Every finding on record at Caton Park Rehabilitation and Nursing Center, LLC

Based on record review and interview, the facility failed to ensure that a comprehensive person-centered care plans for each resident was developed and implemented, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. This was evident for one (1) resident (Resident #22) of five (5) residents reviewed for Accidents, one (1) resident (Resident #9) of two (2) residents reviewed for Respiratory Care, one (1) resident (Resident #101) of five (5) residents reviewed for Unnecessary Medications, and one (1) resident (Resident #6) of one (1) resident reviewed for Dental Care, and out of 27 total sampled residents. Specifically, care plans were not developed for Resident #22 to address use of a wander/elopement alarm, for Resident #9 who was receiving oxygen therapy, for Resident #101 to address care of a resident with a diagnosis of depression, or for Resident #6 who had no teeth.The findings included: The facility policy titled Comprehensive Care Planning with effective date 01/26/2023 and last review date 01/26/2025 documented the facility will establish an interdisciplinary team care planning process to ensure that resident care and treatment is planned appropriately for the resident's needs and condition, impairment, disability or disease process in a timely, systematic and comprehensive manner. It also documented the facility utilizes an interdisciplinary team to provide an individualized comprehensive resident assessment and care planning process in order to maximize and maintain every resident's functional potential and quality of life. The policy further stated all initial care plans must be completed by day fourteen (14) from admission. 1.Resident #22 had active diagnoses, which include Non-Alzheimer's Dementia, Coronary artery disease, and Cerebrovascular accident. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #22 had moderate cognitive impairment. The Quarterly Minimum Data Set assessment also documented Resident #22 was not in use of a wander/elopement alarm. On 05/03/2026 at 12:29 PM, Resident #22 was observed in bed, alert and awake. Resident #22 appeared confused and was observed with a wander guard device on their right wrist. The Elopement Risk Assessments dated 02/10/2026 and 04/30/2026 documented Resident #22 had a score of 3 and was considered at risk for elopement. The Physician Order's dated 06/14/2024 last revised on 04/16/2026 documented Wander Guard: check placement every shift (Location) Right Wrist, Wander guard check functioning daily by 11 PM -7 AM. The Medication Administration Records dated 04/01/2026 to 05/06/2026 documented observation of the wander guard device every night shift daily (11:00 PM -7:00 AM). There was no documented evidence that a comprehensive care plan was created to address wandering and use of a wander/elopement alarm. On 05/06/2026 at 2:05 PM an interview was conducted with Certified Nurse Assistant #3 who stated they have provided care for Resident #22 for about a year. Certified Nurse Assistant #3 also stated Resident is forgetful but is able to make their needs known to staff with minimal conversation. Certified Nurse Assistant #3 further stated Resident #22 walks around attempting to leave the units on several occasions but is easily redirected. Certified Nurse Assistant #3 concluded that they do not monitor the wander guard as the nurses do. On 05/06/2026 at 2:35 PM, an interview was conducted with Registered Nurse #2 who stated that the registered nurse on the unit is responsible for developing and updating care plans, creating a care plan for admission, readmission, quarterly, and episodic ones. Registered Nurse #2 also stated the Minimum Data Set assessors also help in the development of initial and quarterly care plans. Registered Nurse #2 further stated that the facility migrated from one electronic medical record to another, and they are still learning the new system. Registered Nurse #2 concluded that they have reviewed Resident #22's medical record and could not locate a care plan that addressed wandering and elopement or Resident #22's use of a wander guard device. On 05/08/2026 at 2:13 PM, an interview was conducted with the Director of Minimum Data Set who stated that they assist nurse managers in development of comprehensive care plan after completion of Minimum Data Set assessments. The Director of Minimum Data Set also stated that they are still in the process of the new electronic medical record. The Director of Minimum Data Set concluded that they are aware that a care plan that addressed wandering and elopement or use of a wander guard device were not developed for Resident #22, and they are looking into it. 2. Resident #9 had diagnoses that included Unspecified Dementia, Chronic systolic heart failure, and Shortness of breath. The Annual Minimum Data Set assessment dated [DATE] documented Resident #9 had severely impaired cognition and received oxygen therapy while residing in the facility. The Physician's Order dated 03/17/2026 documented that Resident #9 was to receive oxygen via nasal cannula at a rate of 2 liters per minute for shortness of breath. From 05/03/2026 at 9:38 AM to 05/06/2026 at 9:00 AM, Resident #9 was observed lying in bed and receiving oxygen via nasal cannula. The concentrator next to right side of bed was set to and delivering oxygen at a rate of 4 liters per minute. There was no documented evidence that a comprehensive care plan related to oxygen therapy was developed and implemented for Resident #9. On 05/06/2026 at 9:58 AM, Certified Nursing Assistant #1 was interviewed and stated Resident #9 was confused and always received oxygen. On 05/06/2026 at 11:11 AM, Registered Nurse #1 was interviewed and stated Resident #9 had an order to receive continuous oxygen at a rate of 2 liters per minute which began on 03/18/2026. Registered Nurse #1 also stated they were responsible for creating a care plan for residents on the floor. Registered Nurse #1 further stated a care plan related to oxygen use should be created when oxygen use was ordered. Registered Nurse #1 reviewed Resident #9's medical record and stated no comprehensive care plan related to oxygen use had been created. Registered Nurse #1 had no explanation why the care plan related to oxygen use was not developed for Resident #9. 3. Resident #101 had diagnoses of Major Depressive Disorder, Dementia, and Generalized Anxiety Disorder. The Annual Minimum Data Set assessment dated [DATE] documented Resident #101 had severely impaired cognition, had a diagnosis of Depression and was taking an antidepressant. The Physician's order started on 10/08/2025 and last renewed on 04/06/2026 documented Resident #101 was to receive Mirtazapine 15 mg 1 tablet by mouth at bedtime for depression. There was no documented evidence that a comprehensive care plan related to depression was developed and implemented for Resident #101. On 05/06/2026 at 10:58 AM, Registered Nurse #1 was interviewed and stated they were responsible for creating comprehensive care plans, and a resident taking an antidepressant medication should have a care plan for mood management or depression. Registered Nurse #1 reviewed Resident #101's medical record and was unable to find a care plan related to depression. Registered Nurse #1 stated the care plan related to depression should have been created when Resident #101 was ordered the antidepressant, and they could not explain why the care plan related to depression was not created. 4. Resident #6 had diagnoses that include Peripheral Vascular Disease, Diabetes Mellitus, Malnutrition, and Anxiety. The Significant Change Minimum Data Set assessment dated [DATE] documented Resident #6 had intact cognition, required substantial/maximal assistance for oral care and had no natural teeth or tooth fragment(s)(edentulous). The Dental consult dated 01/08/2026 documented that on the admission exam Resident #6 presented with an edentulous mouth (no teeth), no complaints and was functional. There was no documented evidence that a comprehensive care plan was created to address care for dental care for Resident #6. On 05/06/2026 at 9:53 AM, an interview was conducted with Registered Nurse #3 who stated they are also the Supervisor. Registered Nurse #3 also stated all supervisors on all shifts are responsible for initiating and updating care plans. Registered Nurse #3 further stated Resident #6 is diabetic, and they are aware Resident #6 had no teeth, and they were not sure why a dental care plan was not initiated. Registered Nurse #3 stated the facility changed from one electronic medical record to another and a number of the care plans did not migrate over. On 05/08/2026 at 2:04 PM, the Director of Nursing was interviewed and stated each care plan should be initiated by the Unit Nurse Supervisor or Registered Nurse, and the Minimum Dat Set department conducts the care planning meeting. The Director of Nursing also stated care plans are initiated on admission, and if an issue develops for a resident a care plan should be initiated, and every physician order required a care plan to address the medical concern. The Director of Nursing further stated they monitor the care plan process by discussing care plans after the morning meeting huddle. The Director of Nursing stated they periodically do spot checks in the systems, and they are not sure what happened here. 10 New York Code, Rules and Regulations 415.11(c)(1)

Based on observation, record review, and interviews, the facility failed to ensure sufficient nursing staff was provided to meet the residents' needs in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being, as determined by resident assessments and individual plans of care. Specifically, 1). Review of the actual staffing schedules dated from 10/01/25 to 12/31/25 revealed that staffing assignments were consistently less than the projected staffing needs specified in the Facility Assessment for Certified Nursing Assistants and Licensed Nursing Staff, and 2.) the facility Payroll Based Journal (Quarter 1 2026 (October 1 - December 31) also triggered for excessively low weekend staffing. The findings include:The Facility Assessment dated 02/20/2026 documented the facility had a bed capacity of 119 residents with an average daily census of 116. The Facility Assessment also documented that 1st floor total bed capacity is 38-39 residents, 2nd floor is 39 to 40 residents, and 3rd floor is also 39 to 40 residents. The Facility Assessment further documented that based on the resident population and their needs for care and support, the total number of required staff needed to appropriately meet the needs of the residents at any given time were 8 Registered Nurses, Licensed Practical Nurses, and 27 Certified Nursing Assistants on a daily basis.The Payroll Based Journal Staffing Data Report Quarter 1 2026 (October 1-December 31) documented that excessively low weekend staffing was triggered.A review of the actual staffing schedules from 10/01/2025 to 12/31/2025 revealed low Certified Nursing Assistants staffing especially on weekends. This included but was not limited to:On 10/04/2025 (Saturday), on the 7:00 AM to 3:00 PM shift, there were 3 Certified Nursing Assistants instead of the 4 scheduled on Unit 3.On 10/05/2025 (Sunday), on the 7:00 AM to 3:00 PM shift, there were 3 Certified Nursing Assistants instead of the 4 scheduled, and 1 Licensed Practical Nurse was scheduled, but no Licensed Practical Nurse worked on Unit 3.On 10/26/2025 (Sunday), on the 11:00 PM to 7:00 AM shift, there was 1 Certified Nursing Assistants instead of the 2 scheduled, and 1 Licensed Practical Nurse was scheduled, but no Licensed Practical Nurse worked on Unit 1.On 11/08/2025 (Saturday), on the 3:00 PM to 11:00 PM shift, there were 2 Certified Nursing Assistants instead of the 3 scheduled for Unit 2.On 11/15/2025 (Saturday), on the 11:00 PM to 7:00 AM shift, there was 1 Certified Nursing Assistants instead of the 2 scheduled on Units 1 and 3.On 11/22/2025 (Saturday), on the 11:00 PM to 7:00 AM shift, there was 1 Certified Nursing Assistants instead of the 2 scheduled on Unit 1.On 12/06/2025 (Saturday), on the 7:00 AM to 3:00 PM shift, there were 3 Certified Nursing Assistants instead of the 4 scheduled on Unit 3.On 12/06/2025 (Saturday), on the 11:00 PM to 7:00 AM shift, there was 1 Certified Nursing Assistants instead of the 2 scheduled on Unit 3.On 12/14/2025 (Sunday), on the 3:00 PM to 11:00 PM shift, there were 2 Certified Nursing Assistants instead of the 3 scheduled for Unit 2.On 12/27/2025 (Saturday), on the 7:00 AM to 3:00 PM shift, there were 3 Certified Nursing Assistants instead of the 4 scheduled on Unit 3.On 12/27/2025 (Saturday), on the 11:00 PM to 7:00 AM, shift there was 1 Certified Nursing Assistant instead of the 2 scheduled on Unit 1.On 12/28/2025 (Sunday), on the 3:00 PM to 11:00 PM shift, there were 3 Certified Nursing Assistants instead of the 4 scheduled on Unit 1, Unit 2, and Unit 3.On 05/04/2026 at 10:31 AM, an interview was conducted with Resident #98 who stated they need partial assistance with grooming, however, they observed other residents not getting help they need on time, as at times it took 15 to 30 minutes for call bells to be answered.On 05/04/2026 at 10:55 AM, an interview was conducted with Resident #64 who stated that they are partially dependent in grooming and toileting. Resident #64 also stated that there were times when they have one (1) to (2) two Certified Nursing Assistants in the evenings. Resident #64 further stated that they often heard other residents calling for help but could not say how long they waited before help reached them.On 05/05/2026 at 10:00 AM, an interview was conducted with Certified Nursing Assistant #4 who stated they work in the morning shifts, both days and weekends. Certified Nursing Assistant #4 also stated that Certified Nursing Assistants sometimes called out or run late. Certified Nursing Assistant #4 further stated the supervisor would try to call standby staff and sometimes they come, and sometimes they will be short staffed. Certified Nursing Assistant #4 concluded that this does not happen often, but when it does, they manage with the staff they have.On 05/08/2026 at 10:28 AM, an interview was conducted with Certified Nursing Assistant #8 who stated they work weekends and there were times when there were only one (1) to two (2) Certified Nursing Assistants working on Unit 2 during the day shift. Certified Nursing Assistant #8 also stated they try to manage, but there will be a delay in caring for residents when there is not enough staff.On 05/08/2026 at 11:45 AM, an interview was conducted with Licensed Practical Nurse #2 who stated they work five (5) days a week and the units are supposed to be staffed with four (4) Certified Nursing Assistants during the 7:00 AM to 3:00 PM shift. Licensed Practical Nurse #2 also stated they sometimes when they only have three (3) Certified Nursing Assistants working on the unit, they have to stop what they are doing to help the Certified Nursing Assistants.On 05/08/2026 at 12:00 PM, an interview was conducted with Registered Nurse #2 who stated residents had not been complaining to them about low staffing. Registered Nurse #2 also stated that there are times when they have less staff than scheduled and they have to help out. Registered Nurse #2 further stated that they have list of people to call if they need help, but they have not seen a situation they could not handle based on staffing.On 05/08/2026 at 12:30 PM, an interview was conducted with the Regional Staff Coordinator who stated that they have software that is linked with the time clock, and they export the time record from the software, and upload it for the Payroll Based Journal. The Regional Staff Coordinator stated that they would not be able to know if the facility has low staffing when the submit the Payroll Based Journal data.On 05/08/2026 at 1:30 PM, an interview was conducted with the Staff Coordinator who stated that they do have days when staff call out and they replace them right away and there are times we cannot replace them. The Staff Coordinator also stated that they create the schedule for the weekend, and the nursing supervisors are responsible for calling staff for replacement on the weekend. The Staff Coordinator further stated that they provide the nursing supervisors with a list of staff, and if they cannot find someone, they have to ask someone to stay over.On 05/08/2026 at 02:18 PM, an interview was conducted with the Director of Nursing who stated that the facility is well staffed. The Director of Nursing also stated that there might be sometimes when staff call out and they get them replaced as much as possible. The Director of Nursing concluded that the facility has not experienced a severe shortage of staff.On 05/08/2026 at 02:28 PM, the Administrator was interviewed and stated that the facility had not experienced shortage of staffing in recent times. The Administrator also stated that when staff call out, they try to get staff replaced as soon as possible. The Administrator further stated that they hire people from time to time and they rarely use outside agency because they have a quite a number of staff. 10 New York Code, Rules and Regulations 415.13(a)(1)(i-iii)

