Every finding on record at Clinton Rehabilitation and Nursing Center

Based on observation, record review, and interview during the survey, the facility failed to implement infection prevention and control practices to prevent the transmission of infection. Specifically, one certified nurse aide failed to wear the required personal protective equipment while providing high-contact care to Resident #72, who was on Enhanced Barrier Precautions for Extended Spectrum Beta-Lactamase (ESBL). Findings include: The facility's Infection Prevention and Control Manual, approved by the Infection Control Committee on 12/17/2025, documented the facility would maintain an effective infection prevention and control program to control the spread of infections and outbreaks. The policy required nursing to maintain written policies and procedures related to transmission-based precautions and to follow infection control practices. Resident #72 had diagnoses of Extended Spectrum Beta-Lactamase (ESBL) resistance (a multidrug-resistant organism), severe dementia, and hemiplegia (left-sided weakness). Review of the Minimum Data Set an assessment tool), dated 06/08/2026, documented the resident had severe cognitive impairment, was rarely understood, and was unable to understand. Review of the resident's care plan, revised 03/03/2026, directed staff to follow Enhanced Barrier Precautions, including the use of gown and gloves during high-contact resident care activities. During an observation on 07/08/2026 at 11:46 A.M., Certified Nurse Aide #5 provided incontinence care for Resident #72 without wearing the required personal protective equipment. Certified Nurse Aide #5 stated they had been unaware which two residents in the four-bed occupied room had required enhanced barrier precautions. They stated if they had known they would have put on a gown, gloves and the specific recommendation would have been followed. Certified Nurse Aide #5 stated taking measures to block the transmission of infection was very important and should have been followed. They further stated the specific care plan for the resident was located inside the closet and should have been reviewed prior to care. During an interview on 07/08/2026 at 11:53 A.M., Nurse Manager #1 described their expectation would have been for all staff to have been familiar with the resident and to have approached the care accordingly. All staff were aware of the care card location. During an interview on 07/08/2026 at 12:22 P.M., Certified Nurse Aide #3 stated care card instructions were located inside each resident's closet. They were helpful to identify specific needs required for each resident. Precaution signage was posted outside all resident rooms. Certified Nurse Aide #3 identified Resident #72 as a resident on enhanced barrier precautions and required a gown and gloves during care. During an interview on 07/09/2026 at 2:09PM, Infection Preventionist #1 stated all staff were trained to identify the appropriate precautions and required personal protective equipment. Infection Preventionist #1stated, care cards were located inside each resident's closet and precaution signs were posted outside resident rooms. Staff should all understand which residents were on precautions not taking precautions and could be detrimental to resident health. Infection Preventionist #1described the certified nurse aide as very young and was most likely just nervous during the observation. Infection preventionist #1 stated there would be a refresher on the importance of preventing infection and the best practice to approach each individual resident. 10 New York Code of Rules and Regulations 415.19(a)(b)(1-3)

Based on observation, record review and interview during a survey, the facility did not ensure each resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of quality of life. Specifically, (a) paper cups and plastic utensils were provided to residents during dining room observation on 07/09/2026 which did not foster a home-like environment. (b) resident's call bells were observed to not be within their reach while in their room impacting their ability to call for help in a timely manner. Findings include: Facility Policy and Procedure titled Resident Call System revised 02/2025 documented the facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or centralized work area from each resident's bedside and toilet and bathing facilities. The call system must be aligned within the resident's reach, whether the resident was in bed or a chair. The availability of the call system was mandatory by the facility. During a breakfast dining observation on 07/09/2026 in the main dining room at 9:29 AM, the following was observed: Resident #71 was provided with paper cups containing their beverages, and the resident was provided with a plastic fork for meal consumption. Resident #14 was provided with paper cups containing their beverages and the resident was provided with a plastic fork for meal consumption. Resident #43 was provided with paper cups for their beverages. Resident #27 was provided with paper cups for their beverages, and the resident was provided with a plastic fork for meal consumption. Resident #9 was provided with paper cups for their beverages, and the resident was provided with a plastic fork for meal consumption. During an observation on 07/08/2026 at 11:18 AM, Resident #68 was in their wheelchair next to their bed watching television. Their call bell was draped over the light fixture attached to the wall above their bed and hanging down, out of their reach. During observations on 07/10/2026 at 7:15 AM, Resident #'s 9, 38, 46, 50 ,58, 59, and 72 were in bed and did not have access to a call light that was in reach. During an interview on 07/09/2026 at 9:38 AM and 11:32 AM, Licensed Practical Nurse #3 stated they did not know why beverages were served in a paper cup and it was a question for the kitchen staff. They stated it was expected for residents to be provided with metal silverware during meals. They stated call bells should be within arm's reach of wherever the resident was sitting or next to them in bed so they could call for assistance without yelling. During an interview on 07/09/2026 at 11:23 AM Certified Nurse Aide #3 stated it was expected for residents to be provided with metal silverware as plastic silverware was not homelike. They stated call bells should be placed in a resident's hand or close by if they were in bed so if they needed assistance, they could use the call bell to alert staff. During an interview on 07/10/2026 at 9:36 AM, Food Service Director #1 stated there were a few residents that horded silverware so there were occasions when plastic silverware were put on meal trays. They stated it was the expectation for residents to have metal silverware and plastic cups for dignity and respect and so the residents felt like they were in their own home. During an interview on 07/10/2026 at 10:02 AM, Director of Nursing #1 stated residents should be provided with metal silverware as it was related to a concern of dignity if they were provided with plastic utensils. They stated it was expected that call bells were within reach of the resident for safety concerns and so residents were able to make their requests known so staff could meet their needs. New York Code of Rules and Regulations 483.10 (a)(1)

