12/25. During a telephone interview on 6/12/25 at 9:00 AM, Certified Nurse Aide #1 stated they were a mandated reporter, and they were following the chain of command by reporting to the facility first. They stated they felt filing a complaint with the New York State Department of Health would not help so, they posted the pictures on social media sites of the facility and residents. The pictures had people in them but there were no faces, names or identification, so HIPAA (Health Insurance Portability and Accountability Act) was not broken. The pictures showed that the residents were laying in feces and the linens needed to be changed. Certified Nurse Aide #1 stated because there were no resident faces in any of the pictures there would be no issues related to HIPAA or dignity. During an interview on 6/12/25 at 9:42 AM, Certified Nurse Aide #2 stated the pictures posted on social media contained residents' exposed backside, including their buttocks. Certified Nurse Aide #2 stated Resident #4 was in one of the pictures that was shared on social media. During an interview on 6/12/25 at 9:48 AM, Certified Nurse Aide #3 stated they saw the social media post and Resident #4 was pictured in the post. They stated they knew it was Resident #4 because after taking care of someone so often, they were just able to tell it was Resident #4. During an interview on 6/12/25 at 1:25 PM, the Administrator stated they were aware within an hour of the post on social media that included allegations against the facility as well as pictures of residents laying in their beds. They began an investigation immediately but did not think about the possibility of abuse at the time. Allegations of suspected abuse should be reported within two (2) hours to the State Agency. Further interview at 3:30 PM, the Administrator stated they had not notified the State Agency or the local law enforcement agency at that time. During an observation and interview on 6/12/25 at 3:27 PM, the Director of Nursing was at their computer in their office and the Administrator was on their cell phone. The Administrator stated the Director of Nursing was filing an incident with the State Agency and they were on the phone with the Local Police Department. During an interview on 6/18/25 at 9:00 AM, Social Worker #1 stated if they were to see pictures of undressed residents including their buttocks and genitalia posted on social media, they would report it to the abuse coordinator immediately and file a report against the person who made the post. They stated that was something that could be humiliating and degrading for the residents involved. During an interview on 6/18/25 at 11:10 AM, the Director of Nursing stated the types of abuse include verbal, financial, sexual, physical, mental/emotional and neglect. An example of mental/emotional abuse would include making a resident feel humiliation shame, or embarrassment. The Director of Nursing stated that the social media incident was reported immediately after the recertification team brought it to their attention and questioned if it was abuse. Reporting allegations of suspected abuse was completed by the Director of Nursing, Administrator or Assistant Director of Nursing and should be reported to mitigate and maintain resident safety. Everyone in the facility has the responsibility to ensure the safety of the residents. During an interview on 6/18/25 at 11:35 AM, the Administrator stated the day that the incident happened was on 6/9/25, the incident was not seen as suspected abuse but was viewed a dignity concern and was investigated as a dignity concern. Any suspected abuse should be reported within two (2) hours to the State Agency. The incident on 6/9/25 was reported to the State Agency on 6/12/25. During an interview on 6/18/25 at 11:55 AM, the Director of Clinical Operations stated they expected the Director of Nursing or Administrator to report suspected abuse to the State Agency within two (2) hours. They stated that because the pictures that were posted on social media certainly could be humiliating and degrading, the incident should have been reported to the State Agency. 10NYCRR 415.4 (b)(2)

Based on interview and record review conducted during a Complaint investigation (#NY00383127), the facility did not ensure that all alleged violations of abuse and neglect were thoroughly investigated for four (4) (Resident #1, #2, #3, #4) of four (4) residents reviewed. Specifically, there was a lack of employee and resident interviews and statements to rule out abuse regarding a post on social media containing allegations against the facility and pictures of residents in the state of undress. The finding is: The policy and procedure titled Abuse dated 6/2024 documented allegations/reports of suspected abuse, neglect, mistreatment, distortion, injury of unknown etiology or misappropriation shall be promptly and thoroughly investigated by facility management. The Administrator and Director of Nursing are responsible for investigation and reporting. Initiate the investigative process. The investigation should be thorough with witness statements from staff, residents, visitors and family members who may be interview able and have information regarding the allegation. The policy and procedure titled Investigations, How to Conduct dated 11/2019 documented the aim is to complete the investigation as soon as possible from the day of the incident. The investigator conducts interviews in the following order: The resident(s) involved, obtain a statement (if possible) about what occurred from the resident and complete appropriate nursing assessments. Locate and arrange interviews with the people involved in, or who may have witnessed the incident (i.e. the person who found the resident/patient or to whom the incident was first reported, people who were near the incident scene, the staff member responsible for the care of the resident or patient, the nurse responsible for the unit. This may involve going back 24 hours and interviewing staff on previous shifts (or greater than 24 hours if alleged incident occurred earlier). Witnesses should be interviewed separately, and all provide written statements whenever possible. Collect information (evidence) that is related to the facts and circumstances of the incident being investigated. The information should include who, what, when, where, how and why. Resident #1 had diagnoses including generalized anxiety disorder, major depressive disorder, and selective mutism (a mental health condition where an individual was unable to speak in certain situations due to fear or anxiety). The Social Service Assessment and Documentation dated 5/23/25 documented Resident #1 was usually understood, usually understands and had moderate cognitive impairment. Resident #2 had diagnoses including morbid obesity, chronic kidney disease and hypothyroidism (thyroid disease). The Minimum Data Set (a resident assessment tool) dated 4/1/2025 documented Resident #2 was always understood, always understands and was cognitively intact. Resident #3 had diagnoses including encephalopathy (a disease in which the functioning of the brain was affected), polyneuropathy (a disease process involving a number of nerves), and anemia. The Minimum Data Set, dated [DATE] documented Resident #3 was always understood, always understands and had severe cognitive impairment. Resident #4 had diagnoses including cerebral infarction (stroke), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body). The Minimum Data Set, dated [DATE] documented Resident #4 was usually understood, usually understands and had severe cognitive impairment. Review of the Complaints/Incidents Tracking System Investigative Report received on 6/10/25 at 10:52 AM revealed photographs were posted on social media sites by Certified Nurse Aide #1, as well as a text message that was sent to the Administrator. The photographs attached to the report revealed heavily soiled, incontinent residents in various stages of undress, with their buttocks and genitalia exposed. The social media post indicated the post was publicly shared 825 times. The facility investigation dated 6/11/25 documented on 6/9/25 social media posts alleged that Resident #1, Resident #2, and Resident #3 did not receive care on 5/25/25 to 5/26/25. The social media posts also showed photographs of facility residents in various states of care. Multiple staff (more than ten (10)) reported the social media posts to the Administrator. The investigation included attestations of attempts to contact Certified Nurse Aide #1 for a witness statement, resident dignity interview worksheets, nursing progress notes, Certified Nurse Aide care documentation, and five (5) Certified Nurse Aide witness statements regarding care completed on 5/25/25. The investigation lacked staff witness statements regarding the social media post on 6/9/25. The investigation did not include Resident #4. Review of the Resident Dignity Interview Worksheets dated 6/9/25-6/12/25 documented residents were asked if staff treated them with kindness, spoke to them respectfully, knocked prior to entering their room, listened to them, provided personal care in private, if their belongings and space were treated with care, if they felt comfortable speaking up when something was wrong, and if they felt safe and well cared for. Resident #1 answered yes to all questions and signed the worksheet. There were no follow up notes documented. Resident #2 answered that Certified Nurse Aides sometimes treat them with kindness and that they did not feel safe or well cared for. Under the notes section it was documented care concerns - night shift without any further details. There were no further follow-up notes on the worksheet for Resident #2. Resident #3 answered all of the questions with yes with the exception that sometimes they were not sure staff were listening. There was no follow-up notes documented for Resident #3. There were no specific questions regarding concerns of abuse, use of cell phones, staff taking pictures, or social media on the worksheet. There was no Resident Dignity Interview Worksheet completed for Resident #4. Review of Resident #4's interdisciplinary progress notes dated 6/1/25-6/16/25 lacked documented evidence that Resident #4 or their responsible party was interviewed regarding the social media investigation. Review of the facility staffing sheet dated 5/25/25 documented during the 7 AM-3 PM shift, seven (7) Certified Nurse Aides, three (3) Licensed Practical Nurses, and one (1) Registered Nurse worked on Unit Two (2). During the 3 PM-11 PM shift, six (6) Certified Nurse Aides, three (3) Licensed Practical Nurses and one (1) Registered Nurse Supervisor worked on Unit Two (2). During the 11 PM-7 AM shift, three (3) Certified Nurse Aides and three (3) Licensed Practical Nurses worked on Unit Two (2). Review of the facility staffing sheet dated 6/9/25 documented during the 7 AM-3 PM shift four (4) Certified Nurse Aides, two (2) Licensed Practical Nurses, two (2) Registered Nurses, and two (2) Unit Managers worked on Unit Two (2). During the 3 PM-11 PM shift, seven (7) Certified Nurse Aides and three (3) Licensed Practical Nurses worked on Unit Two (2). During the 11 PM-7 AM shift one (1) Certified Nurse Aide, two (2) Licensed Practical Nurses, and one (1) Licensed Practical Nurse Supervisor worked on Unit Two (2). During an interview on 6/12/25 at 1:25 PM, the Administrator stated within an hour of the social media post, about eight (8) staff members in the facility had gone to their office to inform them of the social media post. There were other staff members that had texted or called them. The social media post had occurred on 6/9/25 around 3:00 PM and it was a former employee who was posting the pictures on social media and posting that they were from the facility. The Administrator stated at the time that the staff notified them of the social media post, they immediately started investigating by obtaining Certified Nurse Aide documentation and statements. The Director of Nursing had the investigation, and it was ongoing. The Administrator stated they did not ask the staff if they were able to identify the residents in the post because it was inappropriate and would feel uncomfortable with it. They stated they did not think of the pictures and social media post to be a form of abuse. During a telephone interview on 6/12/25 at 4:00 PM, Resident #4's Responsible Party stated they never received a phone call from the facility regarding pictures posted on social media. During an interview on 6/18/25 at 9:00 AM, Social Worker #1 stated they completed dignity rounds for all residents on Unit Two (2). During the dignity rounds they would go to each resident ask them if they felt comfortable or if they had any concerns with the facility. They used the Resident Dignity Interview Worksheet to complete the dignity rounds and only asked the questions that were on the worksheet. Social Worker #1 stated they had not personally asked any of the residents on the unit if they were ok with their pictures being taken or if they would be ok with their pictures being posted online. They stated they were not aware that the social media post on 6/9/25 contained any resident pictures. Any pictures taken of residents, even if it was just their face, consent needed to be obtained from the resident. They stated that they did not interview any of the families about their feelings at the facility or regarding any social media posts. During an interview on 6/18/25 at 11:10 AM, the Director of Nursing stated the investigation was focused on dignity because it was a dignity concern and not abuse. That included the social workers completing dignity rounds, reviewing Certified Nurse Aide documentation to see if residents received care, and nurses completed skin checks. The Director of Nursing stated they believed they received witness statements from all the Certified Nurse Aides they needed to because they looked at the assignment sheets and had the Certified Nurse Aides who were responsible for care of Resident #1, Resident #2, and Resident #3 on 5/25/25 write statements. The Director of Nursing stated they talked to other staff members about the social media post but never had them write any statements because she had a cheat sheet of who she talked to. When the Director of Nursing was asked what the conversation was between them and their staff regarding the cheat sheet no answer was given. The DON stated the statements from the staff were verbal and the incident was a dignity issue. During an interview on 6/18/25 at 11:35 AM, the Administrator stated because they did not know who the residents were in the pictures or when the pictures were taken, the investigation was general. Social work spoke with residents themselves and asked if there were any negative interactions with staff or if they felt cared for. The Director of Social Work was the one who reached out to the families and Social Worker #1 completed the Resident Dignity Interview Worksheet. They had looked for any previous grievances regarding resident care but were unable to find any grievances; they relied on the Social Workers' dignity audits. The Certified Nurse Aide Witness statements that were obtained were staff that had worked on the unit through various shifts and since the residents pictured could not be identified, they did not interview all of the Certified Nurse Aides on the unit. The Administrator stated they did not feel it would have been appropriate to interview all of the staff on the unit. They stated they had questioned the staff who had reported the social media post if they were able to identify the residents and they were unable to. The Administrator stated without specific identifiers, the incident was investigated the best they could and as a dignity and respect issue. During an interview on 6/18/25 at 11:55 AM, the Director of Clinical Operations stated their expectation was for the investigation to be done objectively and a full sweep of the unit should have been completed. They stated they thought that the Director of Nursing had spoken to everyone on the unit because they had a cheat sheet that they were working off of. The investigation to rule out abuse should have been started when the Administrator and Director of Nursing became aware of the social media post. During an interview on 6/18/25 at 12:30 PM, the Director of Social Work stated their part of the investigation was assisting in completing dignity rounds with the Resident Dignity Interview Worksheet. If a resident was unable to complete the worksheet, then the responsible party should have been called and it would have been documented in the progress notes. 10 NYCRR 415.4(b)(3)

Based on observation, interview, and record review during a Complaint Investigation (Complaint #NY00381783) conducted during the Standard survey completed on 6/17/25, the facility did not maintain an effective pest control program so that the facility was free from insects. Specifically, three (3) (Second Floor, Third Floor, and Fourth Floor) of three (3) resident units had issues with many flies observed throughout the facility. The findings are: The policy titled, Pest Control, created 11/2022 documented the facility shall maintain an effective pest control program. The facility maintains an on-going pest control program to ensure the building is kept free of pests and pest control services are provided through contract with an approved pest control provider. The Licensed Exterminator's most recent Service Report, dated 6/6/25, documented the fourth floor was inspected for large flies. The Technician Notes documented resident room [ROOM NUMBER] seemed to be the source of the flies and large flies were observed in the hallway and other patients' rooms in a lesser proportion than in room [ROOM NUMBER]. The Technician Notes also suggested daily rubbish management, working insect light traps, additional glue board devices, and replace or install tight fitting insect screens on windows. A second Service Report, also dated 6/6/25, documented two insect light trap bulbs were repaired and a new insect light trap glue board was provided on the fourth floor. Also, a fly bait sticker, a new insect light trap, and four fly glue sticks were provided for resident room [ROOM NUMBER]. Review of Licensed Exterminator Service Reports from 3/4/25 to present revealed the two Service Reports dated 6/6/25 were the only ones to address flies. Observation on the fourth floor on 6/10/25 at 8:30 AM revealed one dead fly was in the freezer in the Nourishment Room. At the time of the observation, Certified Nurse Aide #1 stated the fly in the freezer was disgusting. During an interview on 6/11/25 at 12:00 PM, Resident #114 stated the flies go room to room on the third floor. They stated they had neither seen improvement or worsening of the flies recently. Resident #114 also stated the windows at the ends of the halls did not have screens on the top panes and people had been opening those windows without screens, which they believed to be the cause of the issue. During an interview on 6/11/25 at 12:20 PM, Resident #229 stated there were flies in their room and on their body. They also stated because they ate their meals in their room, the flies were around their food. Resident #229 stated, They try to get in your food, and that happened at lunch today. At the time of the interview, two live flies were observed on Resident #229's legs. During an interview on 6/11/25 at 12:35 PM, the Maintenance Director stated they had screwed shut the top panes of the windows at the ends of the hallways this week. They stated staff members were opening the windows from the top down and the bottom up, which could have let in flies due to no window screen at the top half. Observation on the second floor on 6/11/25 at 12:35 PM revealed a small plug-in style fly light, missing the glue paper, was plugged in inside resident room [ROOM NUMBER]. At the time of the observation, the Maintenance Director stated the facility did not provide this device. During an interview on 6/11/25 at 12:40 PM, Resident #51 stated flies were around and they were bothersome during meals. During an interview on 6/11/25 at 12:50 PM, Resident #386 was seated in a chair next to their bed and stated there were flies in their room. At this time, two live flies were observed on Resident #386's bed and pillow. During an interview on 6/11/25 at 1:48 PM, Resident #158 stated they hated flies and sometimes flies landed on their body. At this time, one live fly was flying back and forth inside Resident #158's room. Observation on the fourth floor on 6/11/25 at 2:02 PM, revealed a small plug-in style fly light, missing the glue paper, was plugged in inside resident room [ROOM NUMBER]. At the time of the observation, the Maintenance Director stated the facility did not provide this device. During an interview on 6/12/25 at 12:05 PM, the Maintenance Director stated they purchased and installed insect light traps in the corridors, and inside resident room [ROOM NUMBER] three to four months ago. They stated they maintained the insect light traps by replacing the glue papers about once every two weeks, or as needed. The Maintenance Director stated the fly issue had gotten worse over the last two to three weeks because of the warmer weather. They stated the files on the second and third floor had recently improved, and the flies on the fourth floor were under control, but not improving, so last week they asked the licensed exterminator to get involved. The Maintenance Director stated they did not know why the licensed exterminator identified resident room [ROOM NUMBER] as the source of the flies and the resident in that room refused to allow most people to enter their room. The Maintenance Director stated staff could communicate any pest sightings to them verbally, and they would add it to the Pest Control Log that was maintained between themselves and the licensed exterminator, or staff could write any pest concerns in the Maintenance Log binder that was kept at each Nurses' Station. Review of the Pest Control Log dated 1/13/25 to present revealed it contained no entries about flies. Review of the Maintenance Log binders located at the second, third, and fourth floor Nurses' Stations revealed they contained no recent entries about flies. During an interview on 6/12/25 at 12:20 PM, the Director of Housekeeping and Laundry stated flies in the facility had been an issue off and on, but not a constant problem. They stated the resident inside room [ROOM NUMBER] did not let most staff enter their room, but did allow one Housekeeper to enter for daily cleaning. They stated the Housekeeper removed the garbage and cleaned as much as they could on a daily basis, but the resident would not allow them to touch the area around or under their bed or their tray table. The Director of Housekeeping and Laundry also stated the resident inside room [ROOM NUMBER] had a habit of throwing food and drink, which made it difficult to maintain cleanliness. The Director of Housekeeping and Laundry stated the flies inside resident room [ROOM NUMBER] were unsanitary. Observation on 6/16/25 at 11:30 AM, revealed a yellow fly glue strip was hanging from the ceiling in the center of resident room [ROOM NUMBER], and there were at least 50 dead flies stuck to the strip. At this time, the Maintenance Director stated the facility provided the yellow fly glue strips, they were temporary, and they were more for function than for looks. The Maintenance Director also stated the fly glue strip in resident room [ROOM NUMBER] needed to be changed. 2. Observation on 6/10/25 at 9:42 AM in resident room [ROOM NUMBER] there were approximately five to six flies in the room and on the resident's bed. The resident stated, there are flies everywhere and that it bothered them. Observation on 6/10/25 at 9:52 AM in resident room [ROOM NUMBER] there were approximately three flies in the room and on the resident's body. Observation on 6/10/25 at 10:00 AM in resident room [ROOM NUMBER] there were flies in the room. The resident stated that the flies in the room bothered them. Observation on 6/10/25 at 10:12 AM in resident room [ROOM NUMBER] there was a fly strip hung from the ceiling with approximately 20 to 30 dead flies stuck to it. Observation on 6/10/25 at 11:00 AM on Unit 2 C hall numerous flies flying throughout the hallway. Observation on 6/11/25 at 8:48 AM, resident room [ROOM NUMBER] had 10 to 15 flies in the room and three flies landed on the resident. Observation on 6/12/25 at 12:15 PM in resident room [ROOM NUMBER] there were approximately 30 flies on the wall, bedside table, and resident's bed. During an interview on 6/11/25 at 8:21 AM Resident #19 stated that there were large, black house flies that landed on them, their face, and it bothered them. They stated that they told staff about the flies and staff stated they would tell maintenance. During an interview on 6/12/25 at 3:14 PM Resident #16 stated that the flies in the room bothered them. They stated that a fly strip did not bother them, but the flies bothered them. During an interview on 6/12/25 at 3:20 PM Certified Nurse Aide #14 stated that the flies have been bad since they started working there. They stated that the flies land on residents and they thought it was dirty. They stated that it was difficult for residents to brush flies away who can't do that for themselves. During an interview on 6/12/25 at 4:00 PM, Resident #33's representative, stated they asked staff to clean up the room to get rid of the flies. They stated that they knew that flies would bother Resident #33. During an interview on 6/17/25 at 9:03 AM with Licensed Practical Nurse Unit Manager #1 stated that they believed there were flies on the unit due to a resident urinating on the floor and on their mattress. During an interview on 6/17/25 at 11:35 AM, the Administrator stated that they were aware of the fly issue. They stated that they had been working with the pest control contractors who have been coming in weekly or twice weekly to control the flies. They stated that the pest control contractors brought in an entomologist (a scientist who specializes in the study of insects and their environment) for recommendations to control the flies. They stated that they had insect lights installed to take care of the flies, but it did not work as they needed complete darkness to work. They stated that the entomologist recommended another type of insect light that would work better in a nursing home environment. They stated that they believed this light worked better than the previous one. 10 NYCRR 415.29(j)(5)