Number of residents sampled:Number of residents cited:Based on observation and interviews, the facility failed to ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident in two (2) medication rooms (Unit 2 and Unit 3) of three (3) medication rooms observed during the Medication Storage and Labeling task and the Central Supply room. Specifically, the medication rooms on Unit 2 and Unit 3, and the Central Supply room in the basement were observed to contain expired foley insertion trays.The findings are: The facility's policy titled Infection Control Program with last review date of [DATE] stated the facility will ensure that the Infection Prevention and Control Program is designed to prevent, identify, report, investigate, and control the spread of infections and communicable disease for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement; provide a safe, sanitary and comfortable environment; and to help prevent the development and transmission of disease and infection. The facility's policy titled Maintain Central Supply with last review date of [DATE] stated that Central Supply Clerk will check expiration dates to ensure medical supplies are being used in a rotating inventory according to the date of expiration. The policy also documented that any expired medical stock, equipment or supplies will be discarded according to manufacturers' instruction. On [DATE] at 10:54 AM, the medication room on Unit 2 observed with Licensed Practical Nurse #2. Two (2) out of seven (7) Foley Insertion Trays in the medication room were found with an expiration date of [DATE]. On [DATE] at 10:59 AM, Licensed Practical Nurse #2 was interviewed and stated they did not check the medical supplies in the medication room. Licensed Practical Nurse #2 also stated the expired supplies might have been delivered to the unit this morning by the Medical Record Staff #1. On [DATE] at 11:02 AM, Medical Record Staff #1 was interviewed and stated they had not yet delivered any supplies to the units this morning. On [DATE] at 11:07 AM, Registered Nurse #2 was interviewed and stated they did not check the expiration date of medical supplies in the medication room before using them. Registered Nurse #2 also stated three (3) residents had a foley catheter inserted in [DATE] at the hospital and had no foley catheter change done at the facility yet. On [DATE] at 11:16 AM, the medication room on Unit 3 was observed with Registered Nurse #3. Nine (9) Foley Insertion Trays were observed and two (2) foley insertion tray had expiration dates of [DATE] and one (1) had an expiration date of [DATE]. Registered Nurse #3 was immediately interviewed and stated the nurses on the unit should check the medical supplies at least once every shift to make sure the medical supplies were not expired. Registered Nurse #3 could not explain why the expired foley insertion trays were still stored in the medication room. Registered Nurse #3 stated there was one resident on the unit who returned from the hospital last month with an indwelling catheter and they had not had a catheter change yet at the facility. On [DATE] at 12:28 PM, the Director of Nursing was interviewed and stated they made rounds on the units two to three times each day. The Director of Nursing also stated they checked the environment, resident care, and medication rooms during the rounds. The Director of Nursing further stated they checked if the medications and medical supplies were expired and refrigerator temperature when checking the medication rooms. The Director of Nursing stated the medication nurse on every shift was responsible for checking the medications and medical supplies in the medication room to make sure they were not expired. The Director of Nursing also stated they just checked all three (3) medication rooms last night on [DATE] and did not find any expired supplies. The Director of Nursing further stated the expired foley insertion tray might be delivered to the unit by Medical Record Staff #1 this morning. The Director of Nursing had no explanation when they were informed the Medical Record Staff #1 interviewed earlier denied having delivered anything to the unit today. The Director of Nursing stated that the expired supplies were a concern for infection as the medical supplies were not considered sterile to use anymore. On [DATE] at 12:59 PM, an observation of the Central Supply room was made with the Director of Nursing and the Administrator. Two (2) cases containing 20 foley insertion trays were observed in the room. In one (1) case, all 20 foley insertion trays had an expiration date of [DATE]. The Director of Nursing stated the Medical Record Staff #1 was responsible for checking the expiration dates of medical supplies in the room and should discard them if they were expired. On [DATE] at 1:18 PM, Medical Record Staff #1 was interviewed again and stated their primary duties included managing medical records and purchasing supplies. Medical Record Staff #1 also stated they delivered supplies to the units every Monday and Friday and as needed. Medical Record Staff #1 further stated they had a lot of work to do, and it was hard for them to maintain and check to see if the medical supplies in the room were expired or not. Medical Record Staff #1 stated they should discard the expired medical supplies and not deliver expired medical supplies to the units. Medical Record Staff #1 stated they did not recall if they delivered the expired foley insertion trays to Unit 2 and Unit 3. On [DATE] at 8:58 AM, the Administrator was interviewed and stated that the Medical Record Staff #1 was responsible for making sure the medical supplies in the Medical Supplies room were not expired. The Administrator also stated the Medical Record Staff #1 should go through everything in the Medical Supplies room and remove the expired supplies regularly. The Administrator further stated they were not sure how often the Medical Record Staff checked the inventory in the medical supplies room. On [DATE] at 12:02 PM, the Assistant Director of Nursing was interviewed and stated they were the Infection Preventionist for the facility. The Assistant Director of Nursing also stated the unit supervisors were responsible for checking the medical supplies in the medication room once every shift and discarding the expired supplies. The Assistant Director of Nursing further stated there was no log to record the time and date the medication room was checked. The Assistant Director of Nursing stated the expired supplies were a concern for infection prevention as they were no longer sterile for use. 10 New York Codes, Rules and Regulations 415.19 (a)(1-3), (b)(4)

Based on observation, record review and interviews, the facility to ensure that the resident was free from chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms. This was evident for one (1) resident (Resident #105) of five (5) residents reviewed for Unnecessary Medications, out of 27 total sampled residents. Specifically, there was no adequate clinical indication documented in the clinical record to support the ongoing use of Aripiprazole 15 MG daily, no documentation of monitoring of behavioral symptoms, and no documented evidence that a gradual dose reduction had been attempted for Resident #105 since 09/20/2024. The findings include:The facility policy titled Psychotropic Drug Use dated 03/06/2025 stated it is the policy of the facility to utilize psychotropic drugs appropriately. The policy also stated that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. The policy further stated that the facility would utilize non-pharmacological methods for residents prior to the use of psychotropic drugs, and a gradual dose reduction will be attempted Resident #105 had diagnoses which include Dementia, Traumatic brain injury, Anxiety disorder, and Schizophrenia. The Annual Minimum Data Set assessment dated [DATE] documented Resident #105 had severely impaired cognition, was dependent on staff for Activities of Daily Living.On 05/03/2026 at 12:24 PM, Resident #105 was observed in bed, alert and awake. Resident #105 appeared confused, was unable to make appropriate conversation when asked about their name and did not talk or move any part of their body. On 05/04/2026 at 12:52 PM, Resident #105 was observed in bed with no eye contact when called by their name. Resident #105 appeared confused and could not communicate when called by their name. Review of physician orders revealed Aripiprazole 15 Milligrams, 1 tablet by mouth one time a day for diagnosis of schizophrenia was started on 09/20/2024 and the order was last renewed on 05/01/2026, Clonazepam 1 Milligram, 1 tablet by mouth daily for Anxiety was started on 12/30/2024, last renewed on 05/01/2026. Psychiatry notes dated 03/20/2026 and 12/21/2025 documented that Resident #105's chart was reviewed, discussed with staff, Resident #105 had a history of schizophrenia and traumatic brain injury, well managed with antipsychotic medications. Alert in bed, anxious, screams and yells on and off. The Psychiatry notes also documented Resident #105 was paranoid, delusional, responded to hallucinations, was disoriented to time and place with poor judgement. Continue Aripiprazole 15 milligram orally daily. Gradual Dose Reduction is not recommended currently.No additional psychiatric notes for 2024 or 2025 were provided to the State Surveyor. There was no documented evidence in Resident #105's medical record of behavioral symptoms they exhibited that would support ongoing use of antipsychotic medication at the current dosage.There was no documented evidence that a gradual dose reduction had been attempted for Resident #105.On 05/07/2026 at 11:33 AM, an interview was conducted with Certified Nursing Assistant #3 who has provided care for Resident #105 on and off for over two (2) years. Certified Nursing Assistant #3 stated Resident #105 is confused, cannot call for help and cannot make needs known to staff. Certified Nursing Assistant #3 also stated Resident #105 is totally dependent with care, is transferred via Hoyer lift and uses a Geri chair. Certified Nursing Assistant #3 also stated Resident #105 does not have behavioral problems other than screaming occasionally.On 05/07/2026 at 11:55 AM, an interview was conducted with Registered Nurse #2 who has worked on the unit for the past year and stated Resident #105 is confused and rarely talks, only screams at times. Registered Nurse #2 also stated that they do not document behavioral notes unless there is a behavior reported by staff or witnessed by the nurses. Registered Nurse #2 concluded that they have reviewed medical records and could not find behavioral concerns documented anywhere. On 05/08/2026 at 10:12 AM, an interview was conducted with the Assistant Director of Nursing who stated that residents on psychotropic medications received gradual dose reduction based on the recommendation of the psychiatrist. The Assistant Director of Nursing also stated no behavioral notes were documented in the medical record unless resident exhibits such behavior, and then staff will document. The Assistant Director of Nursing stated that they will review Resident #105's, however they did not provide any additional documents to the State Surveyor. On 05/08/2026 at 11:18 AM, an interview was conducted with the Psychiatrist who stated that they see residents based on certain referrals from the facility. The Psychiatrist also stated that some residents are seen every three months for follow-up, and some are seen as needed. The Psychiatrist further stated they have been following Resident #105 for a few years, and Resident #105 is confused with psychotic features, is paranoid, delusional, psychotic and hears things that are not real. The Psychiatrist stated they obtained information about Resident #105 through direct conversations with staff members and chart review. The Psychiatrist also stated that they do not believe that the current psychotropic medications are too much for the resident, and they do not do gradual dose reductions with residents who have a psychiatry history. On 05/08/2026 at 2:15 PM, an interview was conducted with the Medical Director who stated that they do not interfere with psychiatrist evaluation of residents, and that whatever they recommend, the facility will carry out. The Medical Director also stated that any issues related to psychiatry are left up to the psychiatrist. The Medical Director also stated that they spoke with the psychiatrist about Resident #105, and the psychiatrist informed them that Resident #105 did have any side effects from the medications, and because of the resident's age, and the resident being stable on the current medications, there was no need to do a gradual dose reduction for them. 10 New York Code, Rules and Regulations 415.4(a)(1) and 415.3(d)(1)(vii)

Number of residents sampled: 5Number of residents cited: 1 Based on record reviews and staff interviews, the facility failed to ensure assessments accurately reflect the resident's status. This was evident for one (1) resident (Resident #22) out of five (5) residents reviewed for Accidents out of 27 sampled residents. Specifically, the Minimum Data Set assessment for Resident #22 did not capture the use of a wander/elopement alarm. The finding includes: Resident #22 had active diagnoses which include Non-Alzheimer's Dementia, Coronary artery disease, and Cerebrovascular accident. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #22 had moderate cognitive impairment and did not document use of wander/elopement alarm. On 05/03/2026 at 12:29 PM, Resident #22 was observed in bed, alert and awake. Resident #22 appeared confused and was observed with a wander guard device on their right wrist.The Elopement Risk Assessments dated 02/10/2026 and 04/30/2026 documented Resident #22 had a score of 3 and was considered at risk for elopement.The Physician Order's dated 06/14/2024 last revised on 04/16/2026 documented Wander Guard: check placement every shift (Location) Right Wrist, Wander guard check functioning daily by 11:00 PM -7:00 AM.The Medication Administration Records dated 04/01/2026 to 05/06/2026 documented observation of the wander guard device every night shift daily (11:00 PM -7:00 AM).On 05/06/2026 at 10:30 AM, an interview was conducted with the Minimum Data Set Coordinator who stated they did not complete the Minimum Data Set, however, they are responsible for overseeing the Minimum Data Set assessments for accuracy. The Minimum Data Set Coordinator also stated the assessors perform physical assessment and review records and interviewing staff when completing assessments. The Minimum Data Set Coordinator further stated that they should not solely rely on medical records, and they have to see the residents. The Minimum Data Set Coordinator stated the wander guard was not coded on the assessment, and they concluded it was an oversight. 10 New York Code, Rules and Regulations 415.11(b)

Number of residents sampled: 1Number of residents cited: 1Based on record review and staff interviews, the facility failed to ensure that the baseline care plan was completed within 48 hours of a resident's admission. This was evident for one (1) resident (Resident #119) of one (1) resident reviewed for Discharge out of 27 sampled residents. Specifically, the baseline care plan for Resident #119 was not completed within 48 hours of admission.The findings are:The facility policy titled Comprehensive Person-Centered Care Plan/Baseline Care Plan/Plan of Care Summary effective 01/15/2017 and last reviewed on 07/02/2025 documented a baseline care plan is developed and implemented within 48 hours of a resident's admission. Resident #119 was admitted to the facility on [DATE] with diagnoses that included Wound Infection, Peripheral Vascular Disease, and Arthritis. The admission Minimum Data Set, dated [DATE] documented Resident #119 was admitted from a short-term general hospital on [DATE], was cognitively intact, and both Resident #119 and their representative participated in the assessment. The document titled Baseline Care Plan -V2 was created on 02/10/2026. Section 1 General Information and Initial Goals, Section 2 Functional Status, Section 3 Health Conditions, and Section 5 for BCP (Baseline Care Plan) Summary and Signatures were signed on 02/10/2026. Section 4, which included Dietary, Therapy, and Social Services section was not signed off. There was no lock date for the baseline care plan.On 05/06/2026 at 12:49 PM, the Minimum Data Set Coordinator was interviewed and stated they were responsible for overseeing the completion of the baseline care plans. The Minimum Data Set Coordinator also stated they check the electronic medical record daily and notify the department heads if their disciplinary sections were not completed on the baseline care plan. The Minimum Data Set Coordinator further stated they were informed by their corporation that they had three (3) days or 72 hours to complete the baseline care plan. The Minimum Data Set Coordinator reviewed the Dietary, Therapy and Social Services section of the baseline care plan for Resident #119, and stated the section was completed and not signed off. The Minimum Data Set Coordinator stated they could not tell which discipline completed the section late, and the last discipline to complete the section is responsible for signing it off as the baseline care plan was not complete until all sections were signed off. The Minimum Data Set Coordinator also stated they could not tell why the section was completed late and not signed off. The Minimum Data Set Coordinator had no explanation as to why they did not find the outstanding baseline care plan during their daily monitoring of the completion of baseline care plans. On 05/06/2026 at 2:30 PM, the Director of Nursing was interviewed and stated they did not recall the timeframe to complete the baseline care plan. The Director of Nursing also stated the baseline care plan was not considered as complete until all sections were signed off. 10 New York Code, Rules and Regulations 415.11(c)

Number of residents sampled:2Number of residents cited:1 Based on record review and interview, the facility failed to ensure that a resident's comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This was evident for one (1) resident (Resident #70) of two (2) residents reviewed for Activities of Daily Living out of 27 sampled residents. Specifically, the comprehensive care plan related to Activities of Daily Living for Resident #70 was not reviewed and revised after each assessment.The findings are:The facility policy titled Comprehensive Care Plan last reviewed 01/26/2026 documented the care plan is revised when appropriate to reflect the resident current needs based on evaluation and episodic changes to include but not limited to progress towards goals, response to care and treatment. Resident #70 had diagnoses that included Alzheimer's Dementia, Heart Disease, and Peripheral Vascular Disease. The Quarterly Minimum Data Set assessments dated 12/02/2025 and 2/26/2026 documented Resident #70 had intact cognition and required supervision for all activities of daily living. The Certified Nursing Assistant Task List Report dated 05/01/2026 documented Resident #70 and received showers twice a week as scheduled and at times four (4) times weekly. The care plan titled Activities of Daily Living dated created 05/18/2025 and last reviewed 10/07/2025 had interventions which included Bathing/Showering with no specific days noted in care plan, and the resident requires assistance from staff with bathing and showering as necessary. The care plan did not document what specific assistance was needed, or the number of staff needed to help with Resident #70's showers.There was no documented evidence that the Activity of Daily Living care plan had been reviewed or revised after the completion of Minimum Data Set assessments on 12/02/2025 and 02/26/2026. On 05/08/2026 at 11:06 AM, Registered Nurse #3 was interviewed and stated all nurses are responsible for initiating and updating care plans. Registered Nurse #3 also stated that they were not sure why the care plan was not updated and that the facility began using a different electronic medical record in May 2025. Registered Nurse #3 further stated when the transition occurred, not all the care plans were transferred which caused a mix up, and the facility is still working to add care plans and or update care plans as needed. On 05/08/2026 at 1:59 PM, the Director of Nursing was interviewed and stated the transition from one electronic medical record to another was a process, and staff are still learning the system and learning how to how to update care plans. The Director of nursing stated they monitor the care plan process by reviewing issues in morning meetings and doing audits as needed. 10 New York Code, Rules and Regulations 415.11(c)(2)(i-iii)

Number of residents sampled: 27Number of residents cited: 1Based on observation, record review, and interviews, the facility failed to ensure that an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident was provided. This was evident for one (1) resident (Resident #63) of three (3) residents reviewed for Activities out of 27 total sampled residents. Specifically, Resident #63 was not provided with activities in their preferred language. The findings include:The facility policy titled Therapeutic Recreation effective 11/2018 and last reviewed 11/24/2025 stated the facility will strive to provide each resident with individual meaningful activities to promote engagement and enhance quality of life. The policy also stated that the interdisciplinary team would ensure residents are provided with recreational activities appropriate and meaningful based on their comprehensive assessment. Resident # 63 had diagnoses which included Stroke, Seizure, and Depression.The Annual Minimum Data Set assessment dated [DATE] documented Resident #63's preferred language was Cantonese and needed an interpreter to communicate with health care staff. The Annual Minimum Data Set assessment also documented Resident #63 had moderately impaired cognition, and it was very important for Resident #63 to have books/newspaper/magazines to read, listen to music, and do favorite activities. The Annual Minimum Data Set assessment further documented that both Resident #63 and their representative participated in the assessment. On 05/03/2026 at 09:56 AM, Resident #63 was interviewed and stated they spoke Fuzhounese and Mandarin (languages spoken in China) and they liked to have activities offered in their languages. Resident #63 also stated staff had not asked them about their activity preferences. Resident #63 further stated the facility did not have activities in their preferred language, and they could only use their smart phone to pass the idle time at the facility. On 05/03/2026 at 11:13 AM, the Resident Representative for Resident #63 was interviewed and stated Resident #63 had been at the facility for five (5) years, and no staff asked them about the activity preference for Resident #63. The Resident Representative also stated Resident #63 did not understand English and like to engage in activities like watching television, listening to music, and keeping up with news in their preferred language when at home. The Resident Representative further stated the facility had no activities to offer in the preferred language for Resident #63. From 05/03/2026 at 09:56 AM to 05/08/2026 at 9:35 AM, there were multiple observations of Resident #63 sitting in a wheelchair in their room and main dining room and there were no recreational activities provided to them in their preferred language. The Comprehensive Care Plan titled Activities initiated 05/16/2025 and last updated 03/13/2026 documented interventions which included to assist Resident #63 with independent leisure activities, provide leisure/community resources and use Mandarin translator. The Activities Quarterly assessment dated [DATE] documented Resident #63's spoken language was Mandarin, and their favorite activities included television and movies. The undated facility Television Channels documented the facility offered regular television channels (2-25). Channels 11 and 12 were Spanish language and the rest were English language channels.There was no documented evidence that Resident #63's was provided with their preferred activities in a language they understand. On 05/06/2026 at 9:48 AM, Certified Nursing Assistant #1 was interviewed and stated Resident #63 was alert and oriented and did not refuse care. Certified Nursing Assistant #1 also stated that Resident #63 did not watch television and had no activities provided to them in their room. Certified Nursing Assistant #1 further stated Resident #63 stayed in their room most of time with their own smartphone and had family visits. On 05/06/2026 at 12:04 PM, Recreation Aide #1 was interviewed and stated they conducted the activity assessment for Resident #63 by calling their representative. Recreation Aide #1 also stated Resident #63 spoke Mandarin, and their preferred activity was to watch television. Recreation Aide #1 further stated they had been working at the facility for about one year and interviewed Resident #63's relative about recreational activities for Resident #63 but did not actually ask Resident #63 about their preferred activities. Recreation Aide #1 stated the television channels provided by the facility were in English and Spanish, and Resident #63 did not understand English and Spanish. Recreation Aide #1 had no explanation as to how the facility met the activity preferences of Resident #63 in their preferred language. On 05/07/2026 at 9:19 AM, the Director of Therapeutic Recreation was interviewed and stated the facility provided 23 English and 2 Spanish language television channels. The Director of Therapeutic Recreation also stated Resident #63 did not request to watch television channels in their preferred language, and they did not know if their staff asked Resident #63 about their preferred language for television and other activities. The Director of Therapeutic Recreation further stated Resident #63 was often watching videos on their smartphone. The Director of Therapeutic Recreation did not provide an explanation on how the facility was providing Resident #63 activities in their preferred language. The Director of Therapeutic Recreation stated the facility had some smart televisions which were connected to the internet, and it would be possible to watch television channels in different languages on them. The Director of Therapeutic Recreation also stated the facility did not provide a smart television to Resident #63. 10 New York Codes, Rules and Regulations 415.5(f)(1)