Based on observation, interview and record review conducted during a Standard survey completed 6/17/25, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and a comfortable environment, to help prevent the development and transmission of communicable diseases and infections for five (5) (Residents #165, #173, #381, #382 and #387) of seven (7) residents observed for Enhanced Barrier Precautions (interventions designed to reduce transmission of multi-drug-resistant organisms including gown and glove use during high contact resident care activities). Specifically, staff did not maintain enhanced barrier precautions and wear the appropriate personal protective equipment while providing direct care for residents with a feeding tube (#173, #381); urinary catheter (#382); a peripherally inserted central catheter (#387) and for a resident with a pressure ulcer requiring a dressing (#165). In addition, there was no Enhance Barrier Precautions sign posted outside Resident #165's door. The findings are but not limited to: The policy titled Enhanced Barrier Precautions last revised on 3/12/25, documented enhanced barrier precautions will be implemented and is applicable for residents with any of the following: infection or colonization with a Multiple Drug-Resistant Organisms, wounds (any type of wound requiring a dressing) and/or indwelling medical devices (central line, urinary catheter, feeding tube, etc.) regardless of Multiple Drug-Resistant Organisms colonization status. Enhanced Barrier Precaution requires wearing disposable gloves and an isolation gown prior to high contact activity. High contact resident care activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use e.g. central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care - any skin opening requiring a dressing. Signage is placed on the door or just outside the resident's room to indicate Enhanced Barrier Precautions are in place. Review of the Enhanced Barrier Precaution signage (a sign used by the facility that was posted outside a resident's door to indicate they required enhanced barrier precautions) documented that providers and staff must wear gloves and a gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, and wound care (any skin opening requiring a dressing). 1. Resident #387 had diagnoses including septicemia (a severe blood stream infection), diabetes mellitus, and hypertension (high blood pressure). The Minimum Data Set (a resident assessment tool) dated 6/13/25 documented Resident #387 had intact cognition, was understood, and understands. The undated comprehensive care plan identified as current by Registered Nurse Unit Manager #1, documented the resident had a risk for Multiple Drug-Resistant Organisms, colonization/infections related to a peripherally inserted central catheter (PICC line). Interventions included enhanced barrier precautions which included wearing a gown and gloves when providing high contact activities at the bedside. The Kardex Report (a guide used by staff to provide care) dated 6/16/25/25 documented Resident #387 was dependent on two or more staff for transferring from the bed to the wheelchair using a mechanical lift device and was on enhanced barrier precautions. During an observation on 6/11/25 at 10:01 AM Registered Nurse Unit Manager #1 entered Resident #387's room, put on gloves and disconnected their intravenous antibiotic, and flushed the peripherally inserted central catheter (PICC line) without wearing a gown. There was an Enhanced Barrier sign posted on the wall next to the room's entrance that notified staff and visitors what personal protective equipment should be utilized when caring for the resident. Additionally, there was personal protective equipment available in the hallway. During an observation on 6/12/25 at 9:44 AM, Registered Nurse Unit Manager #1 while only wearing gloves, accessed the Intravenous tubing and intravenous bag, flushed the peripherally inserted central catheter (PICC line) and connected the intravenous antibiotic. Registered Nurse Unit Manager #1 did not wear a gown. During an interview on 6/16/25 at 10:45 AM, Registered Nurse Unit Manager #1 stated Resident #387 had a peripherally inserted central catheter which was covered with a dressing and was a closed system, therefore they thought enhanced barrier precautions were not required. After reviewing the posted Enhanced Barrier Precaution sign, Registered Nurse Unit Manager #1 stated they should have worn a gown and gloves when working with Resident #387's peripherally inserted central catheter (PICC line). During an observation on 6/16/25 at 10:49 AM Certified Nurse Aide #15 and Physical Therapist #1 transferred Resident #387 with the mechanical lift from their bed into a wheelchair. Certified Nurse Aide #15 wore a mask and gloves but did not wear a gown. Physical Therapist #1 wore gloves but did not wear a gown. During an interview on 6/16/25 at 10:56 AM, Certified Nurse Aide #15 stated they followed standard precautions for all residents but should have followed enhanced barrier precautions and worn a gown while transferring Resident #387. During an interview on 6/16/25 at 11:02 AM, Physical Therapist #1 stated they did not see the Enhanced Barrier Precaution Sign posted and was not aware Resident #387 had a peripherally inserted central catheter (PICC line). They stated in addition to the gloves they should have worn a gown while transferring Resident #387. Transferring was considered a high care activity. During an interview on 6/17/25 at 9:20 AM, the Assistant Director of Nursing/Infection Preventionist stated Resident #387 had a peripherally inserted central catheter and staff were expected to wear gloves, gowns, and masks when splashing could occur during high care activities. 2. Resident #173 had diagnoses including intracerebral hemorrhage (bleeding in the brain, stoke), dysphagia (difficulty swallowing) and gastrostomy (surgical procedure for inserting a tube through the abdomen wall into the stomach for the purposes of nutrition) infection. The Minimum Data Set, dated [DATE] documented Resident #173 was severely cognitively impaired, understood and understands. The assessment tool documented that resident had a feeding tube. The comprehensive care plan updated 3/8/25, documented Resident #173 was at risk for multiple drug resistance colonization/infection related to a percutaneous endoscopic gastrostomy tube (PEG tube/feeding tube). Interventions include to educate resident and visitors on enhanced barrier precautions and wear gown and gloves when providing high contact activities at the bedside. The Kardex dated 6/16/25, documented Resident #173 was on enhanced barrier precautions and to use gown, gloves and mask when performing high-contact activities. During intermitted observations on 6/11/25 at 10:17 AM, 6/12/25 at 3:38 PM, 6/13/25 at 8:41 AM and 6/13/25 at 1:40 PM, Resident #173 had an Enhance Barrier Precaution sign posted outside of their door that directed staff to wear gloves and gowns when providing care during high-contact resident care activities for device care: use of a feeding tube. During on enteral feed observation on 6/13/25 at 1:40 PM Licensed Practical Nurse #3 put on gloves and administered 500 milliliters of Nutren 2.0 enteral feed to gravity along with water flushes via Resident #173's percutaneous endoscopic gastrostomy (PEG) tube. Licensed Practical Nurse #3 did not wear a gown while providing care. During an interview on 6/13/25 at 3:57 PM, Licensed Practical Nurse #3 stated that Resident #173 was on enhance barrier precautions for an open area to their right ankle. They stated they should have worn a gown when they administered Resident #173 enteral feed. Licensed Practical Nurse #3 stated enhance barrier precautions were to be utilized when a resident had a percutaneous endoscopic gastrostomy (PEG) tube. During an interview on 6/17/25 at 9:14 AM, Licensed Practical Nurse Unit Manager #1 stated enhanced barrier precautions were to be used when a resident had a percutaneous endoscopic gastrostomy (PEG) tube and staff should be wearing gloves and gowns when they do any resident care. During an interview on 6/17/25 at 11:13 AM, the Director of Nursing stated that enhanced barrier precautions should be utilized on residents that have tubes going in/out of the body. 3. Resident #382 had diagnoses including sepsis (severe blood infection), urinary tract infection and obstructive and reflux uropathy (urinary tract disorders). The comprehensive care plan initiated 6/2/25 documented Resident #382 was at risk for multidrug-resistant organisms (MDRO) colonization/infections related to a urinary catheter (tube inserted into bladder to drain urine). Interventions included enhanced barrier precautions: wear personal protective equipment (PPE) (gown, gloves) when providing high contact activities at bedside including device care and/or use. May additionally wear face protection if there is a risk of splash or spray. Additionally, Resident #382 required assist with self-care and mobility. Interventions included substantial assist of one staff for toileting hygiene. During an observation on 6/10/25 at 9:20 AM Resident #382's room had an Enhanced Barrier Precaution sign posted outside the room above the name placard that directed staff of the appropriate protective equipment to be worn. Certified Nurse Aide #10 entered the room without personal protective equipment, applied gloves and emptied urinary catheter drainage bag into a urinal and then secured urinary catheter bag to side of bed. During an observation on 6/13/25 at 8:25 AM Certified Nurse Aide #10 wearing only gloves emptied Resident #382's urinary leg bag into urinal, spilling urine on floor. During an interview on 6/12/25 at 8:58 AM, Resident #382 stated nursing staff wear gloves when they provide urinary catheter care, but they do not wear gowns. During an interview on 6/13/25 at 8:30 AM, Certified Nurse Aide #10 stated personal protective equipment was supposed to be worn when residents were on enhanced barrier precautions, and they should have worn a gown when they emptied Resident #382's urinary catheter. During an interview on 6/13/25 at 12:05 PM, Licensed Practical Nurse #9 stated nursing staff should have on gloves, gown and face shield when completing urinary catheter care. During an interview on 6/13/25 at 12:41 PM, Licensed Practical Nurse Unit Manager #2, stated residents with urinary catheters were on enhanced barrier precautions and wearing gown and gloves were required. During an interview on 6/16/25 at 12:29 PM, the Director of Nursing stated they expected staff to pay attention to precaution signs posted and wear personal protective equipment according to the sign. 4. Resident #165 had diagnoses including metabolic encephalopathy, (a brain dysfunction leading to altered mental status) hypertension and pressure ulcer of the sacral area. The Minimum Data Set, dated [DATE] documented Resident #165 was severely cognitively impaired, understood and understands. The comprehensive care plan updated 4/22/25, documented Resident #165 had an actual stage 4 pressure ulcer to the coccyx (tailbone). Intervention included to apply treatments per order. The care plan did not address enhanced barrier precautions. The Kardex dated 6/13/25 The Kardex did not document the resident was on enhanced barrier precautions. The medication administration record date 6/1/25-6/30/25 documented Resident #165 had an order to cleanse their coccyx pressure ulcer with Vashe wound cleanser every day and as needed and cover with bordered foam. During an observation on 6/12/25 at 9:07 AM, Certified Nurse Aide #5 completed morning care for Resident #165. Resident #165's had a bandage to their coccyx area with serosanguinous drainage (drainage mixed with blood and serum). At 9:31 AM, Licensed Practical Nurse #4 entered the room and completed the pressure ulcer treatment to the resident's coccyx. Certified Nurse Aide #5 and Licensed Practical Nurse #4 did not wear a gown during the direct hands-on care. There was no Enhance Barrier Precautions sign posted outside of Resident #165's room. During an interview on 6/12/25 at 3:05 PM, Certified Nurse Aide #5 stated if a resident was on enhance barrier precautions there would be a precaution sign posted by or on their door. A resident with an open wound should be on enhanced barrier precautions. They stated they did not wear a gown because there was no sign posted and they did not know the resident had an open wound until it was too late. They stated they should have worn a gown while providing care. During an interview on 6/16/25 at 12:29 PM, Licensed Practical Nurse #4 stated when they completed the pressure ulcer treatment on 6/12/25 there was not an Enhanced Barrier Precaution sign posted by Resident #165's door, and they did not wear a gown because there was no sign. Licensed Practical Nurse #4 stated they should have because the resident had an open pressure ulcer. During an interview on 6/16/25 at 12:43 PM, Register Nurse Assistant Unit Manager #1 stated they initiated an Enhanced Barrier Precaution signage for Resident #165 upon their admission. They stated they were unsure why there was no sign posted at present but there should be. Registered Nurse #1 stated staff were to wear gloves and gowns while completing treatments and care to Resident #165 because they have an open pressure ulcer. During an interview on 6/17/25 at 10:20 AM, the Assistant Director of Nursing/Infection Preventions stated they were responsible for initiating the Enhanced Barrier Precaution signage, but any staff member could initiate one. They stated Resident #165's pressure ulcer was so small, less than a centimeter, and the drainage could be controlled so they did not feel the resident needed to be on enhance barrier precautions. During an interview on 6/17/25 at 11:13 AM, stated the Infection Preventionist was responsible for initiating enhance barrier precautions. The Director of Nursing stated Resident #165's wound was small but if there was drainage then Resident #165 should have been on enhanced barrier precautions. During an interview on 6/17/25 at 10:20 AM, the Assistant Director of Nursing/Infection Preventionist stated residents should be on enhanced barrier precautions for wounds that are bigger than what could be covered by a band-aid, intravenous line, dialysis ports, foley catheters, percutaneous endoscopic gastrostomy tubes (PEG) and residents that have colonized multi-resistant drug organisms. They stated staff were required to wear gowns, gloves and a mask if there was potential for fluid splashing. 10NYCRR 415.19(a)(2) (b)(4)