Number of residents sampled: 2Number of residents cited: 1Based on observation, record review, and interviews, the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice. This was evident for one (1) resident (Resident #9) of two (2) residents reviewed for Respiratory Care out of 27 sampled residents. Specifically, Resident #9 was observed using oxygen via a nasal cannula at a rate of 4 liters per minute when the Physician's order was written for oxygen to be received at a rate of 2 liters per minute.The findings are:The facility's policy titled Oxygen Therapy last reviewed 09/30/2025 stated residents will be provided with oxygen therapy as ordered by the Medical Doctor. The policy also stated that the delivery of supplemental oxygen will be provided in a safe manner, and the nurse will check the liter flow on the tank and the concentrator. Resident #9 had diagnoses that included Unspecified Dementia, Chronic systolic heart failure, and Shortness of breath. The Annual Minimum Data Set assessment dated [DATE] documented Resident #9 had severely impaired cognition and received oxygen therapy while residing in the facility. The Physician's Order dated 03/17/2026 documented that Resident #9 was to receive oxygen via nasal cannula at a rate of 2 liters per minute for shortness of breath. From 05/03/2026 at 9:38 AM to 05/06/2026 at 9:00 AM, Resident #9 was observed lying in bed and receiving oxygen via nasal cannula. The concentrator next to right side of bed was set to and delivering oxygen at a rate of 4 liters per minute. On 05/06/2026 at 9:58 AM, Certified Nursing Assistant #1 was interviewed and stated Resident #9 was confused and always on oxygen. Certified Nursing Assistant #1 also stated they did not check the concentrator for oxygen flow rate. On 05/06/2026 at 10:49 AM, Licensed Practical Nurse #1 was interviewed and stated they always checked the concentrator to make sure the oxygen flow rate was correct before administering medications to Resident #9. Licensed Practical Nurse #1 also stated the oxygen order was 2 liters per minute for Resident #9. Licensed Practical Nurse #1 had no explanation why the oxygen flow rate was observed at 4 liter per minute since 05/03/2026. On 05/06/2026 at 11:11 AM, Registered Nurse #1 was interviewed and stated Resident #9 had an order to receive continuous oxygen at a rate of 2 liters per minute starting on 03/18/2026. Registered Nurse #1 also stated that the medication nurse was responsible for ensuring that the oxygen was running at the ordered rate at the start of their shift. Registered Nurse #1 could not provide an explanation for why Resident #9's oxygen was running at an incorrect rate during observations made from 05/03/2026 and 05/06/2026. On 05/06/2026 at 2:35 PM, the Director of Nursing was interviewed and stated that for a resident on continuous oxygen, the oxygen rate should be verified at least once a shift to ensure it was running at the ordered rate. The Director of Nursing also stated it was the responsibility of the unit nurse supervisor to check at least one (1) time every shift. 10 New York Codes, Rules and Regulations 415.12(k)(6)

Based on interviews and record review conducted during an abbreviated survey (2578058) on 11/10/2025, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours to State Survey Agency after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. This was evident for one (1) out of one (1) resident (Resident # 1) reviewed for Accidents. Specifically, on 07/28/2025, Resident #1 fell from the bed to the floor during care and the facility did not report Resident #1 was found with a laceration of the head, fracture of the third metacarpal bone at right hand, and a fracture of the middle phalanx of the left hand to the New York State Department of Health until 07/31/2025.The facility policy titled 'Abuse Prevention' with effective date 09/19/2022 and last reviewed 12/29/2023 documented the facility staff must report alleged violations related to mistreatment, exploitation, neglect, or abuse, including injuries of unknow source and misappropriation of resident property immediately to the Administrator and/or Director of Nursing, who in turn must make a report to New York State Department of Health immediately, but not later than 2 hours after making aware of the alleged allegations. Resident #1 was admitted to the facility with diagnoses which included Osteoarthritis of hip, Fracture of third metacarpal bone at right hand, and Fracture of middle phalanx of left middle finger.The Quarterly Minimum Data Set (an assessment tool) documented Resident #1 required supervision or touching assistance to roll left and right in bed, and they had one (1) fall with no major injury since admission or prior assessment. The webform submission for Nursing Home Facility Incident Report documented the facility submitted the incident report on 07/31/2025 at 4:13 PM by the Director of Nursing. The submission also documented the incident happened on 07/28/2025 at 09:53 AM, and the Administrator was first made aware of the incident on 07/28/2025 at 10:00 AM. The medical note dated 07/28/2025 documented Resident #1 stated they fell off the bed after trying to change position in bed during care provided by Certified Nursing Assistant #1. The medical note also documented Resident #1 complained of severe pain to head, shoulders, and arms, and 911 was called to transfer Resident #1 to the hospital for evaluation.The hospital emergency department discharge instructions dated 07/28/2025 documented Resident #1 was diagnosed fracture of phalanx (long bone) of digit of hand, fracture of metacarpal (bone in palm of the hand), and laceration of head. The nursing note dated 07/28/2025 at 9:06 PM documented Resident #1 returned to the facility at 9:00 PM from the hospital with the findings included right wrist spiral fracture of the third metacarpal and mildly displaced fracture to the shaft of the fourth middle phalanx. On 11/10/2025 at 01:13 PM, the Director of Nursing was interviewed and stated they were notified Resident #1 fell from bed to floor during care by the nurse supervisor immediately after the incident occurred. The Director of Nursing also stated they were notified by the nurse supervisor that Resident #1 was diagnosed with multiple fractures after returning to the facility from the emergency department. The Director of Nursing further stated the Assistant of Director of Nursing, Administrator, and themselves had access to Health Commerce System to file report to Department of Health, and they should report to the Department of Health within two (2) hours of awareness if there was an allegation of abuse, neglect, exploitation or mistreatment, and if the events that caused the allegation resulted in serious bodily injury. The Director of Nursing stated they are primarily the staff responsible to report to the Department of Health and conduct the incident investigation, and while a fracture was considered as a serious bodily injury, they wanted to gather more detail before reporting to Department of Health for the incident and inadvertently missed the two (2) hours requirement for reporting. 10 NYCRR 415.4(f)(1-4)

Based on record review and staff interviews conducted during the Recertification survey from 08/12/2024 to 08/16/2024, the facility did not ensure that resident's Comprehensive Care Plans were reviewed and revised for 1 (Resident #15) of 7 residents reviewed for Accident out of 26 sampled residents. Specifically, Resident #15 had a multiple history of falls, and the fall care plan was not reviewed and revised after the most recent Minimum Data Set assessment. The finding is: The facility policy and procedure titled Comprehensive Care Plan dated 1/26/23 states that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs are developed for each resident. The policy also stated that the Care Planning Interdisciplinary team is responsible for reviewing and updating the care plan during admission, every quarterly, annual or readmission. Resident #15 was admitted to the facility with diagnosis of Depression, Parkinson's Disease, and Non-Alzheimer's Dementia. The Minimum Data Set assessment dated [DATE] documented that Resident #15 had intact cognition and required assistance with supervision when performing Activity of Daily Living. The Nursing note dated 02/05/24 documented that Registered Nurse #1 was called to assess resident on the floor. Upon arrival to the resident's room, Resident #15 stated that they fell on their buttocks lying on their side to get up from floor to their bed. Resident #15 was alert and verbally responsive. Call bell was within reach but Resident #15 did not use call bell for help. A full body assessment was done. No visible injury noted, no change in level of consciousness. The Nursing note dated 02/09/24 documented that Registered Nurse #1 was called by staff this morning to assess resident on the floor. On arrival Resident #15 was observed sitting on the floor. Resident was alert and verbally responsive. Call bell within reach but Resident #15 did not use call bell for help. A Full body assessment was done, and redness was noted on the forehead. Resident #15 reported hitting their head and reported pain as 4 on a scale 1 to 10. The Quarterly Fall Risk Assessment and Safety Measures dated 7/2/2024 documented that Resident #15 is confused, restless and on laxatives, antihypertensives, and psychoactive medications and had unsteady gait. The Comprehensive Care Plan titled Fall Prevention created 12/16/2023 documented that Resident #15 was at risk for falls due to Psychotropic medication, Parkinson Disease, Dementia and Hypertension. The goal was that Resident #15 would be free of falls. Interventions included ensure call bell is within reach, provide any assistive devices within reach of the resident, Rehab referral, and ensure resident has safe and proper footwear. There was no documented evidence that the Comprehensive Care Plan for Fall Prevention was reviewed and revised after 3/13/2024. The care plan for Fall Prevention was also not revised after the most recent Minimum Data Set assessment dated [DATE]. On 08/16/24 at 10:31 AM, an interview was conducted with Registered Nurse #1 who is also the Unit Manager who stated that Resident #15 was at high risk for falls. Resident #15 was doing well now with ambulation as currently they have steady gait and appeared improved lately. Registered Nurse #1 also stated that the care plans are supposed to be updated every quarter, annually or if there is a significant change and Registered Nurse #1 is responsible for ensuring this is done. Registered Nurse #1 further stated that despite Resident #15's improvement in ambulation, they should have done a revision back in July, but they missed it. On 08/16/24 at 01:43 PM, an interview was conducted with the Director of Nursing who stated that the Unit Nurse managers are responsible to ensure care plans are updated accordingly. The Director of Nursing also stated that the Minimum Data Set staff are responsible for admission and readmission care plans. The Director of Nursing further stated that if a resident had a history of falls, and a quarterly Minimum Data Set was done recently, they should have updated the fall care plan. NYCRR 415.11(c)(2)(i-iii)

Based on staff interview and record review conducted during the Recertification Survey from 08/12/2024 to 08/16/2024, the facility did not ensure a resident received assistance devices consistent with a resident's needs, goals, and care plan to prevent accidents. This was evident for 1 (Resident #75) 7 residents reviewed for Accidents out of 26 total sampled residents. Specifically, floor mats were not in place for Resident #75 as per Physician Order. The findings include: The facility policy titled Fall Prevention with an effective date of 02/2022 and revised 2/2024 states that the interdisciplinary team will take effort to provide the resident with multiple falls a protective environment to mitigate the chance of serious injury. This includes but is not limited to furniture padding, floor mats, protective padding on head or foot of bed, and furniture re-arrangement in room. Resident #75 was admitted to the facility with diagnoses that included Depression, Diabetes Mellitus, and Contracture of Right Upper Arm. The Quarterly Minimum Data Set, dated dated dated [DATE] documented Resident #75 had severely impaired cognition, impairment on both upper and lower extremities, was dependent on staff for all Activities of Daily Living and was always incontinent of bowel and bladder. The Physician order dated 06/20/2024 and renewed 07/08/2024 documented Adaptive/Assistive Device: Floor mats on both sides all time while in bed. The Comprehensive Care Plan with focus Fall or Injury Potential dated 3/21/2022 and revised on 05/14/2024 states resident is at risk for falls and injury due to conditions such as Cerebrovascular Accident, Hemiplegia, neurological impairment, poor safety awareness, incontinence/urgency, impaired vision. The goal was that Resident #75 will have no falls related to unsafe environment factors and interventions included bed in lowest position and bilateral floor mats doubled on each side of bed. On 08/13/24 at 09:36 AM, 08/13/24 at 09:55 AM, and 08/14/24 at 09:54 AM, Resident #75 was observed resting in bed with no floor mats on either side of bed. On 08/15/24 at 02:26 PM, Certified Nursing Assistant #2 was interviewed and stated that they administer morning care for Resident #75 while Resident #75 is lying in bed and do not recall ever putting mats on the floor or seeing mats on the floor. Certified Nursing Assistant #2 also stated that they do not recall if there are standing orders for floor mats. Certified Nursing Assistant #2 reviewed the Electronic Medical Record and stated that they were able to see the order for the floor mats but overlooked it and did not pay attention and lay out the floor mats for Resident #75. Certified Nursing Assistant #2 further stated that they were is unsure if resident is a fall risk. On 08/15/24 at 09:47 AM, Licensed Practical Nurse #4 was interviewed and stated that Resident #75 has a history of falls in the past but has not had any falls recently. Licensed Practical Nurse #4 also stated that Resident #75 is still a fall risk, and it is the responsibility of the nurse and the Certified Nursing Assistants to make sure that floor mats are on either side of the bed. Licensed Practical Nurse #4 further stated that Resident #75's roommate is ambulatory and sometimes they move the floor mats from the side of the bed, however, there should be frequent checks to ensure floor mats are always in place. Licensed Practical Nurse #4 stated that Resident #75 can have serious injury if they fall from the bed without floor mats in place. On 08/16/24 at 09:28 AM, the Physician was interviewed via telephone and stated Resident #75 has a history of stroke, falls, and acute left hemiplegia. Floor mats were ordered on 06/20/2024 to avoid any injury to resident if Resident #75 falls or rolls out of bed as Resident #75 is a fall risk. The Physician also stated that Resident #75 can sustain an injury if they have a fall. On 08/16/24 at 11:53 AM, the Director of Nursing Services was interviewed and stated that Resident #75 has an order to have floor mats on both sides of the bed as Resident #75 is a fall risk and has a history of falls. Resident #75 has history of confusion, is elderly and is at risk for falls and serious injury. The Director of Nursing Services also stated they are unsure how the order for floor mats were missed by multiple staff. 10 NYCRR 415.12(h)(1)

Based on observation, record review, and interviews conducted during the Recertification survey from 08/12/2024 to 08/16/2024, the facility did not ensure that infection control prevention practices and procedures were maintained. This was evident for 1 resident (Resident #87) observed during the Medication Administration task. Specifically, Enhanced Barrier Precautions were not maintained for gastrostomy tube medication administrations for Resident #87. The findings are: The facility policy titled Enhanced Barrier Precautions, last reviewed 3/28/24, documented that Enhanced Barrier Precautions refers to an infection control intervention designed to reduce transmission of multidrug resistant organisms that employs targeted use of gown and glove use during high contact resident care activities. The policy also stated that all residents with indwelling medical devices and chronic wounds will have Enhanced Barrier Precautions used by staff during high contact resident care activities. Examples include device care or use as central line and feeding tube. Resident #87 was admitted with diagnoses that include Dysphagia following unspecified Cerebrovascular disease. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident's #87 cognition as intact, with a Brief Mental Status of 12, and has a feeding tube while a resident. The Physician's Order dated 8/12/24 documented Plavix 75mg tablet by feeding tube once daily and LPS Supplement 30ml twice a day via feeding tube. On 08/14/2024 at 09:25 AM, Licensed Practical Nurse #2 was observed entering Resident #87's room to administer medication to Resident #87 via gastrostomy tube. There was signage at the side of the door indicating Enhanced Barrier Precautions. Licensed Practical Nurse #2 checked for patency, administered the medications via gastrostomy tube, and flushed the gastrostomy tube. Licensed Practical Nurse #2 did not don a gown prior to administering medication to Resident #2 via their gastrostomy tube. On 08/14/2024 at 09:30AM, immediately after the medication administration, Licensed Practical Nurse #2 was interviewed and stated that they needed to don the Personal Protective Equipment because of the open orifice with the gastrostomy tube, but they forgot to wear it. On 08/14/24 at 09:45 AM, Registered Nurse #2 was interviewed and said that all the staff were in-serviced on enhanced barrier precautions, and when to use the personal protective equipment. Registered Nurse #2 said that in reference to administering medications via the gastrostomy tube, they were not told to do anything different but to wear gloves. Registered Nurse #2 also stated that Enhanced Barrier Precautions is specific for providing care, bathing, dressing, and during a wound dressing change. On 08/15/24 at 03:25 PM, the Infection Control Preventionist was interviewed and stated that they do in-services on the units. All staff including Licensed Nurses were in-serviced on Enhanced Barrier Precautions, specific to residents who have chronic wounds, and residents with gastrostomy tube and Foley Catheters. The Licensed Nurses are supposed to use Personal Protective Equipment. As soon as the resident is identified, signage is placed in the doorway, and an order is placed in the electronic medical records. The Infection Control Preventionist said that during rounding, they do observations on the units, to monitor that the staff is utilizing the Personal Protective Equipment for residents on Enhanced Barrier Precautions. On 08/16/24 at 3:00PM, the Director of Nursing was interviewed and stated that they have been employed at the facility just over a month and is not knowledgeable about the use of Enhanced Barrier Precautions, however, the Infection Control Preventionist and the Corporate Nurses are involved. 10 NYCRR 415.19(b)(4)

Based on Record reviews and interviews during the Recertification survey from 08/12/2024 to 08/16/2024, the facility did not ensure that all completed resident assessments were submitted and transmitted into the Quality Improvement Evaluation Assessment Submission and Processing in a timely manner. Specifically, 4 (Resident #66, Resident # 9, Resident #6, and Resident #95) of 6 Minimum Data Set submissions reviewed for Resident Assessment were not submitted to Center for Medicaid and Medicare Services system within 14 days of completion. The findings are: The Admission Minimum Data Set Assessment for Resident #66 dated 12/08/23 was completed on 06/04/24. The Annual Minimum Data Set Assessment for Resident #6 dated 5/28/24 was completed on 6/4/24. The Quarterly Minimum Data Set Assessment for Resident #95 dated 5/25/24 was completed on 06/03/24. The Quarterly Minimum Data Set Assessment for Resident #9 dated 05/25/24 was completed on 06/01/24. The Validation Report dated 8/13/24 documented that these four Minimum Data Set Assessments were submitted to the Center for Medicaid and Medicare Services system on 8/14/24 during the Recertification survey. On 08/16/24 at 12:31 PM, the Director of Minimum Data Set was interviewed and stated that they follow the Resident Assessment Instrument manual to determine when an Assessment should be completed and submitted which are submitted by the Controller. The Director of Minimum Data Set also stated that the late submissions were an oversight as the assessments were completed on time. On 08/16/24 at 12:51 PM, the Controller was interviewed and stated that they receive a report on Sigma Care daily with a list of all Minimum Data Set assessments that need to be submitted to Center for Medicaid and Medicare Services. The Controller also stated that they were unaware that six books were submitted late, and it was an oversight which should have never happened. 10 NYCRR 415.11

Based on observation, record review, and interviews conducted during an Abbreviated survey (NY00323120), the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. This was evident in 1 out of 3 residents (Resident #1) sampled. Specifically, Resident #1 was observed with facial grimacing and pointed to their right leg while being cared for by Certified Nursing Assistant #1 on 08/27/23 at approximately 06:00pm. Licensed Practical Nurse #1 and Nurse Supervisor #1 both stated that they observed Resident #1 with facial grimacing, right leg swollen and warm to touch on 08/27/23. There was no documented evidence to support that Resident #1 was assessed and the medical doctor was notified on 08/27/23. A nursing note dated 08/28/23 at 10:41pm documented that an x-ray of Resident #1's right knee was done. The x-ray result dated 08/28/23 documented no fracture subluxation. Additionally, Resident #1, who was severely impaired, was not assessed appropriately and was not transferred to the hospital timely. The nursing notes from 08/28/23 to 08/30/23 documented continuous facial grimacing and complaints of pain. A medical note, by Nurse Practitioner #1 dated 08/29/23 at 09:59am documented that Resident #1 had facial grimacing, guarding to right hip and knee, mild swelling to the right knee and right thigh. Resident #1 was reexamined by Nurse Practitioner #1 on 08/30/23 and was observed with external rotation and shortening of the right leg. Resident #1 was transferred to the hospital on 08/30/23 at 09:39pm. The hospital diagnostic test results dated 08/30/23 documented that Resident #1 had an acute comminuted and distracted intertrochanteric facture of the right hip. The hospital medical notes dated 09/05/23 documented that Resident #1 was status post right hip intramedullary nail on 08/31/23. The findings are: The facility Policy and Procedure titled Documentation in the Medical Record reviewed 04/22/22 that it is the policy of the facility to ensure that licensed professionals document changes in resident condition, accident and incidents, transfers, discharges, expirations, and leaves against medical advice to ensure that all events of the resident stay are included. The Licensed Professional must maintain medical record on each resident in accordance with acceptable professional standards and practices that are complete and accurately documented. The Licensed Nurse will document in the medical record and notify the physician, resident representative, and resident when there is significant change in resident's physical, mental and psychosocial status in either life threatening conditions or clinical complications. Resident #1 was admitted to the facility with diagnoses including Cerebrovascular Accident with Right Hemiparesis and Type 2 Diabetes Mellitus. The Minimum Data Set, dated dated dated [DATE] documented that Resident #1 had severely impaired cognition. A review of Resident #1's medical record revealed that an appropriate assessment of Resident #1 was not done timely to ascertained if Resident #1 had sustained a fracture. From 08/27/23 to 08/30/23, only two Registered Nurse Supervisors documented on Resident #1. Registered Nurse Supervisor #3 (who worked on 08/28/23 from the 08:00am - 04:00pm) documented that Resident #1 complained of pain to their right knee and cried out in pain upon palpation. Registered Nurse Supervisor #4 (worked on 08/30/23 from 03:00pm - 11:00pm) documented right leg pain without cessation after administration of Tylenol and that the medical doctor was notified. All other notes were written by Licensed Practical Nurses who continues to document that Resident #1 had facial grimacing, complaints of pain, swollenness to right leg, and Tylenol administered. A Radiology Report (done in facility) result dated 08/29/23 documented that an x-ray was done of Resident #1's right knee and revealed no fracture subluxation. Osteopenia and Degenerative changes noted. Nurse Practitioner #1's note dated 08/29/23 at 09:49am documented that an x-ray of Resident #1's right knee and Tylenol were ordered. Resident #1 was assessed with positive facial grimacing, guarding to right hip and knees, mild swelling to right knee and right thigh, and no bruising. The x-ray documented no fracture. Osteopenia and degenerative changes. Nurse Practitioner #1's note dated 08/30/23 at 08:10pm, documented that Resident #1 was reexamined with facial grimacing, guarding to right hip and knee persist, and external rotation of the right leg with shortening. Resident #1 to be transferred to the hospital. A hospital x-ray report dated 08/30/23 revealed findings of an Acute Comminuted and Distracted Intertrochanteric fracture of the right hip. Mild osteopenia consistent with mild osteoporosis. A Hospital discharged note dated 09/05/23 documented that Resident #1 was status post Right hip intramedullary nail on 08/31/23. During a telephone interview on 02/01/24 at 03:35pm, Certified Nursing Assistant #2 stated that they worked on 08/27/23 on the evening shift (03:00pm - 11:00pm). Certified Nursing Assistant #2 stated that Resident #1 started complaining of pain at around 6:00pm while they were providing care to Resident #1's lower extremities. Certified Nursing Assistant #2 stated that Resident #1 pointed to their right leg that was observed with mild swelling. Certified Nursing Assistant #2 stated that they notified Licensed Practical Nurse # 1. During a telephone interview on 01/31/24 at 11:03am, Licensed Practical Nurse #1 (worked a double shift on 08/27/23 from 03:00pm - 11:00pm and 11:00pm - 07:00am on 08/28/23) stated that they were called by Certified Nursing Assistant #2 to check on Resident #1. Licensed Practical Nurse #1 stated that they observed Resident #1's right leg to be swollen and warm to touch. Licensed Practical Nurse #1 stated that they called Registered Nurse Supervisor #1. Licensed Practical Nurse #1 said that they received instructions from Registered Nurse Supervisor #1 to give Tylenol to Resident #1 for pain that was relieved. Licensed Practical Nurse #1 stated that Registered Nurse Supervisor #1 assessed Resident #1. A follow up interview was done on 02/29/24 at 12:25pm with Licensed Practical Nurse #1 who stated that on 08/28/23 (does not recall time) Certified Nursing Assistant #3 notified them that Resident #1 complained of pain to their right leg and that Registered Nurse Supervisor #2 was notified. During a telephone interview on 01/31/24 at 05:00pm, Registered Nurse Supervisor #1 stated that they assessed Resident #1 on 08/27/23 on the evening shift (04:00pm-12:00am). Registered Nurse Supervisor #1 stated that Resident #1 was observed with slight swelling to the leg (stated can't remember which leg) and that it was painful to touch. Registered Nurse Supervisor #1 stated that they called Nurse Practitioner #1 and obtained an order to give Tylenol 650 mg tablet by mouth for one dose. Registered Nurse Supervisor #1 stated that they did not document their observation and interventions implemented. Registered Nurse Supervisor #1 stated that they had endorsed Resident #1's condition to incoming Registered Nurse Supervisor #2. During a telephone interview on 01/31/24 at 09:54am, Registered Nurse Supervisor #2 stated that they worked on the night shift on 08/27/23 (from 12:00am to 08:00am on 08/28/23). Registered Nurse Supervisor #2 stated that Registered Nurse Supervisor #1 endorsed to them that Resident #1 had pain in their right leg and that pain medication was administered at 06:45pm by Licensed Practical Nurse #1. During an interview on 01/30/23 at 01:40pm, Registered Nurse Supervisor #3 (worked on 08/28/23 from 08:00am-04:00pm) stated that they were notified by Licensed Practical Nurse #2 and Certified Nursing Assistant #4 on 08/28/23, between 09:00am and 10:00am, that Resident #1 has pain on right leg. According to Registered Nurse Supervisor #3, they assessed Resident #1 and there was a small bruise on Resident #1's right shin area. Registered Nurse Supervisor #3 stated that Resident #1 cried out in pain when Resident #1's right knee was touched. Registered Nurse Supervisor #3 stated that they notified Nurse Practitioner #1 between the time of 09:00m-10:00am on 08/28/23 and a telephone order was obtained for a right knee x-ray and Tylenol 650mg every six hours as needed for pain. During an interview on 01/31/24 at 11:19am, Nurse Practitioner #1 stated that they don't recall receiving a phone call from Registered Nurse Supervisor #1 on 08/27/23. Nurse Practitioner #1 stated that they received the first phone call on 08/28/23 (does not recall time) from Registered Nurse Supervisor #3. Nurse Practitioner #1 stated that Registered Nurse Supervisor #3 reported that Resident #1 complained of pain to the right knee and that Resident #1 had facial grimacing. Nurse Practitioner #1 stated that they ordered Tylenol as needed for one week and an x-ray of Resident #1's right knee. Nurse Practitioner #1 stated that they first assessed Resident #1 on 08/29/23 at approximately 09:00am and observed that Resident #1 had facial grimacing. Resident #1 was also guarding their right hip and knee. Nurse Practitioner #1 went on to say that Resident #1 also had mild swelling to their right knee and thigh with no bruising. Nurse Practitioner #1 stated that they review the x-ray (of Resident #1's right knee) result received on 08/28/23 and it showed that Resident #1 had no fracture but had osteopenia and degenerative changes. Nurse Practitioner #1 stated that they discussed Resident #1's condition with the Medical Doctor and additional x-rays were ordered of bilateral hip. Nurse Practitioner #1 stated that they reassessed Resident #1 on 08/30/23 during the evening (does not recall time) and observed that Resident #1 had external rotation and shortening of their right leg. Nurse Practitioner #1 stated that they conducted a video call with the Medical Doctor who ordered to transfer Resident #1 to the hospital to rule out fracture. During a telephone interview with the Director of Nursing on 03/12/24 at 03:23pm, the Director of Nursing stated that the Registered Nurse Supervisors on all shifts should have conducted a thorough physical assessment of Resident #1 to rule out fracture and report their findings to the doctor. The Director of Nursing stated that the Registered Nurse Supervisors should have conducted range of motion, assessed for swelling, discoloration, pain, and if Resident #1 is able to move their extremities. The Director of Nursing stated that the supervisors should have also assessed for shortening of limb. According to the Director of Nursing, the Registered Nurse Supervisors should have monitored Resident #1 and documented their findings and interventions implemented. 10 NYCRR 415.11(C)(3)(i)