Based on observation, interview, and record review during a complaint investigation (#NY00382491) conducted during a Recertification survey completed 6/17/25, the facility did not provide a safe, clean, comfortable and homelike environment for two (Second Floor and Third Floor) of three resident units. Specifically, there were dirty community shower room chairs and floors, dirty resident medical equipment (feeding poles); unlabeled and inappropriately stored personal hygiene products and care items in shower rooms and in resident rooms. In addition, offensive odors were noted in and outside of the soiled linen room. The findings are: The undated facility titled Your Rights as a Nursing Home Resident in New York State and Nursing Home Responsibilities documented the resident had a right to dignity, respect and a comfortable living environment. It was documented that the nursing home was responsible to provide the resident with a safe, clean and comfortable room and surroundings. The policy and procedure tilted Environmental Services dated 5/18 documented the cleaning of the shower room was to provide safe and sanitary environment for the purpose to prevent the development and transmission of disease and infection. The policy titled Infection Prevention and Control revised 2/19/2025 documented policies, procedures, and practices of Infection Prevention and Control in the facility are designated to maintain a safe, sanitary and comfortable environment for residents, staff, visitors and others who may visit the facility. Provide guidance for safe cleaning and disinfection of resident care equipment supplies, and the facility environment. The policy titled Standard Precautions revised 2/19/25 documented resident-care equipment soiled with blood, body fluids, secretions, and excretions are handled in a manner that prevents transfer of microorganisms to other residents and environments. Reusable equipment shall be cleaned and disinfected between each resident use and is not used for the care of more than one resident until it has been appropriately cleaned and disinfected. Single resident items are used only for a single resident. During an interview on 6/17/25 at 8:52 AM, the Director of Nursing and the Cooperate Registered Nurse stated the facility did not have a policy for storage/labeling of resident supplies as that is a standard of care and not a policy. Second Floor: Intermittent observations and interviews revealed the following: B Wing- Shower Room, and Soiled Linen Room: -6/10/25 at 8:50 AM, plastic (PVC - polyvinyl chloride tubing) wide shower chair was dirty with a brown substance noted on the seat of chair; 2-3 inch raised area of dark black substance on shower room floor near the drain. There were three unlabeled opened bottles of 8-ounce shampoo/body wash cleansers; two unlabeled 8-ounce spray body cleansers. -6/10/25 at 9:00 AM, the soiled linen room had a strong foul odor of urine and feces. There were four barrels within the room; three of the barrels were uncovered and contained garbage and soiled linens. Additionally, there was no soap, paper towels or alcohol-based hand sanitizer present. -6/11/25 at 8:45 AM, the plastic (PVC - polyvinyl chloride tubing) wide shower chair remained dirty with the brown substance on the seat; the unlabeled opened bottles shampoo/body wash cleansers; spray body cleansers remained as well as the dark black debris on shower floor near the drain. The other shower stall had black debris on floor, and an unlabeled hairbrush on floor. -6/11/25 at 8:49 AM, the soiled linen room had a strong odor of urine and feces. There was an uncovered grey plastic barrel with garbage and an uncovered blue barrel with soiled linen. Additionally, there was no soap, paper towels or alcohol-based hand sanitizer available within the room. -6/11/25 at 8:56 AM, Resident room [ROOM NUMBER] had a strong urine odor and there was a urine-soaked brief on floor. At 9:02 AM, Licensed Practical Nurse #11 entered room and removed soiled brief from room. During an interview on 6/11/25 at 9:03 AM, Licensed Practical Nurse #11 stated dirty briefs should not be placed on the floor for infection control purposes. They stated the resident that was in room [ROOM NUMBER] was sent out to the hospital last night and the room should have been cleaned up immediately. They stated any aide, nurse and housekeeper could pick up a soiled brief, See it. Pick it up. During an observation and interview on 6/11/25 at 10:14 AM, Certified Nurse Aide #5 stated they did not know what the black/brown debris were on the shower room floor. They stated it looked like someone pooped on the shower chair and it had not been cleaned. Certified Nurse Aide #5 stated the person giving the shower was responsible for picking up and cleaning the shower room after giving a shower. They stated residents go to the bathroom while in the shower; and the shower chair, floor can get messy. They stated the shower chair and floor should be rinsed, cleaned off for infection control. Additionally, they stated used shampoo/body wash cleansers, used hairbrushes shouldn't be left in the shower room, because they don't know who they belonged to and should not be used on another resident. -6/12/25 at 8:55 AM, the B hallway had a strong urine odor present, flies were noted in the area. -6/12/25 at 9:20 AM, Resident room [ROOM NUMBER] had linen and a soiled brief on the floor. -6/12/25 at 9:25 AM, the soiled linen room had a strong odor of urine and feces. There were uncovered garbage and linen barrels containing garbage and soiled linens. There was no soap, paper towels or alcohol-based hand sanitizer available within the room. Second floor C wing/Central Shower/Bath, shower room, and soiled linen room: Intermittent observations revealed the following: -6/10/25 at 11:22 AM, plastic (PVC - polyvinyl chloride tubing) shower chair was dirty with a dried/smeared substance on the seat; there was a dirty washcloth laying on shower floor; and a clump of brown substance on shower floor. -6/10/25 at 11:27 AM, soiled linen room with strong foul odor of urine and feces and flies were noted within the room. There were uncovered soiled linen (blue) and garbage (grey) barrels. -6/11/25 at 9:17 AM, soiled linen room with strong foul odor of urine and feces and brown substance on the floor. Garbage and linen barrels remained uncovered. Flies observed in the hallway outside soiled linen room. -6/11/25 at 9:19 AM, the plastic (PVC - polyvinyl chloride tubing) shower chair was dirty with smeared brown substance on the seat; a clump of brown/black debris on shower floor; two 8-ounce unlabeled opened bottles of shampoo/body wash cleansers stored on the railing in shower stall. During an observation and interview Certified Nurse Aide #11 stated the aides were responsible for cleaning up after themselves after utilizing the shower rooms and equipment, to prevent cross contamination; and so, it was clean for the next resident to use. They stated the brown substance on the shower chair and floor should have been cleaned after resident use and housekeeping should have sanitized for infection control. During an observation of C wing shower room and interview on 6/11/25 at 9:56 AM, Licensed Practical Nurse #11 stated the substance on floor and shower chair was feces. They stated the feces looked like it had been there for a while. They stated the shower stall and shower chairs should be cleaned and sanitized between every resident for infection control purposes. Additionally, they stated opened soaps should not be left or stored in the shower room. -6/12/25 at 9:58 AM, the soiled linen room had a strong foul odor of urine and feces. The garbage and soiled linen barrels within the room were uncovered. Additionally, there were no paper towels available at hand washing station and no alcohol-based hand sanitizer present. During an observation and interview on 6/12/25 at 10:00 AM, Certified Nurse Aide #12 was observed to open soiled linen room door and stated Oh come on. I should have worn a mask; it smells so bad. Certified Nurse Aide #12 stated the soiled linen room smelled like a sewer and had no idea why it smelled like that. They stated the linen and garbage barrels should be covered with lids but even when covered the odor was still present. They stated the odor was not homelike and unsanitary. Certified Nurse Aide #12 stated housekeepers were not supposed to pick up poop. They stated the aides and nurses were supposed to clean up after themselves then notify housekeeping to sanitize as needed. Additionally, Certified Nurse Aide #12 stated they never tried to wash their hands in soiled linen rooms, never paid it much attention, but they should be able to immediately wash their after getting rid of soiled linen and trash for infection control purposes. During an interview on 6/12/25 at 10:38 AM, Housekeeper #1 stated any bio, biohazards: urine, vomit, feces, blood must be removed by nursing. They stated linen must be picked up and placed in soiled linen room by nursing. They stated they were not allowed to pick up any linen and are not supposed to pick up garbage's with biohazards. They stated if there is bio in the shower rooms they must wait for an aide to remove it so they can then sanitize. They stated when they see biohazards on the floor and on equipment, they report it to the first aide they see. They stated sometimes staff don't see things. They stated it was important for the shower rooms to be clean and organized because that was where the residents were showered and for infection control purposes. During an interview on 6/13/25 at 1:10 PM, Licensed Practical Nurse Unit Manager #2 stated nurse aides should be picking up linen, cleaning shower rooms, and putting supplies away after each shower so housekeeping can come in and sanitize. They stated personal supplies, shampoo/body washes should not be left in shower rooms. Licensed Practical Nurse #2, Unit Manager, stated shower chairs should not be stored dirty. Shower chairs should be wiped down and sanitized between residents for infection control. During an interview on 6/16/25 at 12:29 PM, the Director of Nursing stated they expected shower chairs to be wiped down between each resident. They stated once the bulk of debris was cleaned, housekeeping should sanitize. They stated they expected the shower rooms to be cleaned before being used again. They stated supplies should be labeled with resident name if being used more than once for infection control purposes. Additionally, the Director of Nursing stated housekeeping staff can remove soiled linen if proper personal protective equipment was worn. During an observation and interview on 6/10/25 at 9:10 AM, Resident room [ROOM NUMBER] had a urine odor in the room. Noted in the garbage can near the bed was a urine-soaked brief. The resident in the room stated they no longer notice the offensive odors because their nose got used to the smell. They stated when their family member visits, they notice the foul odors right away, so they brought in air freshener. Aerosol air freshener spray was observed on the resident tray table. During observations on 6/10/25 at 10:00 AM and 6/12/25 at 9:13 AM, Resident room [ROOM NUMBER] the shared bathroom had an unlabeled wash basin on floor the under sink. During an interview on 6/10/25 at 10:00 AM, Resident #381 stated some housekeepers do their jobs, they clean and collect garbage; while other housekeepers just remain in the hallway and must ask for their garbage to be removed. During an observation on 6/10/25 at 9:42 AM of Resident room [ROOM NUMBER], there was a wash basin was on the floor of the bathroom. During an observation and interview on 6/10/25 at 12:09 PM, Resident room [ROOM NUMBER]'s private bathroom had a wash basin on floor under sink. Resident #388 stated there was a urine odor every day on unit. Resident #388 stated housekeeping needed to do a better job cleaning the rooms. They stated their room should be cleaned like it was their home. During observations on 6/12/25 at 9:13 AM, 12:20 PM and 6/16/25 at 11:27 AM, Resident #381's tube feeding pole (medical equipment) was dirty with a thick dried tan substance and floor near pole was sticky with tan liquid. 2. Third Floor: Observations: a. The following was observed on 6/10/25 at 2:19 PM, 6/11/25 at 9:09 AM and 6/12/25 at 3:50 PM in Resident room [ROOM NUMBER]: -upon entering the room, there was a gray basin on the floor to the right of the doorway that contained a yellow liquid (near the door side bed). To the right side of the door bed there were plastic totes stacked on top of each other. The totes had personal belongings and clothing piled on top. Noted at the top of the pile of was a large gray bedpan placed up-side down. - a second empty gray basin was on the floor at the head of next to the bed by the window. The resident in room (door bed) at the time of the observation stated the basin had been on floor for a while, and they did not like the basin being stored on the floor or the bedpan being placed and stored on their clothes. The resident stated they did not feel their room was homelike. During an observation and interview on 6/12/25 at 3:53 PM, Licensed Practical Nurse Unit Manager #1 entered the room with the surveyor and stated they were not sure why the bedpan was stored on top of the resident's belongings. They were was not sure why there were basins on the floor but that was not a good place to store them. They stated floors were dirty and basins, including bedpans, should be stored in the night stand or in the bathroom. They stated they were not sure why the resident by the door did not have a dresser. Licensed Practical Nurse Unit Manager #1 stated the liquid in the basin was the color of urine but had no odor and did not know what it was. They stated the storage of bedpans on top of a pile of personal belongings and basins on the floor was an infection control issue and did not provide a homelike environment. During an interview on 6/12/25 at 4:00 PM, Licensed Practical Nurse #13 stated they do not know why there were basins stored on the resident's floor and they should not be there because they could cause a fall. Licensed Practical Nurse #13 stated bedpans should be stored in the bathroom, not upside down on a pile of clothes. They stated the basins and bedpans had germs and could spread germs everywhere. b. Third Floor A Wing hallway Shower Room: Observations -6/10/25 at 10:23 AM, there was six open/unlabeled house stock body washes, two open/unlabeled house stock powders and one open/unlabeled house stock shaving gel stored on the handrail in the shower stall. -6/12/25 at 3:40 PM, there were seven open/unlabeled house stock body washes, two open/unlabeled house stock powders and one open/unlabeled house stock shaving gel stored on the handrail in the shower stall. During an observation and interview on 6/12/25 at 4:05 PM, Licensed Practical Nurse Unit Manager #1 entered the A wing shower room with the surveyor. Licensed Practical Nurse #1 stated there stock hygiene items in the shower stall that were open and not labeled with any resident's name. They stated the facility process was each resident was designated stock hygiene items that were to be labeled with their name. Licensed Practical Nurse #1 stated it was not appropriate for staff to leave used soaps in the community shower room because there was a potential for the product to be used on more than one resident causing an infection control hazard. During an interview on 6/17/25 at 10:28 AM, the Infection Preventionist/Assistant Director of Nursing stated they would expect the linen bins to be covered in any soiled utility room so there was no chance of spreading infection and it would be helpful prevent odors. They stated they would expect staff to perform hand hygiene after disposing of the soiled linens at the hand sanitizing station in the hallway or even in the shower room. The infection preventionist stated it would not be a bad idea to place a hand sanitizing station in the soiled utility rooms. The Infection preventionist stated basins should not be stored on residents' floor for infection control reasons. The Infection Preventionist stated that staff should not be leaving/storing stock personal care items in the shower rooms because of infection prevention purposes. The Infection Preventionist added cleanliness in the facility was something they needed to work on, and the environmental concerns were not considered home-like. During an interview on 6/17/25 at 11:22 AM, the Director of Nursing stated their expectation for storage of basins and bedpans would be stored in the resident's cupboard on top of a clean barrier. The Director of Nursing stated that housekeeping/laundry department should ensure lids were on the soiled laundry bins to mitigate odors. They stated staff should have the means to sanitize their hands inside of the soiled utility room and a hand hygiene station needed to be place inside of the soiled utility room. The Director of Nursing added that these issues would detract (diminish) from a home-like environment. 10NYCRR 415.5 (h)(1)(2)

Based on observation, interview, and record review conducted during the Standard survey completed on 6/17/25 the facility did not ensure that a resident who was fed by enteral means (method of feeding that uses the gastrointestinal (GI) tract to deliver part or all a person's caloric requirements) received the appropriate treatment and services to prevent possible complications for one (1) (Resident #381) of two (2) residents reviewed for feeding tubes. Specifically, the facility did not provide the tube feed as ordered. The finding is: The policy and procedure titled Enteral Nutrition reviewed 6/2023 documented Dietary-Nursing Nutritional support would be provided to residents unable to obtain nourishment orally and are receiving enteral feeding ordered by a physician. The feeding method will be determined to optimize resident's independence whenever possible (at night or during hours that do not interfere with the resident's ability to participate in facility activities). In the event that a resident does not receive the prescribed amount of enteral feeding, the licensed nurse would notify the physician. Resident #381 had diagnoses that included gastrostomy (opening into stomach to insert tube), bulbar palsy (motor neuron disorder), tracheostomy (opening into the trachea), and type 2 diabetes mellitus. The Minimum Data Set (a resident assessment tool) dated 5/29/25 was incomplete, but documented Resident #381 was cognitively intact, understood and understands. The comprehensive care plan initiated 5/16/25 documented Resident #381 required tube feeding. Interventions included to administer tube feeding and water flushes per Registered Dietitian/ Licensed Dietician recommendations and Medical Doctor orders. The comprehensive care plan documented on 6/9/25 the resident had potential for altered nutrition/hydration secondary to nothing by mouth status with alternate feeding as their primary nutrition/hydration and interventions included feeding/flushes as ordered. The Order Summary Report documented an order dated 6/10/25 for Novasource Renal (calorically dense nutritional formula) by enteral tube at a rate of 60 milliliters per hour to begin at 4:00 PM for a total volume of 1080 milliliters to be delivered. May use Glucerna 1.5 (calorically dense nutritional formula) if Novasource Renal was not available every day shift. Stop the tube feed when total volume of 1080 milliliters are infused. Verify with pump setting that total volume has been delivered. Document total volume infused. Verify infusion every shift. Review of Weights and Vitals Summary dated 6/17/25, revealed Resident #381's weight on 5/21/25 at 8:27 AM was 168 pounds (wheelchair) and on 6/13/25 at 2:59 PM was 163.4 pounds (wheelchair), a 2.74 percent weight loss in 23 days. During an interview on 6/11/25 at 10:25 AM, Resident #381 stated their enteral feed was supposed to be started at 4:00 PM every day, but that does not happen, and it angered them. Resident #381 stated they were hungry sometimes and they have watched other residents receive breakfast, lunch and they had not received anything. During an observation and interview on 6/13/25 at 7:59 AM, Resident #381's enteral feed bag was full with 1000 milliliters present. The enteral feed tubing from pump, connected to resident was not primed (no feed in tubing), and the pump was not on. The label on the feed bag was dated 6/12 at 4:00 PM. Resident #381 stated they never received any of their feed since last evening. They stated the pump was beeping and was shut off by the nurse. The resident's roommate was consuming breakfast at this time and Resident #381 stated they were hungry. During an interview on 6/13/25 at 12:05 PM, Licensed Practical Nurse #9 stated they walked in on the feeding pump issue with Resident #381 that morning. They stated they had not been notified during shift report of any concerns with Resident #381's feeding tube or pump and could not believe Resident #381 had not received their enteral feed as ordered. They stated all nurses were responsible for verifying the correct feed, rate and volume infused were accurate. They stated it was important to verify orders to ensure residents were not receiving over or under the feed amount. They stated not receiving proper volume of enteral feed could cause weight loss. During an interview on 6/13/25 at 12:41 PM, Licensed Practical Nurse #2 Unit Manager stated enteral feed orders should be verified every shift. Enteral feed bottles/bags should be labeled with resident's name, date/time when hung and rate per hour to be given. They stated the enteral feed tubing and pump should be primed, feeding tube placement and residual checked prior to connecting feed to resident. They stated they expected nurses to ask for assist, report issues/concerns with feed tubes, feeding pumps to them or a supervisor. Licensed Practical Nurse #2 Unit Manager stated they were not notified of any issues with Resident #381's feeding pump on 6/12/25. They stated they were notified by Licensed Practical Nurse #9 at 8:00 AM on 6/13/25 that Resident #381 had not received their enteral feed and that there was an issue with the feeding pump. They stated it was important for Resident #381 to receive their enteral feed as ordered to prevent weight loss and ensure proper nutrition. Licensed Practical Nurse #2 Unit Manager stated a medical provider should have been notified to get orders for a bolus feed (method of delivering feed without the use of a pump) or to hold Resident #381's feed. During a telephone interview on 6/13/25 at 3:54 PM, Licensed Practical Nurse #7 stated they were Resident #381's nurse on 6/12/25-6/13/25 from 5:00 PM to 11:00 PM, and 11:00 PM to 7:00 AM. They state they hung Resident #381's feed on 6/12/25 around 5:00 PM. They stated when they initiated the feeding pump it was beeping, indicated clogged. They stated they disconnected the feed and reconnected Resident #381 back to the pump and the machine stated, technical error 22, call tech support. Licensed Practical Nurse #7 stated they notified Licensed Practical Nurse #8 Supervisor. They stated Licensed Practical Nurse #8 Supervisor played around with the pump, pressed some buttons but the pump kept beeping, and they thought Licensed Practical Nurse #8 Supervisor was looking for another pump. They stated for 8-9 hours the pump would not stay on no matter what they did, and they shut it off. Licensed Practical Nurse #7 stated it was very possible that Resident #381 did not receive any of their ordered feed and that it was important for nutritional value. They stated they did not notify a provider because they did not think Resident #381 would not be receiving their feed the whole time and should have. During an interview on 6/13/25 at 4:54 PM, Registered Nurse Supervisor #1 stated they worked as the supervisor on 6/12/25 and was not aware of Resident #381's feeding pump not working. They stated Licensed Practical Nurse #7 made them aware of a different resident's feeding pump not working. They stated the facility was short on pumps and they would have gotten an order from the medical doctor to do bolus feeds temporarily until a pump was available. They stated it was important for residents to receive their ordered enteral feeds for nutrition and so they did not starve. During an interview on 6/16/25 at 12:29 PM, the Director of Nursing stated they would expect nursing to alert a supervisor if there were an issue with a resident's enteral feed, so they can make sure the resident received the proper feed. They stated it was important for residents to receive their enteral feed as ordered to prevent weight loss and ensure adequate nutrition/hydration. The Director of Nursing stated a provider should have been notified, could have administered a bolus feed. During an observation and interview on 6/16/25 at 2:01 PM-2:21 PM, with the Registered Dietitian present, Resident #381 was not connected to their feeding pump and the feed bottle was noted with approximately 100 milliliters remaining in it. Resident #381 stated the nurse was supposed to reconnect them until the feed delivered was 1080 milliliters. Resident #381's feeding pump was observed, and it indicated only 970 milliliters were delivered. Registered Dietitian stated based on what appeared to them Resident #381 had not completed their feeding regime. They stated this was concerning that resident may not be receiving their nutritional needs. Registered Dietitian stated it was brought to their attention on 6/13/25 that Resident #381's enteral feed did not run 6/12/25-6/13/25 as ordered and the feeding had to be made up. They stated the enteral feed was Resident #381's primary source of nutrition. They stated Resident #381 had expressed concern over losing weight and that it was important for them to receive the enteral feed as ordered to meet their nutritional needs, maintain their skin integrity and weight. During an observation and interview on 6/16/25 at 2:33 PM, Licensed Practical Nurse #9 observed the feed hanging from the pump pole had approximately 100 milliliters of feed remaining and the feed pump that indicated only 970 milliliters feed was delivered and stated Resident #381 had not received their total volume of enteral feed, that there was still feed that needed to be delivered. They stated Resident #381 was disconnected from the pump for physical therapy and should have received total volume of 1080 milliliters of enteral feed. Licensed Practical Nurse #9 stated Resident #381 could lose weight if not given the total amount of feed ordered. During a telephone interview on 6/17/25 at 10:14 AM, the Medical Director/Medical Doctor #1 stated they would expect residents to receive their enteral feed as ordered for adequate nutrition and fluids. They stated they would expect a provider to be notified if orders could not be completed as ordered to figure out what else could be done, such as provide a bolus feed. 10 NYCRR 415.12(g)(2)