Based on observation, interview and record review conducted during an Abbreviated Survey (NY00323120), the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practices, the comprehensive person-centered care plan, and the resident's goals and preferences. This was evident for 1 out of 3 residents (Resident #1) sampled. Specifically, Resident #1, who had severely impaired cognition, was on pain management for diagnoses of pain in other joints. An initial pain assessment was not done on 08/27/23. A medical record review also revealed that Resident #1 continued to complain of pain from 08/28/23 to 08/30/23, but there were no changes in pain management. Additionally, there was no documented evidence that Resident #1's pain level was monitored before and after each pain medication was administered to determine effectiveness. The findings are: The Policy and Procedure on Pain Management reviewed 10/09/22, the procedure states a Pain Risk Assessment will be done on admission, re-admission, quarterly and with a change in condition to identify risk factors that could result in pain and resident will be assess for the presence of pain utilizing the 0-10, [NAME] pain scale, or PAINAD. Prior to administering pain medication, the nurse will identify the resident's level of pain and the nurse will re-assess the resident's response to the pain medication and inform the Primary Medical Doctor (PMD) if it was not effective. Resident #1 was initially admitted to the facility with diagnoses including Cerebrovascular Accident with Right Hemiparesis and Type 2 Diabetes Mellitus. The Minimum Data Set, dated dated dated [DATE] documented that Resident #1 had severely impaired cognition. The Comprehensive Care Plan for Pain Management dated 08/04/21 documented alteration in comfort. The interventions included: on-going assessment of Resident #1's pain with emphasis on the onset, location, description, intensity of the pain and alleviating and aggravating factors. Administrator medications as ordered by Medical Doctor, monitor Resident #1's behavior and assessed for pain/discomfort. A Physician's Order dated 08/27/23 at 06:35pm documented Tylenol 325mg tablet give 2 tablets (650 mg) by oral route as one dose. There was no physician's order for monitoring of pain. The August 2023 Medication Administration Record documented that Resident #1 was given Tylenol 325mg tablet, 2 tables by oral route once on 08/27/23 at 06:35pm on the 03:00pm - 11:00pm shift. There was no documented evidence that pain medication was administered to Resident #1 from 08/27/23 from 11:00pm to 07:00am 08/28/23. The August 2023 Medication Administration Record documented that Tylenol 325mg 2 tablets every 6 hours as needed was administered 4 times from 08/28/23 at 03:19pm to 08/30/23. The Medication Administration Record dated 08/28/23 documented that Resident #1 received Tylenol 650 milligram, however, the time of administration was not documented. A nursing note dated 08/28/23 at 03:32pm documented that Resident #1 complained of pain above the right knee and that Resident #1 cried out in pain upon palpation. The Medical Doctor (Nurse Practitioner #1) was notified and ordered an x-ray of Resident #1's right knee. There was no documented evidence that Resident #1's pain levels were assessed using a pain scale prior to and after pain medications were administered for the effectiveness. There was no documented evidence that Resident #1 was assessed for pain management after Resident #1 continued to complain and cried out in pain. There were no changes made to Resident #1's pain medication. During a follow up interview on 02/29/24 at 12:25pm, Licensed Practical Nurse #1 (worked on 08/27/23 on both the 03:00pm - 11:00pm and 11:00pm - 07:00am) stated that Resident #1 was unable to rate their pain scale. Licensed Practical Nurse #1 stated that Resident #1 had facial grimacing and that they used the Wong-Baker faces rating scale to identify Resident #1's pain level. Licensed Practical Nurse #1 stated that they were not sure if they had documented the pain scale. Licensed Practical Nurse #1 also stated that Certified Nursing Assistant #3 notified them that Resident #1 continued to complain of pian to the right leg during the morning tour (unable to recall the time) of 08/28/23 and that Registered Nursing Supervisor #2 was notified. Licensed Practical Nurse #1 stated that they gave Resident #1 Tylenol 325 milligram 2 tablets, and that Resident #1 had some pain relief because Resident #1 was observed sleeping. During a telephone interview on 01/31/24 at 9:54am, Registered Nurse Supervisor #2 stated that they worked on 08/27/23 on the night shift (12 midnight - 08:00am). Registered Nurse Supervisor #2 stated that Registered Nurse Supervisor #1 endorsed to them that Resident #1 had pain in their right leg and that pain medication was administered by the Licensed Practical Nurse #1 on 08/27/23 at 6:45pm. Registered Nurse Supervisor #2 stated that they observed Resident #1 sleeping when they conducted rounds (don't recall time) and that no one reported that Resident #1 complained of pain. During a telephone interview on 01/31/24 at 05:00pm, Registered Nurse Supervisor #1 stated that they assessed Resident #1 on 08/27/23 on the evening shift (04:00pm-12:00am). Registered Nurse Supervisor #1 stated that Resident #1 was observed with slight swelling to the leg (stated can't remember which leg) and that the leg was painful to touch. Registered Nurse Supervisor #1 stated that they called Nurse Practitioner #1 and obtained an order to give Tylenol 650 mg tablet by mouth for one dose. Registered Nurse Supervisor #1 stated that they did not document their observation and was not sure a pain evaluation was done. During an interview on 01/30/23 at 01:40pm, Registered Nurse Supervisor #3 (worked on 08/28/23 (from 08:00am-04:00pm) stated that they were notified that Resident #1 had pain in their right leg by Licensed Practical Nurse #2 and Certified Nursing Assistant #4 on 08/28/23 between 09:00am and 10:00am. According to Registered Nurse Supervisor #3, they assessed Resident #1 and there was a small bruise on Resident #1's right shin area. Registered Nurse Supervisor #3 stated that Resident #1 cried out in pain when Resident #1's right knee was touched. Registered Nurse Supervisor #3 went on to say that they notified Nurse Practitioner #1 between 09:00am and 10:00am on 08/28/23 and received a telephone order for a right knee x-ray and Tylenol 650mg every six hours as needed for pain. Registered Nurse Supervisor #3 stated that a pain assessment for Resident #1 was not done and that it was an oversight. During an interview on 01/31/24 at 11:19am, Nurse Practitioner #1 stated that they don't recall receiving any phone calls from Registered Nurse Supervisor #1 on 08/27/23. Nurse Practitioner #1 stated that they received the first phone call on 08/28/23, sometime during the morning (does not recall time), from Registered Nurse Supervisor #3. Nurse Practitioner #1 stated that Registered Nurse Supervisor #3 stated that Resident #1 complained of pain to the right knee and that Resident #1 had facial grimacing. Nurse Practitioner #1 stated that they ordered Tylenol as needed for one week and an x-ray of Resident #1's right knee. Nurse Practitioner #1 stated that they initially assessed Resident #1 on 08/29/23 at approximately 09:00am and observed Resident #1 with facial grimacing. Resident #1 was also guarding their right hip and knee. Nurse Practitioner #1 went on to say that Resident #1 had mild swelling to their right knee and thigh with no bruising. Nurse Practitioner #1 stated that they review the x-ray (of Resident #1's right knee) result received on 08/28/23 and it showed that Resident #1 had no fracture but had osteopenia and degenerative changes. Nurse Practitioner #1 stated that they discussed Resident #1's condition with the Medical Doctor and additional x-rays were ordered for bilateral hip x-rays. Nurse Practitioner #1 stated that they reassessed Resident #1 on 08/30/23 during the evening (does not recall time) and observed that Resident #1 had external rotation of their right leg. Nurse Practitioner #1 stated that they conducted a video call with the Medical Doctor who ordered to transfer Resident #1 to the hospital to rule out fracture. Nurse Practitioner #1 stated that no one reported to them that Resident #1 had severe pain. Nurse Practitioner #1 stated that they were thinking that Resident #1 had arthritis because of the x-ray result of the right knee showing that Resident #1 had degenerative changes with hypertrophic spur formation of patella and no fracture subluxation. Nurse Practitioner #1 stated that when they assessed Resident #1 on 08/29/23, Resident #1 was not in any excruciating pain and there was no shortening of the right leg. During a telephone interview on 02/13/24 at 03:26pm, the Director of Nursing stated that pain medication must have a pre and post pain scale, prior administration, to monitor for the effectiveness. The Director of Nursing stated that they reviewed and observed that the Medication Administration Record for Resident #1 had no pain scale assessment documented. The Director of Nursing went on to say that there was no initial assessment documented for Resident #1 by Registered Nursing Supervisor #1 on 08/27/23. 10 NYCRR415.2

42 CFR 483.90(i)(4): Maintain an effective pest control program so that the facility is free of pests and rodents. Based on observation, record review and staff interviews conducted during the Abbreviated Survey (Complaint # NY 00320109) initiated on 07/26/2023, the facility did not ensure that an effective pest control program was maintained so that the facility was free of pests. Specifically, there was evidence of roaches in the resident rooms. This occurred on 2 of 5 resident floors. The findings are: Observations during the tour of the facility on 07/26/2023 between 09:00 AM - 03:00 PM identified the following: - One live roach was observed by the leg of three drawer nightstand of bed A in room [ROOM NUMBER] located on the first floor. - One dead roach was observed under three drawer nightstand of bed B in room [ROOM NUMBER] located on the third floor. - One dead roach was observed by the radiator near the TV in the dining room adjacent to room [ROOM NUMBER] on the third floor. On 07/26/2023 between 09:00 AM - 03:00 PM, the following documentation was reviewed: a) Policy and Procedure entitled Pest Control effective: 06/2000, which stated that it is the Policy of Caton Park Nursing to maintain an effective pest control program to ensure that the facility is free of insects and rodents. b) Record of weekly Pest Control vendor invoices for a year from 07/28/2022 - 07/17/2023. Recent Pest control records documented the following: - On 07/17/2023, signed logbooks and treated both rooms gel baited cracks and GM crevices and hinges of appliances. Service description 307 & 203 - Roaches. Drain cleaning service done on all drains. Checked in with security and signed logbook. Service description - Drain IPM Service - On 07/20/2023, Checked in with front desk, housekeeping office treated all rooms accordingly in the logbooks. Gel baited cracks and crevices treated pantries and commons areas. Treated basement and locker rooms. Service description - PEST MANAGEMENT On 07/13/2023, Checked in with housekeeping, staff treated all floors all pantries in all rooms in the binders. Signed Logbooks, gel bait in cracks and crevices as needed treated kitchen, all drains and appliances behind and underneath checked in with Mr. [NAME] treated basement locker rooms and break room. Service description - PEST MANAGEMENT. On 07/06/2023, Checked in with [NAME] and housekeeping notified them about the pantries need a wipe down. Treated room's accordingly & signed logbooks gel baited cracks and crevices. Treated basement and lobby common areas. Service description - PEST MANAGEMENT. On 06/29/2023, Checked in with front desk signed logbook. Checked in with Mr. [NAME] for the kitchen. Treated basement and common areas. Treated behind and underneath appliances, treated rooms accordingly and signed logbooks. Treated pantries and day rooms. Service description - PEST MANAGEMENT. On 06/22/2023, Checked in with front desk, treated the lobby. Treated all floor pantries the rooms and rooms accordingly treated basement kitchen. Treated behind and underneath appliances. Service description - PEST MANAGEMENT. On 06/15/2023, Checked in with front desk and [NAME] treated all floors checked all binders, sign logbooks treated all common areas, pantries and day rooms treated front desk for ants treated kitchen all the drains and appliances behind gel baited cracks and crevices. Service description - PEST MANAGEMENT. On 06/08/2023, Checked in with front desk treated all floors all common areas pantries, Porter rooms, and all rooms in the logbooks to the lobby and exit by where the cooks barbecue door has open gaps, which are letting flies. Come in room around should be silicone. Service description - PEST MANAGEMENT. In an interview on 07/26/2023 at approximately 09:40 AM, the first floor Registered Nurse (RN) stated if anybody saw any roaches, they noted it in the Vendor's Pest Control Inspection & Service Report book available. Exterminator came in weekly. The Exterminator looks into the book and address the issues. In an interview on 07/26/2023 at approximately 09:45 AM, the CNA on 1st floor stated they saw roach 2 months ago and ants sometimes mostly in the summer. Because during summer many visitors and family members come to visit the residents, and sometimes they bring food or articles for residents. Food crumbs can fall on the floor. In an interview on 07/26/2023 at approximately 10:30 AM, the Housekeeping Staff stated a month ago they saw about 3 roaches in room [ROOM NUMBER] B. They reported them to housekeeping supervisor. In an interview on 07/26/2023 at approximately 10:10 AM, the Director of Maintenance and Housekeeping stated the facility has contracted the vendor Pest Control Company and the exterminator comes every Thursday and was onsite last week. The Director of Maintenance and Housekeeping further stated that the vendor comes weekly and any time during the week when they are called. 42 CFR 483.90 (i)(4) 10 NYCRR 415.29 (j)(5)

Based on record review and interviews conducted during the recertification survey, the facility did not ensure Minimum Data Set 3.0 (MDS) assessments were electronically transmitted in a timely manner. This was evident for 5 of 14 residents reviewed for the Resident Assessment task (Resident #4, 13, 8, 17, 9). Specifically, a quarterly assessment was not transmitted within 14 days after the completion date. The findings are: The facility policy titled Resident Assessment using the MDS dated [DATE] with revision on 08/09/2022 documented MDS Assessments will be transmitted to CMS within 14 days after completion by MDS coordinator/designee and a monthly validation report will be downloaded from MDS to ensure that all MDS transmissions have been received by CMS . 1. Resident # 4 ---- Target date Assessment Reference Date (ARD) 05/16/2022 -- Completed ---5/30/2022 -- Transmission and verification Date --- 08/08/2022 2. Resident # 13 -- Target date ARD 05/16/2022 -- completed ---5/30/2022 ---transmission and verification date ----08/08/2022 3. Resident # 8 -----Target date ARD 05/24/2022---Completed ----06/06/2022--Transmission and verification date ---08/08/2022 4. Resident # 17 ----Target date ARD 05/08/2022---Completed ---05/21/2022 -- Transmission and verification date --08/08/2022 5. Resident # 9 -----Target date ARD 05/27/2022 ---Completed --- 06/10/2022--Transmission and verification date --08/08/2022 On 08/9/2022 at 11:00 AM, the MDS Coordinator was interviewed and stated the Comptroller transmits the MDS assessments to the Centers for Medicare Services (CMS). On 08/09/2022 at 11:37 AM, the Comptroller was interviewed and stated they were responsible for transmitting MDS assessments. The Comptroller was unable to explain the reason there were MDS assessments that were not transmitted within 14 days of completion. There was no verification or transmission acceptance from CMS and the Comptroller resent the MDS yesterday. 415.11

Based on interviews and record review conducted during a recertification and complaint (NY 611) survey from 08/03/22 to 8/10/2022, the facility did not ensure that allegations of abuse, including injury of unknown origin, were reported to the New York State Department of Health (NYSDOH) within 2 hours. This was evident for 1 (Resident #40) of 3 residents investigated for abuse. Specifically, Resident #40 complained of right shoulder pain and subsequent right shoulder dislocation was not reported to the NYSDOH within 2 hours. The findings are: The facility's policy titled Abuse Prevention, last reviewed 12/09/2021, documented the facility must report alleged violations related to mistreatment, exploitation, neglect, or abuse including injuries of unknown source and report the results of all investigations to the proper authorities within prescribed timeframes. Resident #40 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #40 was severely cognitively impaired and required extensive assistance to transfer out of bed. The Aspen Complaint Tracking System report received 9/22/21 documented Resident #40 was found on 8/30/21 with discoloration and pain to their right shoulder and the facility staff were unable to provide an explanation of how the injury occurred. A Nursing Note dated 08/30/2021 documented Resident #40 complained of pain to the right shoulder. Medical Doctor (MD) was made aware, and x-ray was ordered. Resident #40 was unable to lift their right arm. An Accident/Incident Report initiated 08/30/2021 documented Resident #40 was sitting upright in the chair in their room upon discovery at 1:40 PM, was noted with swelling and discoloration to the right shoulder with mild pain and limited range of motion. No one recalled the resident falling. The resident's injury was consistent with getting up and falling to the right with their shoulder touching the nightstand and the wall, landing on the floor, and getting back up. The Incident Report was concluded on 9/1/21 with no abuse or mistreatment identified. A Physician Note dated 08/31/2021 documented the x-ray showed a separation of the right acromioclavicular joint with superior dislocation of the right clavicular end. There was no documented evidence the facility reported Resident #40's injury of unknown origin to the NYSDOH within 2 hours of occurrence. On 08/10/2022 at 10:38 AM, the Director of Nursing (DON) was interviewed and stated they were not working in the facility at the time of Resident #40's incident. The facility is required to report injuries of unknown origin to NYSDOH within 2-24 hours depending upon the severity of the injury. The x-ray showed no acute fracture, rather a separation injury, and might have occurred spontaneously. It was not of unknown origin and would not have required reporting. On 08/10/2022 at 12:44 PM, the Physician's Assistant at Resident #40's orthopedist's office was interviewed and stated that Resident #40 was diagnosed with a Grade 3 dislocation, and it is not common for such an injury to occur spontaneously. 415.4(b)

Based on observation, record review and interviews conducted during the recertification survey, the facility did not ensure comprehensive person-centered care plans (CCP) were developed and implemented to meet each resident's needs. This was evident for 2 of 34 sampled residents (Resident #81 and #102). Specifically,1.) Resident #81 had did not have a CCP to address bleeding and [CONDITION(S)], and 2.) Resident #102 did not have a CCP developed to address their Intravenous (IV) hydration and antibiotic treatment. The findings are: The facility policy titled CCP last revised 12/2/2021 documented the CCP will be resident centered having the Individual Resident as the Locus of Control. The CCP will be ongoing, constantly evolving, focusing on everyone as a unitary being constantly changing and interacting with the environment/energy fields. The CCP will consist of identified or potential problem areas, or needed areas of focus to maximize wellness, Individualized resident centered goals and specific interventions and will include new medical diagnosis, newly diagnosed infection, new or revised treatment. 1. Resident # 81 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #81 was cognitively intact. Nurses notes dated 07/29/2022 documented Resident #81 was readmitted from the hospital where the resident was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] Medical Doctor (MD) notes dated 08/01/2022 documented Resident #81 was post hospitalization for vaginal bleeding and [CONDITION(S)]. Colonoscopy revealed hemorrhoids and Ultrasound (US) showed a thickened endometrium of 2.6 centimeter (CM). Nurse Practitioner (NP) notes on 08/02/2022 documented Pelvic US done on 08/02/2022 with very abnormal appearing posterior bladder wall, suggestive of a neoplasm. The plan of care was cystoscopy for further evaluation and follow up at the hospital gynecology clinic. There was no documented evidence the facility developed or implemented a CCP related to Resident #81's vaginal bleeding and [CONDITION(S)]. 2. Resident # 102 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #102 was severely cognitively impaired. On 08/03/2022 at 11:45 AM and 08/04/2022 at 2:29 PM, Resident #102 was observed with a dressing to the left antecubital area of the upper arm. During the observation on 08/04/2022 at 2:30PM, Registered Nurse Manager (RNM) # 1 was interviewed and stated Resident #102 had a midline IV to the left arm and RNM #1 removed it. Resident #102 received IV hydration on 7/11/22 and the midline should have been removed once IV therapy was completed. Medical Doctor Order (MDO) dated 07/11/2022 documented Resident #102 was to receive Intravenous (IV) 0.9 Normal Saline Solution (NSS) to be started at 60 cubic centimeter (cc) per hour for 24 hours. IV hydration was discontinued on 7/12/2022. There was no documented evidence the facility developed and implemented a CCP related to Resident #102 need for IV hydration or midline IV care. On 08/08/2022 at 3:30 PM, the RNM #1 was interviewed and stated the resident's CCP is formulated and started by any RNM. If the resident is admitted in the afternoon, the CCP should be started by the afternoon admitting Supervisor and completed by the morning Unit Manager. Resident #81 and Resident #102 did not have developed CCPs because of RNM #1's oversight. If the resident has new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 415.11(c)(1)