Based on observation, interview, and record review conducted during the Standard survey completed on 6/17/25 the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for (3) three (Residents #47, #111, and #173) of five (5) residents reviewed. Specifically, weights were not obtained as recommended by the Registered Dietician and as ordered by the physician (#111 and #173). In addition, surgical staples were not removed as ordered by the physician (#47). The findings are: The policy titled Weight: Measuring, dated 3/1/24, documented weights will be obtained monthly and more frequently as clinically indicated. Staff will note the weight of the resident and document the weight in the resident's clinical record. The policy titled Wound Identification and Wound Rounds revised 11/6/2023 documented the facility will identify, assess, and manage residents with wounds in accordance with current standards of practice. 1 a. Resident #111 had diagnoses including dementia with behavioral disturbances, Wernicke's encephalopathy (a neurological condition), and abnormal weight loss. The Minimum Data Set (a resident assessment tool) dated 3/10/25, documented Resident #111 was severely cognitively impaired, rarely/never understood and rarely/never understands. They required supervision/touch assistance for meals, and they had a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months and was not on a physician-prescribed weight-loss regimen. The comprehensive care plan updated 3/13/25, documented Resident #111 had the potential for altered nutrition/hydration secondary to diagnoses of Wernicke's encephalopathy, history of alcohol abuse, and a Body Mass Index (a calculation based on height and weight to determine healthy weight) of less than 24.9 (underweight). The plan included weekly weights, report significant weight changes to physician and team, encourage meal intake, supplements, and a sandwich in the evening. The Kardex (a guide used by staff to provide care) dated 6/11/25, documented Resident #111 required supervision/touch assist for meals, and to provide an early dinner tray. The Kardex did not address obtaining weights. The Order Listing Report for Resident #111 documented mild to moderate malnutrition - Upon signature of this order Medical Doctor acknowledges that resident qualifies for diagnosis of mild to moderate malnutrition (revised 6/13/25), Boost (nutritional supplement) two times a day, weekly weights X 4, every Wednesday day shift (revised 5/27/25). The Team Meeting note dated 4/5/25, documented the Interdisciplinary team met on 4/1/25 the High Risk Meeting Summary documented previous weight decrease noted, current weight pending, monitor weekly weight. The Dietary Note completed by Registered Dietitian #1 dated 5/29/25, documented weight 145 pounds reflects a significant decrease of 29 pounds (16.7%) in the past 180 days. Weight appears to be stabilizing in the past 3 weights. Weekly weight as ordered. Calorie/protein supplement had been increased to twice a day with acceptance. Increased feeding assistance at partial assist to maximize intake per Occupational Therapy. Monitor intake/weight/labs/skin. Encourage intake as needed. Follow up and adjust plan as needed. The Dietary Note completed by Registered Dietitian #1 dated 6/8/25, documented Resident #111 has a clinical indication for malnutrition The resident's acute malnutrition is moderate as evidenced by: Resident's recent intake compared to estimated requirements reported as a percentage over time has been less than 75% of needs for greater than 7 days. The resident has had a 7.5% weight loss from baseline in 3 months. The Dietary Progress Note completed by Diet Technician #1 dated 6/9/25, documented the most recent weight for Resident #111 was 5/9/25, at 145 pounds on a standing scale. The note documented the resident's weight was not stable, with a 16% weight loss in the past 90 days. Staff reported the resident walks while they eat, sandwiches and finger foods have been provided and accepted. Review of Resident #111 weight tracking records provided by the Registered Dietician revealed the following: December 2024, monthly weight 173.8 pounds February 2025, monthly weight - 172.8 pounds March 2025, weekly weights requested - monthly weight -140.28, reweight- 139.6 April 2025, weekly weights requested- monthly weight - 141.6- reweight- 141.8 May 2025, weekly weights requested- monthly weight- 137.4- reweight- 145 June 2025, weekly weights requested- monthly weight- 144.6 Review of the weight tracking records, and the Weights and Vital Summary revealed weekly weights were not obtained as ordered by the physician and requested by the Registered Dietitian from March through June 2025. During an observation on 6/11/25 at 2:40 PM, Resident #111 was ambulating in the hall on the 3rd floor eating a sandwich. Resident appeared thin, and they were non-verbal. Staff would interact and encourage resident frequently. During an interview on 6/13/25 at 8:34 AM, Licensed Practical Nurse #3 stated Resident #111 was being monitored for weight loss and they were ordered weekly weights. They stated Certified Nurse Aides knew which residents needed to be weighed by checking the weight book at the desk. The Certified Nurse Aides documented the weights in the book. If there was a discrepancy, they notified the nurse and they reweighed the resident. The dietitian reviewed the weight book and documented them in the computer. During a review of the weight book and an interview on 6/13/25 at 8:39 AM, the weight book on the 3rd floor revealed there was not page in the weekly weights tab for Resident #111, and the monthly weight for Resident #111 was blank. Unit Clerk #1 stated the dietitian may have taken the weekly weight page. During an interview on 6/13/25 at 8:44 AM, Licensed Practical Nurse Unit Manager #1 floor, stated the Certified Nurse Aides were responsible for obtaining resident weights, and they knew who needed to be weighed weekly by checking the weight book. They stated the dietitian collected the sheets and documented the weights in the computer. They did not know where the weekly weight sheet for June 2025 was, and they did not know why a monthly weight was not obtained for Resident #111. Licensed Practical Nurse Unit Manager #1 stated they attended the weekly Risk Management meetings. During interviews on 6/13/25 at 8:59 AM, and 12:23 PM, Registered Dietician #1 stated Residents with unstable weights were placed on weekly weights so they can more closely monitor if their interventions were successful. Resident #111 should have weekly weights because they had a large weight loss. The weekly weight sheet from the 3rd floor was reviewed with Registered Dietician #1 and the were no weights documented for Resident #111. They stated they had not been informed that Resident #111 refused to get on the scale. The last weight they had for Resident #111 was from 5/9/25. The Registered Dietitian stated that obtaining weights was consistently a problem in the facility and they stated that the unit managers were aware of the problem. During interview on 6/13/25 at 10:56 AM, Registered Dietician #1 stated the Director of Nursing, and the Unit Managers attended the weekly Risk Management meetings and were made aware the weights were not being obtained. During an interview on 6/13/25 at 9:12 AM, Certified Nurse Aide #9 stated that Resident #111 should be weighed weekly, and they did not refuse to get on the scale. They stated they usually did weights on Mondays and would write it on a scrap paper. They did not know why the weights did not get documented in the book. b. Resident #173 had diagnoses including intracerebral hemorrhage (bleeding in the brain), dysphagia (difficulty swallowing) and gastrostomy (surgical procedure for inserting a tube through the abdomen wall into the stomach) infection. The Minimum Data Set, dated [DATE] documented Resident #173 was severely cognitively impaired, understood and understands. They had no or unknown weight loss or weight gain. The assessment tool documented the resident had a feeding tube and was on a mechanically altered diet. The resident was not on a physician-prescribed weight-loss regimen. The comprehensive care plan updated 3/8/25, documented Resident #173 required a feeding tube. The interventions included to follow weights as ordered; regular consistency with thin liquid diet; report significant weight changes to physician and team; and individualize meal plan as needed to meet preference and needs. The Kardex dated 6/16/25, documented Resident #173 was to be encouraged to use dominant hand for drinking, provide assist and cueing with eating as needed. The Kardex did not address obtaining weights. The Order Summary Report documented the following physician orders: -2/21/25 admission weight then weekly every Wednesday for 4 weeks -4/9/25 Weekly weights every Wednesday for 4 weeks -4/22/25 Weekly weights every Wednesday for 4 weeks Review of the Dietary Progress notes for Resident #173 revealed the following: -2/22/25 at 7:33 AM the Registered Dietician #1 documented they requested an admission weight from nursing. -2/25/25 at 2:18 PM the Diet Technician #1 documented the resident's admission weight was pending. Review of the Comprehensive Nutrition Assessment signed on 3/8/25 by the Registered Dietician documented Resident #173 was to be monitor weekly for weights. Review of the Dietary Progress notes for Resident #173 revealed the following: -4/10/25 at 9:02 AM the Registered Dietician #1 documented the residents by mouth intakes varied and appeared suboptimal. They documented weekly weights were initiated to monitor tend and will recommend initiating 237 milliliters of Nurten 2.0 (enteral feed) via percutaneous endoscopic gastrostomy (PEG) tube for additional support. -5/28/25 at 10:33 AM the Diet Technician #1 documented the resident had a history of dysphagia and percutaneous endoscopic gastrostomy tube (PEG) was in place. They documented by mouth intake was variable and weight was requested and pending. Unit manager was made aware. -5/30/25 at 6:33 AM the Registered Dietician #1 documented they requested current weight to assess, and the nurse manager was made aware. Review of the Weights and Vital Summary dated 6/17/25, Resident #173 had the following weights documented: -2/26/25 184.8 pounds -4/7/25 178.8 pounds -6/10/25 173.2 pounds There were no other weights were documented on the summary. Review of Resident #173 weight tracking records provided by the Registered Dietician revealed the following: March 2025, there was no monthly or weekly weights documented April 2025, monthly weight 161.6 pounds, reweight 157.6 pounds and 3rd reweight requested with no re-weight documented. The record documented Weekly weights were then requested for 4/23/25 and 4/30/25 with no weights documented. Weekly weights were not obtained per the physician's orders dated 4/9/25 and 4/22/25. May 2025, there was no monthly was weight documented. Registered Dietician #1 documented weekly weights were requested for 5/14/25, 5/21/25 and 5/28/25 and no weights were documented. Review of the weight tracking records, and the Weights and Vital Summary revealed weekly weights were not obtained as ordered by the physician in February and April. In addition, weekly weights were not obtained as requested by Registered Dietician #1. Review of the Nursing Progress notes from 2/21/25-6/15/25 revealed there was no documented evidence that weights were obtained or the resident refused to be weighed. During interview on 6/13/25 at 10:56 AM, Registered Dietician #1 stated every resident was to be weighed by the 10th of each month. They stated if they identified any discrepancies, they would request a reweight, and if there still was a concern then they may request weekly weights for the resident. Registered Dietician #1 stated the weight tracking record that was kept in a weight book on the nursing units. They write reweight and highlight the box where the certified nurse aides were to document the weight. They stated a separate weight tracking record sheet was use for the residents who needed weekly weights. They write the specific date the certified nurse aides were to obtain the weight. Registered Dietician #1 stated it was the facilities policy to obtain an admission weight on all residents and then weekly for four weeks. Registered Dietician #1 stated they did not receive a monthly weight nor weekly weights for Resident #173 in March 2025. They stated they requested two reweights in April 2025 because of large weight loss and then a 3rd reweight that staff never completed. Registered Dietician #1 stated they then requested weekly weights for April and nursing staff never completed. In May 2025 Resident #173's monthly weight was not completed, so they again requested weekly weights that again were not completed. During an interview on 6/16/25 at 3:31 PM, Registered Dietitian #1 stated they would attend the facilities weekly risk management meetings to discuss any weight loss concerns and the residents that staff had not obtained weights as requested/ordered. Registered Dietician #1 stated the Administrator, Director of Nursing, Social Worker and Unit Mangers attended these weekly risk management meetings and were made aware weights were not being completed as requested/ordered. The Registered Dietician #1 stated they spoke about Resident #173 at these risk meetings. During an interview on 6/13/25 at 1:13 PM, Certified Nurse Aide #3 stated they were responsible for Resident #173 care for the past few a few months. They stated they would know if a resident needed a weight because they look in the weight book and it would indicate if a resident needed a weekly or monthly weight. They stated the nurses would also keep on top of us to get our weights. Certified Nurse Aide #3 stated that if Resident #173 did not have a weight documented on the weight record, then they probably did not realize a weight was needed. During an interview on 6/17/25 at 9:38 AM, Nurse Practitioner #2 stated they were aware of the weight discrepancies for Resident #173. They stated the weights that were obtained in April 2025 and/or the admission weight were mostly likely inaccurate but would expect staff to follow facility protocol for obtaining weights on a resident and follow the medical providers orders. During an interview on 6/17/25 at 9:14 AM, Licensed Practical Nurse Unit Manager #1 stated the certified nurse aides were responsible for obtaining resident weights. Licensed Practical Nurse #1 stated they did discuss Resident #173's weight discrepancies and the requests for reweights at the weekly risk management meetings. Licensed Practical Nurse Unit Manager #1 stated they were responsible to ensure the aides obtained Resident #173's weights and did not follow through to ensure the weights were obtained. At 1:50 PM, Licensed Practical Nurse #1 stated they could not locate any further weights for Resident #173. During an interview on 6/17/25 at 11:16 AM, the Director of Nursing stated they expected monthly and weekly weights to be completed within a day or two after Registered Dietician #1 requested them and per the medical provider ordered. The Director of Nursing stated Unit Managers should make staff aware of which residents needed weights, and the Unit Managers were responsible to follow up to ensure they were obtained. 2. Resident #47 had diagnoses including right femur fracture (thigh bone break), encephalopathy (disorder/disease of the brain), and non-Hodgkin lymphoma (form of cancer). The Minimum Data Set (a resident assessment tool) dated 5/13/25 documented that Resident #47 had severe cognitive impairment, was usually understood and usually understands. Resident #47 had skin conditions, surgical wound(s) and surgical wound care documented on the Minimum Data Set. The comprehensive care plan initiated 5/9/25 documented Resident #47 had fracture/joint replacement. Interventions included follow up with Orthopedic Surgeon as ordered, incision, wound, site care to prevent infection and promote healing. The Progress Notes completed by Registered Nurse Supervisor #1 dated 5/9/25 documented hip incision with two areas, top area 5 centimeters long with 6 staples and lower area 1 and ¾ with 4 staples. The hospital Discharge summary dated [DATE] documented Resident #47 had surgery to repair right femur fracture on 5/1/25. Ortho recommended staples to be removed on postop day 14 at the rehab facility. The Order Summary Report dated 6/16/25 documented an order dated 5/9/25 for the surgical site staples to be removed on postop day 14 (5/15/25). The Order status was documented as completed. Review of Treatment Administration Record dated 5/1/25-5/31/25 documented staples to be removed post op day 14. Treatment Administration Record designated and assigned the treatment to be completed on 5/15/25. Administration record documented that Licensed Practical Nurse #4 signed the record as treatment was completed. Review of Report of Consultation report completed 6/5/25 by Medical Doctor #2 (Orthopedic Specialist) documented the staples to Resident #47's right hip were removed in their office (post op day 35). During an interview on 6/10/25 at 11:59 AM, Resident #47's family member stated Resident #47's staples were not removed when they should have been at the rehab facility. The staples were not removed until they followed up with their orthopedic on 6/5/25. They did not know why the staples weren't removed sooner. During an interview on 6/16/25 at 11:08 AM, the Assistant Director of Nursing/Infection Preventionist stated they expected orders to be followed and that Resident #47's staples should have been removed as ordered. They stated it was important for staples to be removed as ordered so an infection does not occur and to prevent staples from embedding into the skin. During an interview on 6/16/25 at 2:45 PM, Licensed Practical Nurse #4 stated they can remove staples if there was an order and that they did not remove any staples from Resident #47. Licensed Practical Nurse #4 verified their initials on the treatment administration record for 5/15/25 as having signed for removal of Resident #47's staples. Licensed Practical Nurse #4 stated they must have signed off completing treatment by accident and that nobody brought it to their attention. They stated they should not have signed off they removed Resident #47's staples because they did not. During an interview on 6/16/25 at 2:58 PM, Licensed Practical Nurse #2 Unit Manger stated they expected physicians' orders to completed. If an order was unable to be completed they should be notified, and a progress note written. Licensed Practical Nurse #2 Unit Manager stated if a treatment was not completed it should not be signed out because it could post [NAME] care to the resident. During a telephone interview on 6/17/25 at 10:14 AM, Medical Director/Medical Doctor #1 stated they expected staff to follow orders and would expect to be notified if the staples were unable to be removed. Medical Doctor #1 stated they were not aware Resident #47's surgical staples were not removed as ordered. During a telephone interview on 6/17/25 at 10:45 AM, Medical Doctor #2 (Orthopedic Specialist) stated they would expect recommendations for staple removal to be followed. They stated they were not notified of any reason why they weren't removed as recommended. Medical Doctor #2 stated they removed the staples from Resident #47's right hip themselves on 6/5/25 during an office visit. Additionally, they stated it was scary that the staples were overlooked. 10NYCRR 415.12

Based on observation, interview, and record review conducted during the Standard survey completed on [DATE], the facility did not ensure that each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for two (2) (Resident #20, #47) of six (6) reviewed for dignity. Specifically, flies were observed were observed crawling on the residents' (faces, arms, legs) and their bed linens. The finding is: The policy and procedure titled Quality of Life/Dignity last revised 5/2024 documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Your Rights as A Nursing Home Resident in New York State dated 2022 documented as a resident in this facility, you have rights guaranteed to you by state and federal laws. This facility is required to protect and promote your rights. Your rights strongly emphasize individual dignity and self-determination, promoting your independence and enhancing your quality of life. You have a right to be valued as an individual, to be treated with consideration, dignity and respect in full recognition of your self-worth. You have the right to a comfortable living environment. 1. Resident #20 had diagnoses including dementia, depression and diabetes. The Minimum Data Set (a resident assessment tool) dated [DATE] documented that Resident #20 had severe cognitive impairment, was sometimes understood and usually understands. The undated comprehensive care plan documented Resident #20 had impaired cognition, was able to answer yes and no questions and able to make their needs known. In addition, the comprehensive care plan documented bladder and bowel incontinence related to physical limitations. The Kardex Report (guide used by staff to provide care) with an as of date of [DATE] documented Resident #20 required the assistance of two staff for care related to physical limitations. During intermittent observations and interviews from [DATE] through [DATE] and from [DATE] through [DATE] between the hours of 8:30 AM to 3:00 PM the following was observed: -[DATE] at 8:48 AM three flies were crawling on Resident #20's bare arms, face, and sheets while they slept. Multiple flies were buzzing/flying about the room. Resident #20's roommate stated there was a fly issue and staff swatted and killed them. At 8:50 AM, Resident #20 swatted a fly as it landed on their right eye lid. Resident #20 shook their head yes when asked if the flies made them feel uncomfortable and were bothersome. During a telephone interview on [DATE] at 10:15 AM, Resident #20's family member stated the resident would have a problem with flies all over the room, and on their skin. Anyone would be uncomfortable with flies crawling on them, and deserved respect as this was their home. -[DATE] at 10:43 AM with Licensed Practical Nurse #5 present seven visible flies were counted in Resident #20's room. Five flies were crawling on the bed sheets as Resident #20 slept and two flies were on clean towels that were on the night stand next to the bed. Licensed Practical Nurse #5 stated it was undignified. Resident #20 was helpless and incapable of swatting the flies. -[DATE] at 11:37 AM Certified Nurse Aide #7 stated maintenance was aware of the fly problem and they would not want flies crawling on them while they slept. It would be uncomfortable, and stated it was a dignity concern. -[DATE] at 1:02 PM Resident #20 was seated in their Geri recliner in the dining room. In Resident #20's room three flies were crawling on their bed. -[DATE] at 11:35 AM in the presence of Housekeeper #2 there were five flies buzzing/flying around Resident #20's bare arms and face while they slept and they had their mouth open. Housekeeper #2 stated the flies could land in Resident #20's mouth while they slept. The flies were disgusting, dirty and gross and would not want that to be their parent lying there. Resident #20 deserved respect and this was undignified. Housekeeper #2 stated they notified maintenance a few weeks ago. They stated they frequently cleaned Resident #20's mattress, mopped the floor and under the bed but it was ineffective. -On [DATE] at 11:36 AM in the presence of the Maintenance Director five flies were crawling on Resident #20's arms and face as they were asleep in bed. The Maintenance Director stated they would not want to have flies crawling on them while they slept and the resident should not have too either, and stated it was undignified. -[DATE] at 11:44 AM in the presence of the Administrator Resident #20 was asleep in bed and the Administrator stated there were flies on Resident #20. They had a right to a clean and homelike environment. The number of flies crawling on Resident #20 was not a dignity concern, just not homelike. The Administrator believed the source of the flies were from a room across the hall and maintenance had been addressing the fly problem. During a telephone interview on [DATE] at 9:54 AM, Licensed Practical Nurse #6 stated flies were gross and potentially contributed to the risk of infection and spread bacteria. Licensed Practical Nurse #6 stated they felt discouraged and that Resident #20 should be able to sleep comfortably and have a good quality of life. During a telephone interview on [DATE] at 10:29 AM, the Medical Director stated during their visit with Resident #20 on [DATE] they had noticed increased fly activity. The facility should provide a healthy environment. There were flies everywhere and this was disrespectful toward Resident #20 and all the other residents in the facility. 2. Resident #47 had diagnoses including encephalopathy (disorder/disease of the brain), right femur fracture (thigh bone break), and non-Hodgkin lymphoma (form of cancer). The Minimum Data Set, dated [DATE] documented Resident #47 had severe cognitive impairment, was usually understood and usually understands. During intermittent observations from [DATE] through [DATE] between the hours of 7:46 AM to 12:27 PM Resident #47 was in bed and the following was observed: -[DATE] at 11:53 AM-12:08 PM multiple flies were buzzing/flying around the room, and 3-4 flies had landed on their bare arms and bed sheets. -[DATE] at 9:28 AM two flies landed/crawled on Resident #47's exposed right lower leg skin tear that had dried drainage present. -[DATE] at 9:37 AM multiple flies were buzzing/flying around the room and 3-4 flies landed/crawled on Resident #47's bare arms and bed sheets. -[DATE] at 7:46 AM and 11:59 AM Resident #47 was deceased and had multiple flies crawling on their bed sheets and two flies landed on the residents face near their mouth. During an interview on [DATE] at 11:59 AM, Resident #47's family member stated there had been flies present in Resident #47's room for a while and Resident #47 did not like them in their room. Resident #47's family member stated the flies were attracted to the uncleanliness and the fecal incontinence odor present. They stated no one should have to be around that. During an interview on [DATE] at 10:00 AM, Certified Nurse Aide #12 stated there were always flies in residents' rooms and there should not be. They stated flies were disgusting and unsanitary. Additionally, they stated maintenance was aware of fly issue on the second floor. During an interview on [DATE] at 10:38 AM, Housekeeper #1 stated flies carry bacteria, were not sanitary and should not be present in resident rooms. They stated they had reported concerns with flies on the second floor to the Housekeeping Director. During an interview on [DATE] at 10:48 AM, the Assistant Director of Nursing/Infection Preventionist stated flies should not be in resident care areas as they could spread bacteria. During an interview on [DATE] at 11:03 AM, the Director of Nursing stated flies were a concern for cleanliness. Residents had the right to be comfortable and stated they could not agree it was undignified, but it was unsanitary. 10NYCRR 415.3 (2)(f)(ii)

Based on interview and record review conducted during the Onsite Post Survey Revisit #1 completed on 09/04/2025, the facility did not ensure that the Quality Assurance Performance Improvement Program (QAPI) Committee developed and implemented appropriate plans of action to correct identified quality deficiencies and regularly reviewed, analyzed, and acted on available data to make improvements. Specifically, the Quality Assurance Performance Improvement Program Committee could not provide evidence that all licensed nurses were reeducated regarding the enteral tube feed administration and the use of enteral feeding pump(s) (method of feeding that uses the gastrointestinal tract to deliver part or all a person's caloric requirements) as stated in their plan of correction. The findings are:Refer to: F693 Tube Feeding Management scope and severity = DThe policy and procedure titled Quality Assessment Performance Improvement Program revised 04/28/2025, documented it was the policy of the facility to establish and maintain an effective, ongoing, and data driven Quality Assurance and Performance Improvement (QAPI) Program that addresses the care and unique services the facility provides. The purpose of the QAPI (Quality Assurance and Performance Improvement Program) was to support the continuous evaluation of facility system with the objective of ensuring care delivery systems function consistently, accurately and incorporate current and evidence-based practice standards; prevent deviation from care process; identify issues and concerns with facility system, as well as identifying opportunities for improvement; and develop and implement plans to correct and/or improve identified areas. The facility documented documentation of the Quality Assurance and Performance Improvement Program would include evidence that demonstrates the operation of the facility's program performance improvement project that were being conducted; the reasons for conducting each project; measurable progress achieved during performance improvement projects; and outcomes. Review of Standard Survey Statement of Deficiencies (Form 2567) issued by the New York State Department of Health with an exit date of 06/17/2025 revealed the facility was cited for not providing residents with enteral tube feed as ordered by the medical provider. The Standard Survey Statement of Deficiencies documented, per interviews with the Licensed Practical Nurse and the Nursing Supervisor, that the enteral feeding pump read a technical error, and they could not get the feeding tube pump to work resulting in the resident not receiving their provider ordered nutrition. Form 2567 documented the facilities approved Plan of Correction corrective would include that all licensed nurses would be reeducated regarding enteral tube feed administration, how to utilize the feeding pump(s) and the protocol to follow if a tube feed pump was not functioning as expected. The facilities Plan of Correction documented the deficiency would be corrected by 08/06/2025. Review of the Quality Assurance and Performance Improvement (QAPI) Meeting Summary dated 07/27/2025 documented under the regulatory deficiencies section that multiple tags reviewed including F tag 693 and numerous corrective actions implemented: audits, education, progressive discipline, policy reinforcement.Review of the facilities educational slide presentation titled (name of the city) Plan of Correction dated July 2025, identified as the facility's education presentation by the Director of Clinical Operations, documented Licensed Nurse education included tube feeding. The tube feeding education slide included tube feeing were to be administered per the provider orders, the feeding must run until the prescribed volume was infused utilizing the pump, feeding pumps and poles were to be wiped down, and if feeding pump was not functional the nursing supervisor/designee should be contacted. The slide presentation did not address how to specifically work the feeding tube pump. During an interview on 09/02/2025 at 12:56 PM, Licensed Practical Nurse #1 stated they had not received any recent education or in-services specific to utilizing feeding pumps. During an interview on 09/03/2025 at 1:07 PM, Licensed Practical Nurse Unit Manager #3, stated they do not remember receiving any education regarding utilizing feeding pumps. During an interview on 09/03/2025 at 1:57 PM, Licensed Practical Nurse #5 stated they had not received any education specific to the use of feeding pumps. During an interview on 09/03/2025 at 3:25 PM, Licensed Practical Nurse #2 stated they had not received any education specific to utilizing feeding pump(s). They stated if they did not know something about a pump they would ask a fellow co-worker. During an interview on 09/04/2025 at 10:34 AM, the Director of Clinical Operations, with the presence of the Administrator stated the last Quality Assurance Performance Improvement Program meeting was held was in July 2025 with the former Administrator and they have not had held the August 2025 meeting yet with the current Administrator. They stated at the July 2025 meeting the committee reviewed all the cited deficiencies along with their plan of corrections. The Director of Clinical Operations stated the unit managers were to ensure that all tube feeding were being administer per provider order. They stated they think staff still had some confusion on how to properly document the volume of enteral feed that was administered to the resident each shift in the medication administration record. After review of the provided facility's education from the slide presentation, the Director of Clinical Operations stated the education did not specifically include how to operate the enteral feeding pump. During a telephone interview on 09/04/2025 at 12:20 PM, Licensed Practical Nurse #7 stated they did receive education on the facilities cited deficiencies in July, but it did not include specific education on how to utilize an enteral feed pump. A telephone interview was attempted with Former Nurse Educator on 09/04/2025 at 1:03 PM and Former Director of Nursing on 09/04/2025 at 1:05 PM without success. During an interview on 09/04/2025 at 1:45 PM, the Director of Clinical Operations stated they were unable to locate any documented evidence that all licensed nursing staff were educated specially on how to operate the enteral feeding tube pump, and the nurse medication competencies did not contain a competency for proper pump operation. The Director of Clinical Operations stated they should have been able to provide evidence that all licensed nursing staff were provide education and therefore the facility did not follow their plan of correction. 10NYCRR 415.27(c)(3)(iv)(v)

Based on observation, interview, and record review conducted during the Standard survey completed on 6/17/25, the facility did not ensure that residents who had an indwelling foley catheter (tube inserted into the bladder to drain urine) received appropriate care and services to manage catheters for two (2) (Residents #47 and Resident #382) of three (3) residents reviewed. Specifically, staff improperly emptied the urinary drainage bag (used to collect urine) (Resident #382); did not ensure the tubing and urinary catheter drainage bag remained off the floor and there was lack of monitoring urine output (Residents #47 and #382). Additionally, Resident #47 lacked an order for a urinary catheter. The findings are: The policy titled Catheter- Care revised 5/2019, documented the purpose of the procedure was to prevent catheter-associated urinary tract infections and provide required care of resident's who have an indwelling catheter. Personal protective equipment (gowns, gloves, mask, et cetera, as needed) will be necessary when performing this procedure. 1.Resident #382 had diagnoses including sepsis (life threatening response to an infection), urinary tract infection (bladder infection) and obstructive and reflux uropathy (urinary tract disorders). The Minimum Data Set had not yet been completed. The comprehensive care plan initiated on 6/2/25 documented Resident #382 had an indwelling catheter related to obstructive uropathy. Interventions to maintain privacy bag, monitor and document output were initiated on 6/11/25. The resident required substantial assist of one staff for toileting hygiene. Nursing admission Evaluation progress note dated 6/2/25 at 6:44 PM, documented Resident #382 had a urinary catheter. Review of Progress Notes revealed: -6/9/25 at 8:52 AM by Medical Doctor #1 documented Resident #382 pulled out their foley. Nursing was advised to monitor urine output and reinsert catheter if the resident did not urinate. -6/10/25 at 2:30 PM, the provider progress note documented Resident #382 continued with a foley catheter with straw yellow urine. -6/12/25 at 3:43 PM, provider progress note documented Resident #382 had a foley catheter in place, continue foley catheter and monitor urine output. Review of Resident #382's electronic medical record including nurse notes and certified nursing aide task documentation from 6/2/25-6/13/25, revealed no documented evidence that urinary output was being monitored or recorded. Facility staff were unable to provide any documented evidence of recorded outputs. During an observation and interview on 6/10/25 at 9:20 AM-9:30 AM, Resident #382 was lying in bed, their urinary catheter collection bag was swelled (distended) with urine and looked like a full balloon. There was yellow urine observed in the tubing above the collection bag. The catheter tubing and urine collection bag were lying directly on the floor. Certified Nurse Aide #10 entered the room and stated the resident did not have a urinary catheter. Certified Nurse Aide #10 was shown the swelled catheter bag, and they stated Oh, they must have put it back in. Certified Nurse Aide #10 then applied gloves, placed a urinal on floor, opened the spigot on the catheter bag, filled the 1000 milliliter urinal, clamped the spigot, and emptied the urinal into the toilet. The Certified Nurse Aide #10 emptied the urine collection bag into the urinal twice more to drain the remaining urine. Over 2000 milliliters of urine was emptied from the catheter bag. They did not wear a gown and did not sanitize the spigot on the catheter bag between or after draining the urine and re-clamping the spigot. During an interview on 6/10/25 at 10:27 AM, Certified Nurse Aide #10 stated it was not communicated to them that Resident #382 had a catheter. They stated catheter bags were supposed to be emptied every two to four hours and should not be on the floor for infection control. During an interview on 6/12/25 at 10:18 AM, Resident #382's emergency contact stated Resident #382's catheter got caught on their wheelchair and got pulled out since admission to the facility. They stated Resident #382's urinary leg bag was not checked, emptied and urine had been in the resident's shoes on 6/11/25. During an observation on 6/13/25 at 7:55 AM-8:25 AM, Resident #382 stated their urinary bag was full and needed to be emptied. Resident #382 had a catheter leg bag on that was positioned to their right upper thigh and appeared distended through the pants they were wearing. Certified Nurse Aide #10 wearing only gloves, lifted the resident's right pant leg, accessed the leg bag spigot, and emptied 525 milliliters of urine into a urinal. While emptying Resident #382's leg bag, urine spilled onto the floor. While wearing the same gloves, Certified Nurse Aide #10 wiped the urine off the floor with a towel, then wiped the spigot of the leg bag with an alcohol wipe. During an interview on 6/13/25 at 8:30 AM, Certified Nurse Aide #10 stated they should have worn a gown and sanitized the spigot with alcohol when emptying Resident #382's urinary catheter for infection control. They stated Resident #382's leg bag was full and should not have been because it could leak, cause blockage, or infections. They stated they usually knew when a resident had a urinary catheter by checking resident rooms, looking for a bag. They identify when a urinary bag needed to be emptied by checking the urinary bags, notice if the resident was uncomfortable or if the tubing is tugging. Certified Nurse Aide #10 stated they can check the residents plan of care but usually they just do visual checks for urinary catheters. During an interview on 6/13/25 at 12:05 PM, Licensed Practical Nurse #9 stated the urinary spigot should be disinfected after emptying urine from the urinary drainage bag to decrease the resident's exposure to outer contaminates that could lead to urinary tract infections. They stated urinary output should be measured to make sure residents are urinating and hydrated. During an interview on 6/13/25 at 12:41 PM, Licensed Practical Nurse #2 Unit Manager stated the nursing staff (nurses, aides) were responsible for maintaining urinary catheters. They stated urinary catheter outputs should be recorded in the residents' plan of care by the certified nurse aides to make sure residents are urinating. Licensed Practical Nurse #2 Unit Manager, stated when a catheter drainage bag was emptied, a barrier should be placed on the floor and the spigot should be wiped with alcohol for infection control purposes. They stated urinary catheter bags that were not emptied timely could cause pain, bladder distention, back flow and infection. 2. Resident #47 had diagnoses including right femur fracture (thigh bone break), encephalopathy (disorder/disease of the brain), and non-Hodgkin lymphoma (form of cancer). The Minimum Data Set (a resident assessment tool) dated 5/13/25 documented that Resident #47 had severe cognitive impairment, was usually understood and usually understands. The Minimum Data Set documented no indwelling catheter, and urinary continence was not completed. The comprehensive care plan initiated on 12/3/24, documented Resident #47 required assist with self-care and mobility and the resident was dependent on staff for toileting hygiene. On 6/11/25 Resident #47 was care planned as at risk for multidrug-resistant organisms (MDRO) colonization/infections related to an indwelling foley catheter. There was no active comprehensive care plan for the use of an indwelling catheter. Review of Hospital Discharge summary dated [DATE], documented a foley catheter was placed during Resident #47's hospitalization. Review of Order Summary Report dated 6/16/25 documented an order for an 18 French (measurement scale used to describe the dimension of medical device tubing) 10 cubic centimeter balloon indwelling catheter as needed, and catheter care every shift were ordered on 6/10/25. Orders to remove the urinary catheter and monitor voiding status were ordered on 6/11/25. There was no documented evidence that the resident had orders for an indwelling catheter from 5/7/25-6/10/25. Review of Documentation Survey Report, documented by certified nurse aides, dated May-25 (5/7/25-5/31/25), Resident #47's bladder continence was documented as a 3 (not rated due to indwelling catheter) for 38 out of 57 entries. For Jun-25 (6/1/25-6/11/25), their bladder continence was documented as a 3 (not rated due to indwelling catheter) for 14 out of 20 entries documented. During an observation on 6/10/25 at 11:59 AM, Resident #47 was lying in bed, their urinary catheter tubing was on the floor and the urinary catheter bag was on the floor under the bed frame with no urine present. During an observation on 6/11/25 at 9:28 AM, Resident #47 was lying in bed and holding onto their urinary catheter tubing, with yellow urine present, in their hand. The urinary catheter collection bag was resting on the floor. During an interview on 6/16/25 at 2:45 PM, Licensed Practical Nurse #4 stated they could not recall if Resident #47 had a urinary catheter prior to 6/10/25. They stated urinary catheter orders should have been part of Resident #47's readmission assessment/orders. They stated urinary catheter collection bags and tubing should never be on the floor; they should be kept off the ground for infection control. They stated an order was obtained to reinsert Resident #47's urinary catheter on 6/10/25, because there were no current orders for one. During an interview on 6/17/25 at 8:15 AM, Resident #47's family member stated the resident had a urinary catheter since their surgery, which was around 5/1/25. During an interview on 6/17/25 at 9:27 AM, Licensed Practical Nurse #10 stated they did not recall if Resident #47 had a urinary catheter upon readmission on [DATE]. They stated it would be important and they should have known if a urinary catheter was present so they could obtain orders, and it could be monitored. They stated orders were needed for catheter size, catheter care and urine output every shift. Licensed Practical Nurse #10 stated the certified nurse aides are supposed to let the nurses know what a resident's catheter output is to make sure a residents' kidneys were functioning. During an interview on 6/16/25 at 10:48 AM, the Assistant Director of Nursing/Infection Preventionist stated they expected nursing staff to wear gowns, and gloves when emptying or performing any catheter care. They stated a barrier should be placed on the floor between the urinal when emptying the catheter bag. An alcohol wipe should be used before and after accessing catheter bag spigot so germs, bacteria are not introduced into the resident's body. They stated urinary catheter bags and tubing should not be on the floor due to the potential for infection. The Assistant Director of Nursing/Infection Preventionist stated there should be orders for monitoring output so urinary retention, and decreased kidney function can be monitored. During an interview on 6/16/25 at 12:29 PM, the Director of Nursing stated foley catheters should be emptied at least every shift, so they do not get too full. They stated if a catheter bag is too full it could cause urine to back flow into bladder, and cause infection. They stated foley catheters bags and tubing should not be on the floor for infection control, prevent infections. They stated they expected orders to be in place for urinary catheters and urinary output. The Director of Nursing stated Resident #382 outputs were not being monitored until 6/13/25 when it was brought to their attention. They stated monitoring output was important to be tracked to note any changes in condition. During a telephone interview on 6/17/25 at 10:14 AM, Medical Doctor #1/Medical Director stated it was important for urinary catheter bags to be emptied timely to prevent hydronephrosis (excess fluid in kidney), acute kidney injury, bladder injury or rupture and urinary tract infections. They stated urinary catheter bags and tubing on the floor increased the risk for infection and should not be on the floor. They stated it was important to monitor for urinary output to ensure the urinary catheter was functioning and to monitor clinical situations. 10 NYCRR 415.12 (d)(1)