Based on observation, interviews and record review conducted during an abbreviated survey (NY 057), the facility failed to ensure that the resident environment remains as free from accident hazards as is possible, and each resident receives adequate supervision and assistance devices to prevent accidents. This was evident in 1 out of 3 residents sampled (Resident #1). Specifically, on 03/10/2021 at approximately 7:10 AM, Resident #1 fell from the Hoyer lift (a patient lift used to transfer patients) while Certified Nursing Assistant (CNA) #1 and CNA #2 were transferring the resident from bed to wheelchair. Resident #1 sustained non-displaced fractures of the left first and second ribs and a head wound on the scalp. CNA #1 and CNA #2 failed to ensure that the Hoyer lift sling was securely attached to the Hoyer lift. This resulted in actual harm to Resident #1 that is not Immediate Jeopardy and is Substandard Quality of Care. The findings are: Review of the facility's policy and procedure entitled Hoyer Lift, Safely Transferring Residents via Hoyer-Lift effective in 01/2015 and reviewed in 03/2021 documented: It is the policy of the facility that all residents on Hoyer-Lift must have a minimum of two-person transfer. Bed mobility with 2 assist and requires 2 staff to prepare and transfer the resident. CNA inspects necessary equipment is in good working condition (Hoyer lift and sling) and prepares resident for transfer. Attach sling to Hoyer Lift with two staff members and transfer the resident from bed to wheelchair safely. First staff operates/controls the Hoyer Lift, second staff secures the resident safely by guiding the mobility of the resident's transfer safely. Review of the facility's policy and procedure entitled Occurrence Investigation and Reporting last reviewed on 04/31/2020 documented: It is the policy of the facility to provide an environment that is free from accident hazards over which the facility has control as well as providing the supervision and assistive devices that an individual requires to prevent avoidable accidents as required under Federal Regulation. Occurrence investigation findings will be reviewed to identify additional preventative measures that an individual resident may require to prevent avoidable accidents and to identify any potential hazards in the resident's environment that need to be addressed. Resident #1 was initially admitted with diagnoses including Diabetes, Hypertension, [CONDITION(S)] and Dementia. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 01/15 indicating severely impaired cognition. The MDS identified that Resident #1 was totally dependent with bed mobility and required 2 persons for bed mobility and transfers. A Briggs Fall Risk Evaluation dated 02/09/2021 documented that Resident #1 had a total score of 11 indicating high risk for falls (total score of 10 or greater - the resident should be considered at high risk for potential falls). A Portable Patient Lift Maintenance Log was reviewed and revealed that the Hoyer Lift (involved in accident) was last checked on 02/23/2021, and the front wheels were replaced on the Hoyer Lift prior to the incident. The log also revealed that the Hoyer Lift was checked on 03/16/2021, post incident, with no issues identified as per staff initial. A Resident Nursing Instructions dated from 03/01/2021 to 03/10/2021 for CNA use, documented that Resident #1 was totally dependent of two staff for bed mobility and transfers out of bed with mechanical Hoyer lift. A review of the Resident Nursing Instructions revealed there were no instructions for CNAs to check the sling to ensure that the sling was securely attached to the Hoyer lift before transferring the resident. There were no instructions for CNAs to inspect the equipment (Hoyer lift) to ensure good working condition. There was no documented evidence that resident was care planned for Hoyer lift transfer. A Facility Investigation Summary dated 03/15/2021 documented that on 03/10/2021 at approximately 7:11 AM, Resident #1 was observed laying on the floor at the side of the Hoyer sling. Resident #1 had bleeding from the posterior scalp, vital signs were stable. Resident #1 was transferred to the emergency room (ER) for evaluation and returned at 3:00 PM. ER records documented non-displaced fractures of the first and second ribs and superficial head wound to posterior scalp. Computed Tomography (CT) scan of the head and face negative. The assigned CNA (CNA #1) stated that they provided personal care to Resident #1 and prepared Resident #1 for transfer out of bed at approximately 7:00 AM. The Hoyer Lift was brought to the room at approximately 7:08 AM and CNA #2 entered the room at 7:10 AM. Code E (used for Emergency) was called at approximately 7:11 AM. The Registered Nurse Supervisor (RNS) responded and observed Resident #1 lying on the Hoyer sling, the hooks on the sling were not connected to the Hoyer lift. The CNAs reported that Resident #1 slid from the side of the Hoyer Lift when the Hoyer was being pulled from underneath the bed. The investigation revealed that CNA #1 applied the slings alone and did not follow the facility's policy. Both CNAs did not check to see if the sling was securely attached to the Hoyer lift. Resident #1's care plan was violated and both CNAs were terminated. The facility concluded that there was reasonable cause to believe that abuse, neglect, or mistreatment occurred. A review of an emergency room Note dated 03/10/2021 at 11:19 AM documented that Resident #1 was seen due to fall, head injury and unknown loss of consciousness. The physical examination revealed head with small laceration to the right-side scalp with mild oozing. Computed Tomography (CT) of the head with facial: no acute hemorrhage, no fracture. CT scan of the chest showed non- displaced fracture of the left 1st and 2nd ribs with likely pleural hematoma. CT scan of the spine was negative for fractures. Review of an emergency room Discharge Document dated 03/10/2021 at 4:01 PM documented that Resident #1 was seen by the trauma team and the ER team during the Level 2 Trauma activation. Work up revealed left 1st and 2nd ribs fractures, 4cm long scalp laceration repaired in the ER. Resident #1 was stable for discharge back to the Nursing Home. Diagnoses Fall and Rib Fracture. A review of a Nursing Progress Note dated 03/10/2021 at 5:44 PM documented that Resident #1 returned to the unit at 3:44 PM. On assessment, Resident #1 had a dressing on the left temporal area. No complaint of pain or discomfort. Medical Doctor (MD) ordered Neuro check every 4 hours for 72 hours. Apply [MEDICATION(S)] by topical route to left temporal area after cleaning with Normal Saline, pat dry and cover with dry protective dressing. CT of the Head, no intracranial hemorrhage. CT of the Cervical Spine -no acute fracture or dislocation. CT of the chest/abdomen and pelvis showed non-displaced fractures of the left lateral first and second ribs with adjacent left extra pleural hematoma. A review of Nursing Correction Progress Note dated 03/11/2021 at 2:30 PM documented that at approximately 7:26 AM, Code E was called on the 3rd Floor. The writer immediately went upstairs to Resident #1's room. Resident #1 was found lying on his/her back on the Hoyer Lift pad between the closet and the bed. Resident #1 was laying on the base of the Hoyer Lift. On assessment, bleeding noted from Resident #1''s left posterior scalp. The writer applied pressure to the scalp to stop the bleeding, placed a pillow under the resident's head and instructed staff to call 911. Resident #1's eyes were closed so tactile stimuli was applied to keep Resident #1 awake. Resident #1 remained conscious. Resident #1's oxygen saturation was 98 % when the writer arrived on the unit but desaturated to <90 %. Resident #1 was placed on oxygen via non-rebreather mask at 10 liters per minute. The writer kept Resident #1 alert until 911 Emergency Medical Technicians (EMTs) arrived at 7:35 AM. A review of the Physician's Progress Note dated 03/14/2021 at 7:55 PM documented Late Entry: on 03/11/2021 at about 8:00 AM during rounds, the writer was informed by nursing staff that Resident #1 had fallen and was transported to the hospital prior to the writer's arrival at the facility. The writer called the Emergency Department (ED) and spoke to the ED Attending Physician. The writer was informed that the Resident #1 sustained laceration to the scalp area, rib fractures and small inguinal artery aneurysm. Resident #1 was seen by the trauma team and cleared for discharge. No suture removal were needed since absorbable sutures were used to close the scalp wound. During an interview on 03/02/2022 at 2:30 PM, Registered Nurse #1 (RN #1) stated that he/she was the charge nurse for the day shift from 8:00 AM- 4:00 PM on 03/10/2021. RN #1 stated that on 03/10/2021 he/she arrived at work early and Code E (Emergency) was already in progress. RN #1 stated that there were two other RNs in Resident #1's room and that he/she brought the oxygen to the room. RN #1 stated that Resident #1 was alert and responsive. RN #1 stated that Resident #1 returned from the ER around 2:30PM and he/she observed Resident #1 with dressing to a wound on the left temporal scalp area. RN #1 stated that the Medical Doctor gave an order to apply [MEDICATION(S)] ointment by topical route and for Neuro checks to be done every 4 hours. During an interview on 03/30/2022 at 11:10 AM, Certified Nursing Assistant #1 (CNA #1) stated that he/she was employed at the facility for [AGE] years. CNA #1 stated that he/she always followed the facility's policy for Hoyer-Lift transfer. CNA #1 stated that on 03/10/2021 Resident #1 was lying in bed. CNA #1 stated that he/she turned Resident #1 and placed the Hoyer lift canvas under Resident #1. CNA stated that he/she independently attached the canvas sling to the Hoyer lift hooks while Resident #1 was still in bed then called CNA #2 to assist with transferring Resident #1 out of the bed to the wheelchair. CNA #1 said that he/she did not check the canvas sling to ensure that they were hooked securely to the Hoyer lift. CNA #1 stated that he/she was controlling the Hoyer-Lift while Resident #1 was being transferred from the bed. CNA #1 stated that after Resident #1 was lifted off the bed and while in the process of being transferred to the wheelchair, Resident #1 suddenly slid out from the lift onto the floor. CNA #1 said that he/she was not sure how many of the canvas slings were detached from the Hoyer Lift hooks because he/she was in shock. During an interview on 03/30/2022 at 1:30 PM, RN #2 stated that on 03/10/2021, he/she responded to Resident #1's Code and observed Resident #1 lying on the floor on the Hoyer Lift canvas. RN #2 stated that Resident #1 was lying on their back. RN #2 stated that Resident #1 was bleeding from a laceration on the scalp and that he/she applied pressure and stopped the bleeding. RN #2 said that he/she kept Resident #1 alert and continued to monitor Resident #1 until Emergency Medical Service arrived. During an interview on 04/05/2022 at 1:30 PM, the former Director of Nursing (DON) stated that he/she investigated the Hoyer Lift incident involving Resident #1. The former DON stated that CNA #1 and CNA #2 did not follow Resident #1's plan of care and the facility's policy for Hoyer Lift Transfer. The former DON said that as a result, Resident #1 suffered a scalp laceration and 2 Ribs Fractures. The former DON said that CNA #1 should have called CNA # 2 to assist them to turn Resident #1 to apply the Hoyer Lift canvas and apply the slings to the Hoyer-Lift hooks. The DON also said that the facility camera showed that CNA #2 went into Resident #1's room just prior to the Hoyer- Lift transfer. The former DON said that during the investigation both CNA #1 and CNA #2 stated that they did not verify that the canvas slings were securely attached to the Hoyer Lift before transferring the resident. The former DON stated that the charge nurses on the units are responsible for ensuring that residents care plans and the facility policy are followed for Hoyer-Lift transfer. The former DON also stated that he/she was not aware of how often competencies were done with staff for Safe Hoyer-Lift Transfers. The former DON stated that staff were re-in-serviced on Safe Hoyer Lift Transfer after the incident involving Resident #1. During an interview on 04/13/2022, CNA #2 stated that on 03/10/2021 around 7:00 AM, he/she went into Resident #1's room to assist CNA #1 with Resident #1's transfer from bed to the wheelchair. CNA #2 stated that he/she checked and saw that the canvas slings were securely attached to the Hoyer lift hooks before Resident #1 was lifted off the bed. CNA #2 stated that as he/she and CNA #1 lifted Resident #1 off the bed with the Hoyer Lift, Resident #1 accidentally slid out off the canvas to the floor, and they called for assistance. CNA #2 said that he/she did not assist CNA #1 to place Resident #1 on the Hoyer-Lift canvas. CNA #2 stated that he/she received in-service to call for assistance to apply the canvas, but when they were short staffed, CNA #2 stated that he/she applied the Hoyer-Lift canvas under the residents by himself/herself. During an interview on 04/15/2022 at 3:12 PM, Resident #1's Primary Physician stated that he/she is no longer working at the facility. The Primary Physician stated that he/she assessed Resident #1 the day after Resident #1 fell from the Hoyer Lift. The Primary Physician stated that Resident #1 had sutures to a scalp wound and 2 ribs fractures. The Primary Physician said that Resident #1's scalp wound, and ribs fractures healed without complications. The Primary Physician also said that Resident #1 had multiple medical issues and was totally dependent of staff for care. During a follow up interview on 04/26/2022 at 12:10 PM, CNA #2 stated that Resident #1 slid completely out of the Hoyer Lift to the floor just as the Hoyer Lift was lifted away from the bed. CNA #2 stated that the canvas was still attached to the Hoyer Lift, but he/she did not recall how many of the slings' hooks were detached from the Hoyer lift. CNA #2 stated that the Hoyer Lift did not tilt while Resident #1 was being transferred from the bed to wheelchair. CNA #2 said that he/she was at Resident #1's feet while Resident #1 was being transferred. During a follow up interview on 04/26/2022 at 12:40 PM, RN #1 stated that the facility's policy on Hoyer Lift Transfer was for 2 staff to be present for Hoyer Lift transfer but one staff member places the canvas underneath the resident. RN #1 also stated that the 2 staff check to see that the slings are securely attached to the Hoyer Lift. RN #1 stated that Resident #1 was lying on the canvas when he/she responded to Resident #1's room. RN #1 said that he/she could not recall if the Hoyer-Lift was in the room when RN #1 arrived in the room. During a follow up interview on 04/26/2022 at 1:38 PM, CNA #1 stated that one staff was supposed to position the canvas under Resident #1 and hook the slings to the Hoyer Lift for a resident's Hoyer-Lift transfer. CNA #1 stated that Resident #1 fell from the left side of the Hoyer Lift, off the canvas to the floor. CNA #1 said Resident #1 fell when he/she turned the Hoyer-lift away from the bed during Resident #1's transfer from the bed to the wheelchair. CNA #1 said that he/she controlled the Hoyer lift from the back of the Hoyer Lift and CNA #2 was at the foot of the bed. CNA #1 also said that CNA #1 did not observe the Hoyer Lift tilt when Resident #1 was being transferred from the bed to the wheelchair. CNA #1 stated that CNA #1 had no difficulty when CNA #1 was controlling the Hoyer lift. CNA #1 stated that they did not touch Resident #1 and the Hoyer lift after Resident #1 fell from the Hoyer lift. 415.12(h)(1)