Based on observation, interview, and record review during a Complaint investigation (Complaint #NY00378534) conducted during a Recertification survey completed 6/17/25, the facility did not ensure that pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals) met the needs of each resident for two (2) (Resident #s 380 and #391) of two (2) residents reviewed. Specifically, Resident #380 was not administered doses of their antibiotic medication and there was a delay in acquiring, receiving, and administering Resident #391's medications upon admission. The findings are: The policy titled Physician Orders- Transcription revised 8/2018, documented a clinical nurse shall transcribe and review all physician orders in order to affect their implementation. The clinical nurse shall notify pharmacy per pharmacy policy by telephoning or faxing the order. The policy titled Pharmacy Services revised 4/2020, documented pharmaceutical services consists of the processes of receiving and interpreting prescriber's orders, acquiring, receiving, storing, reconciling, dispensing, packaging, labeling, distributing, administering of all medications, biologicals. Provide routine pharmacy service seven days a week and emergency pharmacy service 24 hours per day, seven days a week, deliver medications to the facility, and help ensure that all deliveries are correct and proper documentation related to delivery is provided. Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner. Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration. The policy titled Admission- readmission revised 9/2022, documented it is the philosophy of the facility to admit residents 24 hours per day, 7 days a week based upon the resident's needs and the ability to meet those needs. Prior to or at the time of admission, the facility must be provided with the following information for the immediate care of the resident, including medication orders. 1.Resident #380 had diagnoses including pneumonia due to Methicillin Resistant Staphylococcus Aurous (MRSA - an antibiotic-resistant bacteria), chronic kidney disease and dependence on renal dialysis (a life sustaining treatment for people with kidney failure). The Minimum Data Set (a resident assessment tool) dated 4/2/25 documented that Resident #380 was cognitively intact, understood, understands and received antibiotic medication. The comprehensive care plan initiated 3/28/25 documented Resident #380 had an actual respiratory tract infection, Methicillin Resistant Staphylococcus Aurous. Interventions included to administer antimicrobials (substance that kills or inhibits growth of bacteria) as ordered, administer medications and treatments as ordered. Review of the Aspen Complaints/incidents Tracking System (ACTS) Complaint/Incident Investigation Report intake dated 4/21/25 at 2:43 PM, the complainant alleged Resident #380 did not receive medications upon return from dialysis. The Order Summary Report printed 6/13/25, documented an order dated 4/2/25 for Linezolid (antibiotic used to treat bacterial infection) tablet 600 milligrams, give 1 tablet by mouth every 12 hours for infection until 4/16/25. The Medication Administration Record dated 4/1/25-4/30/25, documented an order dated 4/2/25 for Linezolid Tablet 600 milligrams give 1 tablet by mouth every 12 hours for infection until 4/16/25. Doses scheduled 8:00 AM on 4/7/25 and 8:00 PM on 4/5/25, 4/6/25, and 4/7/25 were coded 5 (hold/see nurse notes) by Licensed Practical Nurse #6. On 4/14/25 the 8:00 PM dose was coded 3 (out of facility) and on 4/15/25 the 8:00 PM dose was coded 9 (other/see nurses notes). It was documented the resident received 22 out of 28 prescribed doses. Review of Progress Notes dated 4/6/25 at 8:32 PM and 4/7/25 at 9:17 AM, revealed Licensed Practical Nurse #6 documented waiting for pharmacy for the Linezolid. There were no Progress Notes regarding the missed doses on 4/5/25, 4/7/25 8:00 PM, and 4/15/25. During a telephone interview on 6/13/25 at 1:53 PM, Licensed Practical Nurse #6 stated if a medication was not available or unable to be located, they would not indicate the medication as being administered on the medication administration record. They stated they would code the medication administration record and document the medication was not available. Licensed Practical Nurse #6 stated they did not recall that they did not have Resident #380's antibiotic, but if they coded the medication administration record as not given and documented they were waiting for pharmacy, then they did not give the antibiotic (4/5/25 8:00PM, 4/6/25 8:00 PM, 4/7/25 8:00AM and 8:00PM doses). They stated they would document this to cover themselves. Licensed Practical Nurse #6 stated they would have notified the supervisor and checked the medication pyxis (medication dispensing system) to see if the medication was available. Licensed Practical Nurse #6 did not recall what supervisor they notified and stated the antibiotic was not available in the pyxis. They stated it was important for residents to receive their antibiotics as ordered to treat their condition. Licensed Practical Nurse #6 stated a medical provider was not notified and should have been to extend the doses. During an interview on 6/13/25 at 12:41 PM, Licensed Practical Nurse #2, Unit Manager stated if a medication was not available, they would expect nurses to call the pharmacy and contact the medical provider. They stated the medical provider could prescribe an alternate medication on hand in the pyxis or a hold order may be needed until the medication was available from the pharmacy. They stated residents should receive their medications as ordered because they needed them. They stated medications should be reordered timely and that any nurse can take the initiative to reorder medications to make sure they are on hand to be given as ordered. During an interview on 6/16/25 at 12:33 PM, the Director of Nursing stated they expected antibiotics to be given as ordered and for a medical provider to be notified of missed doses of antibiotics so the antibiotic can be extended to ensure a therapeutic benefit of the antibiotics. They stated they did not feel the nurse looked hard enough for the antibiotic and was confused on its location. During a telephone interview on 6/17/25 at 8:02 AM, the Pharmacist #1 stated a total of 20 doses/10 days of Linezolid Tablet 600 milligrams was filled and delivered to facility for Resident #380. They stated Linezolid Tablet 600 milligrams for Resident #380 was first filled on 3/28/25 for a quantity of 10 tablets for 5 days, twice a day. They stated on 4/2/25 there was a new order for Linezolid Tablet 600 milligrams received but the medication was indicated as on hand by the facility and was not refilled at that time. They stated a request to refill from the facility was received on 4/7/25 and the pharmacy provided a quantity of 10 tablets for 5 days, twice a day. The Pharmacist #1 was unable to determine when the facility received the refill order. They stated it was important for residents to receive prescribed antibiotics for effective treatment against infections. During a telephone interview on 6/17/25 at 10:14 AM, the Medical Director/Medical Doctor #1 stated it was important for residents to receive antibiotics as ordered to treat an infection correctly. They stated missed doses of antibiotics can cause a reoccurrence of infection. They stated they expected to be notified of missed antibiotic doses so the course of antibiotics could be extended to ensure full treatment was received. Medical Director/Medical Doctor #1 stated they were not aware of missed antibiotic doses for Resident #380. 2. Resident #391 had diagnoses that included heart failure, alcohol use, and diabetes mellitus. The Minimum Data Set (a resident assessment tool) was not completed yet. Baseline Care Plan effective 6/11/25, documented Resident #391 was admitted for disease/illness management for post-surgical care, substance abuse disorder, heart failure, pain, hypertension (high blood pressure), liver cirrhosis and weakness. Interventions included: administer treatments as ordered, monitor medications and provide care and comfort. The Admission/readmission Evaluation dated 6/11/25, signed by Registered Nurse Supervisor #1, documented Resident #391 was cognitively intact and was alert to person, place, time, and situation. Review of the Order Summary Report dated 6/13/25 documented acetaminophen 325 milligrams, give 2 tablets by mouth every 6 hours as needed for pain was the only by mouth medication pharmacy order entered for 6/11/25 at 5:32 PM upon Resident #391's admission to the facility. Review of the Hospital Discharge summary dated [DATE] documented Resident #391's discharge medications included multivitamin with folic acid (supplement) 400 micrograms by mouth every day; oxycodone 5 milligrams by mouth every 4 hours as needed; albuterol (bronchodilator) meter dose inhaler 90 micrograms, 2 puffs inhaled every 4 hours as needed; eliquis (blood thinner) 5 milligrams by mouth every 12 hours; bumex (diuretic) 0.5 milligrams by mouth every morning; Jardiance (enzyme inhibitor)10 milligrams by mouth every day; trelegy ellipta (bronchodilator) 200-62.5-25, 1 puff inhale daily; lisinopril (heart medication) 2.5 milligrams by mouth every day; magnesium oxide (supplement) 400 milligrams by mouth twice a day; melatonin (dietary supplement) 5 milligrams by mouth every night as needed for sleep; naltrexone 100 milligrams (opioid antagonist) by mouth every day; metoprolol succinate (heart medication) 150 milligrams by mouth every day; zoloft (antidepressant) 50 milligrams by mouth every day; aldactone (diuretic) 25 milligrams by mouth every day; and thiamine (vitamin B-1-vitamin supplement) 100 milligrams by mouth every day. During an observation and interview on 6/13/25 at 8:17 AM, Resident #391 stated they thought they were going through withdrawal during the night. They stated they were throwing up, and sweating. They stated they had not received any of their routine medications from the nurses since they were admitted to the facility on [DATE]. Resident #391 stated they just took their own medication brought from home. Resident #391 had a healthcare provider box present at their bedside with daily medication packets filled with scheduled medications separated by date and morning and bedtime packets. The packet labeled Monday bedtime, June 2, 2025, listed the medications Eliquis 5 milligrams, lisinopril 2.5milligrams, magnesium oxide 400 milligrams, melatonin 5milligrams quick dissolve, metoprolol succinate extended release 100 milligrams, metoprolol succinate extended release 50 milligrams, and Zoloft 50 milligrams on the package containing the medications. The packet of medications Resident #391 stated they took that morning was on top of the garbage next to their bed. The packet was dated 6/3/25, morning and listed bumex 0.5 milligrams, Eliquis 5 milligrams, Jardiance 10 milligrams, magnesium oxide 400 milligrams, naltrexone 50 milligrams, Aldactone 25 milligrams, vitamin B-1 100 milligrams. Resident #391 stated they also had their own inhalers with them. Resident #391 stated they had asked about their medications and the nurses just kept saying they were on order. Resident #391 stated the only medications they had received from the nursing staff at the facility was their pain pill, Oxycodone and melatonin. During an interview on 6/13/25 at 4:37 PM, Registered Nurse Supervisor #1 stated they were Resident #391 admitting nurse and they had problems with inputting their admission orders into the electronic medical record on 6/11/25. They stated Resident #391 was admitted around 6:00 PM. They stated they had tried four to five times to enter Resident #391's orders, based off their hospital discharge summary, into the electronic medical record but couldn't see them or find them after putting them in. They stated the orders were placed as verbal orders from the medical doctor but that they did not speak directly with anyone. They stated the batch orders for acetaminophen were present for Resident #391, but none of their other medications would appear. Registered Nurse Supervisor #1 stated they felt Resident #391 could wait until 6/12/25 to have their medication orders addressed. They stated they phoned and reported their inability to enter Resident #391's medications orders to the Assistant Director of Nursing between 4:00 AM and 5:00 AM on 6/12/25. They stated the medical provider must acknowledge medications in the electronic medical record, but they were not sure how. During an interview on 6/13/25 at 12:05 PM, Licensed Practical Nurse #9 stated the only medication Resident #391 had ordered on 6/12/25 during the day shift was oxycodone. They stated Resident #391 told them that they were missing some medications. Licensed Practical Nurse #9 stated they notified Licensed Practical Nurse #2 Unit Manager, and the Licensed Practical Nurse #2 Unit Manager, administered medication (oxycodone) to Resident #391 from the pyxis. Licensed Practical Nurse #9 stated Resident #391's admission medication orders from the hospital discharge summary should have completed by a Registered Nurse when they were admitted . They stated if a resident was looking for additional medications it was important to communicate this to the supervisor to make sure residents received the right medications. During an interview on 6/13/25 at 12:41 PM, Licensed Practical Nurse #2 Unit Manager stated a Licensed Practical Nurse/Registered Nurse supervisor completed admissions orders. They stated admission orders were taken off the hospital discharge summary and placed into the resident's electronic medical record orders and the Medical Doctor confirmed the orders. They stated nurses were supposed to obtain what medications they could from the pyxis until they arrived from the pharmacy or get an order from the Medical Doctor to start medications as soon as they were available. They stated admission orders should be ordered the day of the resident's admission so there was no delay in receiving medications from the pharmacy and administering medications to residents. They stated they were not aware that Resident #391's medication orders were not transcribed until 6/12/25. During an interview on 6/13/25 at 4:10 PM, Licensed Practical Nurse #7 stated they were Resident #391's assigned nurse on 6/11/25 evening shift and 6/12/25 into 6/13/25 evening/night shift. They stated Resident #391 complained that they did not receive their medication since being admitted , and they reported this to the nursing supervisor. They stated there was nothing entered into Resident #391's electronic medical record, on the medication administration record indicating that any medications were to be administered on 6/11/25 evening shift. Licensed Practical Nurse #7 stated the only medication they administered to Resident #391 on 6/12/25 evening shift was magnesium 400 milligrams that was available as a stock medication. They stated they did not administer prescribed Eliquis 5 milligrams, 8:00 PM dose because it was not available and did not have time to get it from the pyxis. They stated Resident #391's medications did not arrive until late evening on 6/12/25. Licensed Practical Nurse #7 stated they were not aware of Resident #391 having their own medications on hand. During an interview on 6/16/25 at 10:48 AM, the Assistant Director of Nursing stated they received a phone call from Registered Nurse Supervisor #1 on 6/12/25 at 5:30 AM regarding their inability to enter Resident #391's medications into their electronic medical record. The Assistant Director of Nursing stated they did not know why Registered Nurse Supervisor #1 did not notify them prior to that. The Assistant Director of Nursing stated medication orders were supposed to be entered by the nursing supervisor per the hospital discharge summary orders upon admission and a facility medical provider verified the orders the next day when they came into the facility. They stated if there was an issue or a question with the hospital discharge medications, then they would expect the nursing supervisor to call a medical provider for clarification. The Assistant Director of Nursing did not feel there was a delay in resident #391 receiving their medications. During an interview on 6/16/25 at 12:29 PM, the Director of Nursing stated the medical providers can see and review medication entered through the resident's electronic medical record. They stated depending on what time a resident was admitted to the facility, the medical providers may not sign off on admission orders that night. They stated Registered Nurse Supervisor #1 was proficient at writing orders and never had this issue before. The Director of Nursing stated Resident #391's medications should have been reviewed by a medical provider and ordered from the pharmacy on 6/11/25. During a telephone interview on 6/17/25 at 8:02 AM, the Pharmacist #1 stated the facility had two scheduled deliveries daily, one at 1:00 PM and the other at 10:00 PM. They stated medications needed by the 1:00 PM delivery time, needed to be ordered before 11:00 AM. Anything ordered from 11:00 AM to 7:00 PM would be on the facility's 10:00 PM delivery. They stated late admissions were STAT (immediately) sent out the next morning. They stated the pharmacy received electronic orders through their computer system and were filled pending signature from providers or orders that were entered by the nurses. The Pharmacist #1 stated the pharmacy did not receive orders for Resident #391 until 6/12/25 between 10:50 AM and 1:59 PM. They stated the only by mouth medication order they received on 6/11/25 was for acetaminophen. During a telephone interview on 6/17/25 at 10:14 AM, the Medical Director/Medical Doctor #1 stated new admission orders were being entered pretty late. They stated they were notified by nursing in the morning that they had admission orders to sign. They stated they signed orders electronically after they have been entered by nursing staff. They stated it was not fair for the residents to have to wait for their medication due to the time they were admitted and a delay in ordering from the pharmacy. The Medical Director/Medical Doctor #1 stated it was not acceptable that Resident #391's medications weren't entered until 6/12/25. 10NYCRR 415.18(a)

Based on observation, interview, and record review conducted during a Standard survey completed on 6/17/25, the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for one (1) (Resident #14) of two (2) residents reviewed. Specifically, Resident #14 was observed with dirty long fingernails and unwanted/unkempt facial hair. The finding is: The policy and procedure titled Activities of Daily Living (ADL) Care and Support dated 2/28/25 documented the facility shall provide residents with activities of daily living care and support in accordance with current standards of practice, state and federal regulations and are based on the resident's assessed needs, personal preference and goals of care. Nail care should be provided as needed for the resident and facial hair will be groomed as per resident's preference and/or assessed needs. Resident #14 had diagnoses including dementia, encephalopathy (a condition that disrupts normal brain function) and rhabdomyolysis (a condition where one's muscles break down). The Minimum Data Set (a resident assessment tool) dated 4/18/25 documented Resident #14 was cognitively intact, was understood, and understands. The assessment tool documented Resident #14 had no behaviors or refusals of care. It was documented Resident #14 was a maximal assist for hygiene and bathing. The comprehensive care plan revised 3/20/25, documented Resident #14 required assist with self-care and mobility related to weakness. Interventions included the resident was a substantial assist of one for bathing and hygiene. Interventions included to engage the resident to participate in simple, structured activities. The Kardex (guide used by staff to provide care) dated 6/16/25 documented Resident #14 was a substantial assist of one staff member for bathing and hygiene. The Kardex documented to keep fingernails short to prevent the resident from scratching. Review of Progress Notes dated 6/1/25 - 6/12/25, Resident #14 had no refusal of care documented. Review of the Documentation Survey Report (certified nurse aide documentation) dated 6/13/25 documented Certified Nurse Aide #4 gave Resident #14 a shower on 6/11/25. It was documented that Resident #14 had no behavioral symptoms on 6/11/25. During observations on 6/10/25 at 11:45 AM, 6/12/25 at 3:44 PM and 6/13/25 at 8:42 AM, Resident #14 was observed to have long fingernails past their fingertips with brown debris under their nails and unkempt facial hair. During an interview on 6/12/25 at 3:45 PM, at the time of the observation, Resident #14 stated that they do not like their facial hair, and they wanted their beard shaved off. During an observation on 6/13/25 at 8:55 AM, Certified Nurse Aide #3, with the assistance of Certified Nurse Aide #2, provided AM (morning) care to Resident #14. Certified Nurse Aide #3 washed, rinsed and dried Resident #14's face, peri area and buttocks. While Certified Nurse Aide #3 was washing Resident #14's face they stated to the resident you're getting a beard, we will need to shave you soon. Resident #14 was placed in a new brief but remained in the same hospital gown. Certified Nurse Aide #3 and Certified Nurse Aide #2 stated that AM care was completed, and they would get Resident #14 out of bed later for therapy. During an observation at 1:00 PM, Certified Nurse Aide #3 along with Certified Nurse Aide #6 transferred Resident #14 out of bed via the mechanical lift into a Geri chair (reclining chair on wheels). Resident #14 was now dressed in day clothing but remained with the unkempt facial hair along with long fingernails with brown debris underneath the nails. During an interview on 6/13/25 at 9:35 AM, Certified Nurse Aide #4 stated they do not provide nail care or shaving on residents as much as they would like too, even on the resident's shower days because they were busy. They stated when there was a community aide on the schedule, the community aide would do those tasks. Certified Nurse Aide #4 stated on 6/11/25 they gave Resident #14 their scheduled shower. They stated they did not shave Resident #14 or complete nail care. They stated they were afraid to use a razor on any residents and were uncomfortable clipping their nails. During an interview on 6/13/25 at 1:13 PM, Certified Nurse Aide #3 stated they did not shave Resident #14 or provide nail care on 6/13/25. Certified Nurse Aide #3 stated the community aide would give the residents nail care or shave them but anyone could do it when needed. Certified Nurse Aide #3 stated they did not perform nail care on Resident #14 because they were scared' to do nail care. They stated they probably didn't shave Resident #14 because they were used to the community aide doing it but they absolutely should have shaven them. Certified Nurse Aide #3 stated it was a dignity issue not to shave a resident if the resident wanted to because the resident wants to look a certain way. They stated a resident's nails should be cut for safety of the resident. Certified Nurse Aide #3 stated for skin integrity reasons all areas of a resident's body should be washed. During an observation and interview on 6/13/25 at 3:45 PM, Licensed Practical Nurse Unit Manager #1, observed Resident #14 in the dining lounge as the resident was sleeping in their Geri chair. Resident #14 remained unkempt facial hair and long fingernail with brown debris underneath. After looking at the resident's nails, Licensed Practical Nurse #1 stated that Resident #14 was due for some nail care and Certified Nurse Aide #3 should have shaved Resident #14 with morning care. During an interview on 6/17/25 at 9:30 AM, Licensed Practical Nurse Unit Manager #1 stated removal of unwanted facial hair and nail care should be completed on showers days but continued to be monitored all week long and provide as needed. Licensed Practical Nurse Unit Manager #1 stated these were the normal duties of the assigned aide. Licensed Practical Nurse Unit Manager #1 stated at times the unit would have extra certified nurse aides scheduled, and they would be assigned the community aide role. They stated it was not necessarily the same staff member all time, and they would be expected to choose three extra residents of their choice on the unit and provided them extra activities of daily living care. Extra care would consist of showers, shaving and nail care, above the resident's weekly schedule shower for a boost and to make the resident feel better. Licensed Practical Nurse #1 stated Certified Nurse Aide #3 was assigned to Resident #14 on 6/13/25 and should have cleaned/ trimmed the resident's nails and shaved them. During an interview on 6/17/25 at 11:10 AM, the Director of Nursing stated they expected complete AM care for a resident to include oral hygiene, peri care, face washing, hair care and dressing and stated shaving and nail care should be completed as needed and mainly on shower days. They stated these duties were important so a resident can start their day clean and comfortable. 10NYCRR 415.12(a)(3)

Based on interview and record review conducted during a Standard survey completed on 6/17/25, it was determined that the facility did not ensure that a comprehensive assessment of a resident in accordance with the specified timeframes from the Centers of Medicare and Medicaid Services including not less than every 12 months. Specifically, 16 (#4, 11, 14, 15, 18, 35, 90, 93, 114, 128, 154, 152, 160, 161, 173 and 381) of 16 residents did not have a comprehensive assessment completed within required time frames. The findings are, but not limited to: The policy and procedure titled MDS Assessment Coordinator dated 8/2019 documented that a licensed nurse shall be responsible for conducting and coordinating the development and completion of the resident assessment. 1. Resident #4 was admitted to the facility with diagnoses of aphasia (a communication disorder) and peripheral vascular disease. Review of the Minimum Data Set (a resident assessment tool) dated 1/14/25 documented that the resident was cognitively intact, rarely understood by others, and rarely understands others. Review of the Minimum Data Set Assessment Reference Date documented the date the Minimum Data Set was due on 4/15/25. Section Z Assessment Administration of the Minimum Data Set documented that the Minimum Data Set was not completed until 6/9/25. 2. Resident #15 was admitted to the facility with diagnoses of end stage renal disease and diabetes mellitus. Review of the Minimum Data Set, dated [DATE] documented the resident was cognitively intact, understood by others, and understands others. Review of the Minimum Data Set Assessment Reference Date documented that the Minimum Data Set was due on 4/15/25. Section Z Assessment Administration of the Minimum Data Set documented the Minimum Data Set was not completed until 6/9/25. 3. Resident #11 was admitted to the facility with diagnoses of multiple sclerosis, seizure disorder, and diabetes mellitus. Review of the Minimum Data Set, dated [DATE] documented that the resident was severely cognitively impaired, sometimes understands others, and was sometimes understood by others. Review of the Minimum Data Set Assessment Reference Date documented that the Minimum Data Set was due on 5/6/25. Section Z Assessment Administration of the Minimum Data Set documented that the Minimum Data Set was not completed until 6/3/25 and was not submitted to the Centers of Medicare and Medicaid Services. During an interview on 6/16/25 at 9:03 AM, Licensed Practical Nurse Minimum Data Set Coordinator #14 stated that the Minimum Data Set should be completed by the Assessment Reference Date. They stated that they were the only on-site Minimum Data Set coordinator for the facility. They stated that there were Registered Nurse Minimum Data Set coordinators who work remotely and sign off the Minimum Data Set. Licensed Practical Nurse Minimum Data Set Coordinator #14 stated they had informed the Administrator and the Director of Nursing about the Minimum Data Set Assessments being late. A telephone call on 6/16/25 at 12:20 PM was placed to Registered Nurse #3 Minimum Data Set Coordinator. The call was not returned. During an interview on 6/16/25 at 1:32 PM with the Administrator and the Director of Nursing, the Administrator stated they expected staff to complete the Minimum Data Set assessments in a timely manner as this guides the care they provide for residents. They stated that they had a position open for a full time Minimum Data Set Coordinator, but it had not been filled. They stated they were aware of late submissions. 415.11 (a)(3)(i)

Based on observation, interview and record review conducted during a Complaint Investigation (Complaint #NY 662) completed during the Standard survey on 7/20/21, the facility failed to ensure the resident's right to be free from abuse and neglect for two (Resident #10, 90) of eight residents reviewed. Specifically, Certified Nursing Assistant (CNA) #3 entered Resident #10's bathroom, while the resident was in the bathroom. Resident #10 became agitated, an altercation ensued, and CNA #3 slammed the door causing the resident to fall to floor. Resident #10 was sent to the hospital for evaluation and treatment and returned to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in actual harm for Resident #10 that is not immediate jeopardy. Additionally, Resident #90 was found on floor, next to their bed without the care planned safety interventions in place resulting in facial bruising. The findings are: The facility policy and procedure (P&P) Abuse, revision dated 2/2019, documented the facility prohibits the mistreatment, neglect, and abuse of residents/patients by anyone. The policy documented abuse is a willful infliction of injury and neglect is a failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Physical Abuse includes hitting, slapping, pinching, scratching, spitting, holding roughly, kicking etc. It also includes controlling behavior through corporal punishment. If the alleged abuse is confirmed, the employee is to be terminated. 1. Resident #10 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - a resident assessment tool) dated 12/13/20 documented Resident #10 was cognitively intact. The comprehensive care plan (CCP) documented as initiated on 2/18/20 Resident #10 was at risk for falls r/t (related to) weakness and deconditioning. On 3/11/20 the care plan was revised to include the resident exhibited behavioral symptoms such as fabricates stories about events that have not occurred, changes stories depending on audience, and verbally inappropriate with staff, yelling, and swearing at staff. Interventions initiated on 3/13/20 included to have 2 staff members at all times with hands on care. Review of the facility investigation file revealed the following: A document titled Initial Event Documentation dated 1/26/21 completed by the Registered Nurse (RN) #8, Regional Float DON (Director of Nursing), documented Resident #10 called writer (RN #8, nursing supervisor) at approximately 9:00 PM. While on the phone with the resident writer heard a knock on the door and CNA #3 asked the resident are you ok, can I use the water? I (RN #8) heard another knock and CNA #3 again asked Can I come in to use the water? Resident #10 started to yell at CNA #3 with explicate [sic] language and stated I'm on the phone with the supervisor the resident then hung the phone up. While this writer (RN #8) was going to residents' room writer was stopped by CNA #3 who stated that this resident (#10) struck them in the face with a closed fist. The police then called the supervisor phone stating they have a complaint of resident abuse and there is an ambulance on the way. Upon entering the residents (#10) room the resident (#10) was observed sitting on floor in bathroom with legs extended out front of them, their right leg over their left leg with increased swelling to the right knee. Resident (#10) stated [CNA #3] hit me and pushed me down. A handwritten statement by CNA #3, signed and dated 1/26/21 documented on second shift I was doing my rounds. I went to the room to change the resident by the window. I was holding conversation with that resident. I told the resident I was about to get started. I went to get my linen and walked toward the bathroom and knocked on the door and opened it and resident #10 was in the bathroom talking to RN #8 the supervisor. [Resident #10] started calling me out my name, all types of b's and saying I can't kick [the resident] out the bathroom, which I wasn't trying to do. All I asked was to use the sink. [Resident #10] then replied B***** I can walk. [Resident #10] struggled to get up and then punched me in my mouth. I slammed the door in [the residents] face and walked out. The Disciplinary Report dated 1/27/21 documented disciplinary action was issued to CNA #3 for carelessness affecting the health of a resident, infraction of facility rule/regulation, and reported allegation of abuse to resident. CNA #3 was terminated 1/27/21 related to abuse allegation that could not be ruled out based on staff members statement and resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 7/15/21 at 11:48 AM, Resident #10 stated on 1/26/21 in the evening, the resident was in the bathroom, talking to the supervisor on the telephone. Resident #10 stated that they had a roommate at the time and staff frequently interrupted the resident when Resident #10 was in the bathroom. CNA #3 knocked on the door and entered the bathroom to obtain water to provide care for the roommate. Resident #10 stated that they told CNA #3 to wait until they were finished in the bathroom. Resident #10 stated CNA #3 became upset, slamming the door, which hit the resident in the face caused them to fall on the floor and break their glasses. During an interview on 7/16/21 at 11:20 AM, the DON stated a CNA intentionally slamming a door on a resident would be considered an abusive situation. Additionally, it would be considered harm if the resident subsequently fell from the door being slammed and sustained a fracture. During an interview on 7/19/21 at 9:18 AM, the Physician Assistant (PA) stated CNA #3 should have waited until Resident #10 exited the bathroom to obtain water. The PA would consider slamming the door abuse and it would be considered harm if the resident subsequently fell from the door being slammed and sustained a fracture. During an interview on 7/19/21 at 12:24 PM, the facility Administrator stated it was unacceptable, unprofessional, and abusive for a staff member to slam a door on a resident. Additionally, if an alert and oriented resident stated the slammed door hit them, and they fell sustaining a fracture it would be considered harm to the resident. 2. Resident #90 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #90 was cognitively intact. The CCP initiated 3/17/2020 documented Resident #90 was at for risk for falls. Interventions included the use of floor mats initiated on 9/2/2020 and to ensure resident's bed was against the left side of wall was initiated on 9/6/2020. Review of the Bedside Kardex (guide used by staff to provide care) dated 7/19/21 documented safety instructions which included Resident #90 utilized floor mats and the bed should be against the left side of the wall. Review of the facility investigation file revealed the following: Incident Report, completed by RN Supervisor #7, dated 5/18/21 documented Resident #90 had a fall and was found sitting on the floor in their room at 2:45 AM and had an eccymotic (bruise) area noted to their left eye and forehead. Assigned care giver was CNA #7. A document titled Initial Event Documentation completed by RN #7 on 5/18/2021 at 2:45 AM, documented Resident #90's safety (floor) mat was not down and was located on top of the residents' closet. Disciplinary Report completed by the Assistant Director of Nurses (ADON) dated 5/24/21 documented an infraction of a safety rule. On 5/18/21 at 2:00 AM CNA #7 was the care giver for resident #90. The resident had a fall, the floor (safety) mat was not in place on the floor next to the resident's bed, and the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview on 7/19/21 at 8:53 PM, CNA #7 stated on 5/18/21 they worked the 11-7 am shift. Resident #90 was in bed. At 2:45 AM Resident #7 was found on the floor next to their bed and had a purple knot on the left side of their head. CNA #7 stated the bed was in the middle of room and didn't know Resident #90 needed floor mats for safety. CNA #7 stated that that they should have read the care plan, and there were no mats in the resident's room. During an interview on 7/20/21 at 7:12 AM, RN #7 stated Resident #90 was supposed to have a mat down on 5/18/21 and the mat was on top of Resident #90's closet. During an observation on 7/14/21 at 2:42 PM, Resident #90 was in bed sleeping. The bed was in the center of the room (not against the wall) and there were no floor mats in place next to the bed as per the resident's care plan. During an interview and observation on 7/14/21 at 4:35 PM, Licensed Practical Nurse (LPN) Unit Manager #9 stated Resident #90 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . At this time, Resident #90 was not present in the room; however, the bed was in the middle of the room and LPN #9 was unable to locate the floor mats. During an observation on 7/16/21 at 7:30 AM Resident #90 was in bed sleeping. The bed was in the center of the room (not against the wall) and there were no floor mats in place next to the bed as per the resident's care plan. During an interview on 7/20/21 at 10:37 AM, CNA #8 worked on the Resident #90's unit and stated if a resident needed floor (safety) mats it would be on the Kardex, and if floor mats could not be located, the nurse would be notified. Floor mats were very important for residents who fall to prevent injury. If the care plan wasn't followed it would be neglect. During an interview on 7/20/21 at 10:42 AM, CNA #9 stated they were familiar with Resident #90, and added that Resident #90 was definitely a fall risk. The bed should be against the wall and floor mats in place if it is on the Kardex. It was considered abuse if a resident's care plan wasn't not followed. During an interview on 7/20/21 at 10:48 AM, LPN Unit Manager #9 stated if an incident involved not following the residents' plan of care it would be neglect because it was a break in the residents' plan of care. During an interview on 7/20/21 at 11:00 AM, the ADON stated the caregiver would be responsible to ensure a resident's care plan is followed. Resident #90 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 7/20/21 at 11:10 AM, the DON stated all staff were responsible for ensuring that safety measures are in place. Resident #90's care plan wasn't followed, and an injury occurred. Injury with fall per NYS (New York State) guidelines is neglect. During an interview on 7/20/21 at 11:17 AM, the Administrator stated there was a breach of Resident #90's care plan and it would be considered neglect because we forgot to put down the floor mat. 415.4(b)(1)(i)

Based on observation, interview, and record review conducted during an Abbreviated survey (Complaint #NY 451 and NY 008) completed on 5/3/21, the facility failed to ensure sufficient nursing staff to provide nursing and related services and safety to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care in accordance with the facility assessment. Specifically, 5/1/21 to 5/2/21, during the 11:00 PM to 7:00 AM Shift: unit 4's staffing was 1 Licensed Practical Nurse (LPN) and 1 Certified Nurse Aide (CNA) for 53 residents. Resident #1, who is care planned for extensive assistance of 2 staff for bed mobility and hygiene with toileting, was observed at 6:14 AM in a bed with soiled linen. CNA #1 entered the resident room at 6:52 AM and exited room at 7:01 AM with soiled linens. LPN #1 was observed working at the medication cart during this time. Two staff assistance was not provided due to insufficient staffing. On 5/1/21, 3:00 PM to 11:00 PM staffing was 1 Registered Nurse (RN) and 2.5 CNAs. On 5/2/21, 11:00 PM to 7:00 AM shifts staffing was 1 LPN and 1 CNA for 53 residents. Resident #2 who is care planned for 1:1 observation at all times was observed multiple times on 5/1/21 (4:30 PM to 7:00 PM) and 5/2/21(6:00 AM to 12:30 PM) wandering the hallways, in common areas with other residents, and in the resident's room with the corridor door closed without 1:1 supervision. Resident #2 has been involved in resident to resident altercations alleging sexual abuse as recently as February 2021. Resident #3, with a history of exit seeking behaviors, care planned for supervision when ambulating in hallways, pulled a fire alarm on 5/1/2021 and eloped from building at approximately 9:30 AM. Resident was found in the parking lot. This was widespread with no actual harm that is immediate jeopardy to resident health and safety. The findings are: The policy and procedure (P&P) titled Emergency Staffing dated 3/2020 documented the facility should request all nursing administration staff to be available and ready to provide ADL (activities of daily living) care to supplement the CNAs. The facility P&P titled Care Plans - Comprehensive with revision date 10/2019 documented the comprehensive, person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility P&P titled Supervision 1:1 dated 12/2019 documented 1:1 is determined necessary when a resident's safety risk cannot be appropriately monitored through frequent supervision or the Resident is in danger of injuring themselves or another resident. 1. The Facility Assessment Portfolio (used to determine resources necessary to care for facility residents competently during both day-to-day operations and emergencies) dated September 2020, documented a bed capacity of 200 with an average daily census of 181. The required staffing was documented as the following: 2nd floor bed capacity 60: -LPNs: 3 for the day shift (7:00 AM - 3:00 PM). 3 for the evening shift (3:00 PM -11:00 PM); 2 for the night shift (11:00 PM - 7:00 AM). -CNAs: 6 for the day shift; 6 for the evening shift; 3 for the night shift. 3rd floor bed capacity 80: -LPNs: 3 for the day shift; 3 for the evening shift; 2 for the night shift. -CNAs: 8 for the day shift; 6 for the evening shift; 4 for the night shift. 4th floor bed capacity 60: -LPNs: 2 for the day shift; 2 for the evening shift; 1 for the night shift. -CNAs: 6 for the day shift; 4 for the evening shift; 3 for the night shift. The facility Midnight Census Report dated 4/30/21 documented a census of 169. The actual staffing for the 5/1/21 7:00 AM to 3:00 PM shift was 6 LPNs and 15 CNAs (down 2 LPNs and 5 CNAs); the 3:00 PM to 11:00 PM shift was 5 LPNs and 11 CNAs (down 3 LPNs and 5 CNAs). The facility Daily Census dated 5/1/21 documented a census of 170 residents. The actual staffing for the 5/1/21 11:00 PM to 7:00 AM shift was 5 LPNs and 3 CNAs (down 7 CNAs); the 5/2/21 7:00 AM to 3:00 PM shift was 5 LPNs and 11 CNAs (down 3 LPN's and 9 CNAs). The scheduled staffing for the 5/2/21 3:00 PM to 11:00 PM shift was 3 LPNs, 8.5 CNAs (down 5 LPN's and 7.5 CNAs). During an interview on 5/2/21 at 6:22 AM, RN #1 the 11:00 PM to 7:00 AM Nursing Supervisor, stated each unit is typically staffed with one LPN and one CNA for the night shift. RN #1 stated there have been shifts when only one LPN was scheduled for the entire building and staffing is horrible here. During an interview on 5/2/21 at 6:34 AM, the third floor 11:00 PM to 7:00 AM LPN #3 stated resident care and incontinent care are not sufficiently nor provided timely to residents because there is not enough staff. LPN #3 stated residents complain that they were not even touched on the 3:00 PM to 11:00 PM shift. During an interview on 5/2/21 at 6:43 AM, the second floor LPN #4 stated it was impossible to pass medications and assist the CNA with resident care. During an interview on 5/1/21 at 5:20 PM, the third floor 3:00 PM to 11:00 PM CNA #2 stated residents were not transferred out of bed to eat dinner because there was not enough staff. During an interview on 5/1/21 at 5:22 PM, the third floor 3:00 PM to 11:00 PM CNA #3 stated incontinent care was not always provided timely to residents' because there was not enough staff. 2. The facility's Daily Census dated 5/1/21 documented 53 residents resided on the fourth floor, a designated dementia unit. The untitled facility daily nursing schedule, provided by the 11:00 PM to 7:00 AM Registered Nurse (RN) Supervisor #1, dated 5/1/21, documented one LPN and one CNA were scheduled to work on the fourth floor for the 11:00 PM to 7:00 AM shift. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 2/26/21 documented the resident was usually understood, sometimes understands, and had moderate cognitive impairment. The MDS documented the resident required extensive physical assist of two people for bed mobility and toilet use. Resident #1's Visual/Bedside Kardex Report (guide used by CNAs to provide care), dated 5/2/2021, documented extensive assistance of two staff members for bed mobility and total dependence of two staff members for toileting. During an observation on the fourth floor 5/2/21 at 6:14 AM Resident #1 was lying in bed on soiled linens wearing an incontinent brief and a soiled gown. The resident was covered in a foul smelling yellow/brown liquid like substance from their head to their knees. There were areas of this foul-smelling substance drying on the linens. At 6:52 AM CNA #1 entered Resident #1's room, while LPN #1 was observed at the medication cart. CNA #1 exited Resident #1's room at 7:01 AM with dirty linens. LPN #1 did not enter Resident #1's room during this observation. During an interview on 5/2/21 at 6:19 AM, CNA #1 stated they were the only CNA on the fourth floor for the 11:00 PM to 7:00 AM shift and there was one LPN. The CNA #1 also stated they were unable to provide care to the fourth-floor residents as care planned. During an interview on 5/2/21 at 6:25 AM, LPN #1 stated there was only nurse on the fourth floor for the 11:00 PM - 7:00 AM shift and there was one CNA. The LPN #1 stated they assisted the CNA as much as possible, but the LPN was responsible for medications and treatments, and were not always available to assist. During an interview with CNA #1 on 5/2/21 at 7:01 AM the CNA #1 stated, incontinent care was provided for Resident #1. The CNA #1 was aware Resident #1 required extensive assistance of two staff for incontinent care, but was the only CNA working on the unit, making it impossible to provide the care planned level of assist for Resident #1. During an interview with the Administrator on 5/2/21 at 3:26 PM the Administrator stated, the expectation was for care to be provided per the resident's care plan. If there was only one CNA scheduled on a unit, he would expect staff from another unit to assist. 3. The facility's Daily Census dated 5/1/21 documented 53 residents resided on the fourth floor, a designated dementia unit. The untitled, 5/1/21 staffing sheet for the 3:00 PM to 11:00 PM shift documented one LPN and two CNA's with an additional CNA scheduled to come in at 8:00 PM as the actual working schedule for the fourth floor. The untitled, 5/2/21 staffing sheet for the 7:00 AM to 3:00 PM shift, handwritten by the facility Administrator documented one LPN and three CNA's as the actual working schedule for the fourth floor. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented the resident was usually understood, sometimes understands, and had moderate cognitive impairment. Resident #2's comprehensive care plan (CCP) dated 1/29/21 documented the resident was placed on a 1:1 ATC (around the clock) because the resident lacked capacity to consent to sexual contact and had possible sexual contact with peer resident. During an observation on the fourth floor 5/1/21, from 4:48 PM to 5:57 PM, and on 5/2/21 from 6:05 AM to 12:00 PM Resident #2 was wandering independently in the hallways, in the common area with other residents, and in their room without 1:1 supervision. During an interview on 5/1/21 at 5:13 PM, the fourth floor 3:00 PM to 11:00 PM CNA #4 stated Resident #2 required 1:1 supervision, but staff was unable to provide 1:1 supervision. During an interview with CNA #1 (fourth floor 11:00 PM to 7:00 AM) on 5/2/21 at 6:19 AM. CNA #1 stated they were unable to provide 1:1 for Resident #2 throughout their shift. During an interview on 5/2/21 at 6:25 AM, the fourth floor 11:00 PM to 7:00 AM LPN #1 stated, Resident #2 required 1:1 supervision around the clock and LPN #1 was unable to provide 1:1 for Resident #2 during their shift. During an interview with LPN #2 on 5/2/21 at 12:00 PM, LPN #2 stated, they were the only nurse scheduled on the fourth floor with 3 CNAs for the 7:00 AM to 3:00 PM shift. LPN #2 stated there was not enough staff to provide 1:1 supervision for Resident #2 while providing care to other residents on the unit. During an interview on 5/2/21 at 3:26 PM, the Administrator stated, residents on 1:1 supervision require staff to be nearby the resident and have the resident within eyesight. 4. The facility's Midnight Census Report dated 4/30/21 documented 53 residents resided on the fourth floor, a designated dementia unit. The untitled facility daily nursing schedule dated 5/1/21, documented two LPNs and five CNAs were scheduled to work the fourth floor on the 7:00 AM to 3:00 PM shift. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident required supervision for walking in the corridor. Resident #3's Visual/Bedside Kardex Report dated 5/2/21 documented they ambulated in the corridor with supervision. The Facility 24 Hour Report documented Resident #3 had exit seeking behaviors on 4/14/21, 4/15/21, 4/18/21, 4/20/21, 4/23/21, and 5/1/21. The RN assessment dated [DATE] documented at 9:15 AM Resident #3 was observed wandering the hallways on the 4th floor, pushing at fire exit doors, checking doorknobs, and attempted to pull the fire alarm multiple times. At 9:30 AM the fire alarm triggered. During an observation of the fourth floor on 5/2/21 between 6:10 AM and 10:20 AM Resident #3 was ambulating unsupervised in the 4th floor corridor. At 10:20 AM the resident triggered the delayed egress on the C-Hall and no staff responded. During an interview on 5/2/21 at 9:58 AM, maintenance worker #1 stated the fire alarm pull station on the fourth floor C-Hall triggered on 5/1/21 at 9:20 AM and Resident #3 went down the stairwell. During an interview on 5/2/21 at 10:34 AM, the Food Service Director (FSD) stated the fire alarm sounded on 5/1/21 at approximately 9:30 AM and a staff member (Housekeeper #1) alerted the FSD that a resident was alone, ambulating in the parking lot. The FSD immediately went outside and brought Resident #3 back into the building. During an interview with the Director of Nursing (DON) on 5/2/21 at 11:04 AM the DON stated, they were unaware Resident #3 had eloped (left) from the building on 5/1/21. During an interview on 5/2/21 at 12:39 PM, the DON stated the expectation was that resident care be provided per the care plan. If a unit did not have enough staff to provide resident care per the care plan, staff was expected to assist from other units. During an interview on 5/2/21 at 3:26 PM, the Administrator stated there was no minimum staffing P&P and there needed to be sufficient staff to meet the needs of the residents. The Administrator stated the building was sufficiently staffed as evidenced by no negative outcomes. During an interview with the Administrator on 5/3/21 at 1:28 PM the Administrator stated, they were unaware of the staffing issues in the building. 10NYCRR415.13 (a)(1)(i-iii)

Based on observation, interview, and record review conducted during the COVID-19 Infection Control Focus Survey (Complaint #NY 778) completed on 4/30/20, it was determined that the facility did not establish and maintain an Infection Control Program to ensure the health and safety of residents to help prevent the transmission of COVID-19. Specifically, facility staff entered and exited the rooms of residents diagnosed with [REDACTED]. CNA #1 (certified nursing assistant) did not remove their disposable gown after exiting a room of a COVID-19 positive resident on Standard and Droplet Precautions and then entered two non COVID-19 resident rooms and assisted with resident care. Housekeeper #1 completed housekeeping tasks in a room of a resident diagnosed with [REDACTED]. CNA #1 and Housekeeper #1 were unable to identify residents that were on isolation precautions for COVID-19. This was a pattern of no actual harm that is immediate jeopardy to resident health and safety. Additionally, staff were observed not appropriately wearing face masks when within six feet of others. Review of an undated facility Best Practice Reference Guide titled Coronavirus (COVID-19) Admission/ Readmission documented all new admissions should be considered as a potential exposure to the COVID-19 virus and should be placed on droplet and isolation precautions for 14 days, use appropriate PPE, and maintain hand hygiene. Prior to entering and exiting a patients' room healthcare personnel must perform hand hygiene with soap and water or alcohol-based hand sanitizer. Review of a facility Best Practice Reference Guide titled Coronavirus (COVID-19) PPE Use Updated March 31, 2020 documented for staff to wear the same gown when interacting with more than one patient known to be infected with the same infectious disease. Review of a facility policy and procedure (P&P) titled Environmental Cleaning and Disinfecting dated 4/29/20 documented PPE was indicated by the resident's type of isolation and will be worn at all times. Housekeeping is instructed to discuss questions regarding PPE with nursing staff. Isolation rooms will be cleaned after other rooms are completed. Use paper towels instead of washcloths to prevent cross contamination. Use a clean mop head and change after cleaning the room. Change the mop bucket and solution after cleaning room. Review of a facility Quick Reference Guide titled Coronavirus (COVID-19) Infection Control/ Environmental Updated April 29, 2020 documented to use PPE according to established guidelines this includes use of non-sterile gowns and eye protection. Healthcare personnel must perform hand hygiene by washing hands with soap and water or applying alcohol-based hand sanitizer. The findings are: a.) During an interview on 4/30/20 at 8:40 AM, the Director of Nursing (DON) stated there were thirty-seven COVID-19 positive residents on the third and fourth floors. The facility had no residents under investigation for COVID-19. The facilities bed capacity was 200 and the census was 170. During an interview on 4/30/20 at 8:54 AM, Licensed Practical Nurse (LPN) #1 Unit Manager stated the Fourth Floor A - hall had one resident diagnosed with [REDACTED]. During an observation of the Fourth floor A - hall on 4/30/20 at 9:04 AM, Resident #1 diagnosed with [REDACTED]. I need a sock. A sign was posted on the door to the room that stated, Precautions please see nurse prior to entering room. CNA #1, wearing a disposable gown, held Resident #1's hand and walked the resident to their bed and assisted them into the bed. While wearing the same disposable gown CNA #1 exited the room, walked down the hallway and entered the room of a non COVID-19 Resident #2. As CNA #1 assisted the non COVID-19 Resident #2 with adjusting their under clothing, Resident 2's supported themselves by placing their hand on the arm and shoulder of CNA #1, touching the CNA's gown. Continued observation on 4/30/20 at 9:08 AM, COVID-19 positive Resident #1 was pacing in the hallway between rooms (#409, 411, and 412) while holding the handrail stating they were lost. While wearing the same disposable gown, CNA #1 assisted Resident #1 back to their room, and applied slipper socks to the residents' feet. CNA #1 exited the room and entered the room of a non COVID-19 resident while wearing the same disposable gown. During an interview on 4/30/20 at 9:25 AM, LPN #2 stated report was given to the CNA #1 prior to the beginning of the shift that there was one COVID-19 positive resident on the Fourth floor A - hall. During an interview on 4/30/20 at 9:33 AM, CNA #1 stated report was given to her in the morning and that, it slipped my mind a resident was COVID-19 positive. During an interview on 4/30/20 at 9:37 AM the ADON stated, It's cross contamination to go from a (COVID-19) positive to (COVID-19) negative room. The CNA should have changed the gown. Continued observations on the Fourth Floor A- hall on 4/30/20 at 9:48 AM revealed Housekeeper #1 was in street clothes and entered the room of a resident diagnosed with [REDACTED]. She again exited the room gathered supplies from her cart and reentered the room with a toilet brush, cleaning cloth, and spray bottle. When Housekeeper #1 exited the room, she placed the toilet brush, cleaning cloth, and the spray bottle on the housekeeping cart. She removed her gloves, dried hands and face with brown paper towels and applied new gloves without performing hand hygiene. Housekeeper #1 was then observed entering a non COVID-19 room and bathroom at 9:56 AM with the same toilet brush, cleaning cloth, and spray bottle. Housekeeper #1 exited the non COVID -19 room, placed the toilet brush, cleaning cloth, and spray bottle on housekeeping cart. She removed gloves, and again applied new gloves without performing hand hygiene. Housekeeper #1 then entered a COVID-19 positive room, mopped the floor, exited the room, and placed the mop into a pail of water on the housekeeping cart. While wearing the same gloves, using the same cleaning cloth, and spray bottle as above the housekeeper wiped down the hallway handrails and exterior door knobs of rooms 407, 408, 409, 410, 411, 412, 413, and 414, placed cleaning cloth and spray bottle on housekeeping cart. She again removed her gloves and applied new gloves without performing hand hygiene. The housekeeper then entered a non COVID-19 room and mopped the floor using the same mop and water that was used for the COVID-19 positive room. During an interview on 4/30/20 at 10:05 AM, Housekeeper #1 stated, I don't usually work this floor, but I treat everyone as positive. Additionally, Housekeeper #1 stated there were no residents diagnosed with [REDACTED]. During an interview on 4/30/20 at 10:27 AM, the DON stated all staff should wear the proper PPE for the precautions (gown, gloves, face mask, face shield), properly remove PPE (discard disposable gown or disinfect reusable gown) and perform hand hygiene when moving from a COVID-19 positive room to a COVID-19 negative room because there was, the high potential for cross contamination of positive to negative which can lead to death. During an interview on 4/30/20 at 11:10 AM, Registered Nurse (RN) #1 Infection Preventionist (IP) stated staff should wear full PPE (gown, gloves, face mask, face shield) when entering the room of a COVID-19 positive person, remove PPE (discard disposable gown or disinfect reusable gown) when exiting the room, and perform hand hygiene. Staff should not move from COVID-19 positive room to COVID-19 negative rooms because, they could easily cross contaminate at that point. During a telephone interview on 4/30/20 at 12:04 PM, the Medical Director stated the outcomes of COVID-19 are unknown at this time. COVID-19 is very contagious and staff should be following the facility protocols that were put into place. The expectation is not to go from a COVID-19 positive room to a COVID-19 negative room without changing their gowns or disinfecting the reusable yellow suits, and they should be performing hand hygiene when removing their gloves. During an interview on 4/30/20 at 12:18 PM, the Administrator stated staff should be wearing a disposable gown or a reusable jump suit, gloves, N95 and a surgical mask and a face shield when going into a room where a resident has been diagnosed with [REDACTED]. The disposable gowns should be disposed of after exiting a COVID-19 positive room and cannot be disinfected. If they are wearing a reusable jump suit, it should be disinfected when coming out of a COVID-19 positive room and before entering a non COVID-19 positive room. Staff should wear the provided PPE and wash their hands after removing their gloves. During an interview on 4/30/20 at 12:39 PM, the Director of Housekeeping and Laundry stated, the housekeepers in a COVID-19 positive room should wear a face mask, face shield, gown, and gloves. The expectation is to perform hand hygiene between glove changes, and to not wear street clothes because they cannot be disinfected. COVID-19 is a highly infectious disease and moving from a COVID-19 positive room to a COVID-19 negative room could infect the other room. b.) During an observation on 4/30/20 at 7:53 AM revealed Housekeeper #2 was speaking to another staff member near the lobby elevators, within six feet of each other. Housekeeper #1's face mask was at their chin, exposing their mouth and nose. Housekeeper #1 stated she pulled the face mask down to talk to the other staff member. During an observation on 4/30/20 at 8:23 AM revealed the Assistant Director of Nursing (ADON) was walking in the main lobby hallway within six feet of others, entered the elevator with three surveyors and her face mask was below her nose and mouth. The ADON stated she was just in the Administrative area and should have covered her nose and mouth when she was within six feet of others. During an observation in the therapy clinic on 4/30/20 at 8:26 AM there were four employees sitting behind the clinic desk. Two employees, a Speech Therapist and a Physical Therapist (PT) were sitting side by side within two feet of each other. Neither were wearing a face mask or a face covering. During an interview at the time of the observation Speech Therapist #1 and PT #1 both stated they were educated to wear a face mask if they were within six feet of each other and should have had a mask on. During an observation on 4/30/20 at 8:47 AM, Dietary Aide #1 stepped off the elevator and into the elevator lobby of the Third Floor, there were two employees (maintenance worker and an environmental worker) in the area preparing to go on to the COVID-19 unit. Dietary Aide #1 came within two feet of them while handing the maintenance worker a resident's meal tray. Dietary Aide #1 was not wearing a face covering or a mask. During an interview at the time of the observation Dietary Aide #1 stated, he knew he was supposed to wear a mask and he forgot his mask in the kitchen. During an interview on 4/30/20 at 10:27 AM, the DON stated all staff should wear face mask if social distancing cannot be maintained. 415.19(b)(1)