Based on observation, interview and record review conducted during a survey , the facility did not ensure action as a fiduciary (trustee) of the resident's funds and hold, safeguard, manage, and account for the residents' personal funds deposited with the facility for four (Resident #s 1, 15, 16, and 53) of four residents reviewed for personal funds. Specifically, residents were unable to access their personal funds unless Administrator #1 was present in the building. The findings include: A facility policy titled Resident Rights dated 03/22/2026, documented that residents had the right to manage their personal funds, or have the facility manage their funds (if they wished). An undated document included in the Facility admission Agreement titled Resident Fund Management Service documented a resident could have their recurring checks directly deposited to their resident fund account. It also stated the resident would receive a statement of any deposits to and withdrawals from their resident fund account at least quarterly. Per an email sent on 07/08/2026 by Ombudsman #1, during the resident council meetings in January, February, April, and May of 2026, residents complained of not having access to their resident funds. In February, residents stated that they were not getting their Personal Needs Allowance balance statements. Additionally, the following resident-specific financial issues were detailed as below: On 03/12/2026, Resident #15 had been requesting a check to be cashed for them and were unable to resolve the issue until 05/01/2026. On 04/06/ 2026, Resident #55 reported that they were unable to get $50 since 04/02/2026. On 04/27/2026, Resident #66 complained that they had been asking Administrator #1 for access to their money since 04/14/2026. On 05/04/2026 Resident #60 reported that they had been asking for their money since 04/27/2026. On 06/11/2026, Resident #55 stated they had asked for their money, but Administrator #1 was on vacation, and no staff knew how to get money for residents. On 06/15/2026, Ombudsman #1 was told (unknown by who) money would be available Monday through Friday from 8 AM to 4 PM. Ombudsman #1 went to the front desk attendant and was told that they had no idea about money being available and was redirected to Administrator #1. On 06/17/2026 Resident #52 reported they had been waiting three weeks for their money. It was not received until 06/24/2026. During an interview on 07/07/2026 at 9:36 AM, Resident #1 stated that when they wanted money, they had to tell Administrator #1 and then wait weeks to get it. During an interview on 07/07/2026 at 10:24 AM, Resident #53 stated that it took a week to get $100 and they had to ask for it every day. Resident #53 stated that they asked for such a large amount because it took so long to get money when they asked for smaller amounts. During an interview on 07/08/2026 at 9:15 AM, Resident #15 stated they did not believe if they stored their money with the facility, they would be able to access it when they wanted. During an interview on 07/08/2026 at 11:30 AM, Director of Social Work #1 stated they discussed money management with residents. If a resident wanted money, Director of Social Work #1 notified Administrator #1 or Finance Manager #1. Director of Social Work #1 kept a receipt book for keeping documentation of resident money requests and deposits. They believed that if a family member or resident provided cash to the facility for a resident, it was stored in a safe in Administrator #1's office until it could be taken to the bank by Administrator #1. The receipt book would be filled out, and the resident would be given their money. If the request for money was made after business hours, the resident would not be able to get their money until the next day. Residents were told they needed to plan in advance for large amounts and generally try to plan in advance for money requests. Director of Social Work #1 was unable to confirm how much money was available day to day. Director of Social Work #1 stated they had not heard of residents not being able to get money when it was available. They did have one resident ask for money and there was not any available in the building. Director of Social Work #1 stated that sometimes getting money might take a day or two. Administrator #1 was the only person who was able to access the cash box. If large amounts of money were requested, it would require a check to be sent from the corporate office. Typically, getting money was not an issue except on weekends and Friday evenings when there was nobody in the building that could access the money. It had happened but did not happen a lot. Director of Social Work #1 stated it was not safe for multiple people to be able to access the cash box. Director of Social Work #1 also stated that sometimes petty cash would be used to purchase items for residents, but they tried really hard not to combine the use of cash between resident funds and petty cash. During an interview on 07/08/2026 at 12:05 PM with Social Worker #1 and Administrator #1, Administrator #1 stated that they had heard residents were complaining that they could not get their money. Administrator #1 stated that they discouraged resident families from bringing cash or storage at the facility. They did take checks and Administrator #1 would provide the checks to Finance Manager #1 for processing. Typically, Administrator #1 kept $75 to 100 in the cash box, weekends they would leave $100 in it. Administrator #1 stated they had never run out of money in the cash box. During an interview on 07/10/2026 at 12:15 PM, Administrator #1 stated that starting four weeks ago, a cash box was being stored on the nursing unit for off-hours and weekends, and residents were aware of it. 10 New York Code of Rules and Regulations 483.10(f)(10)

Based on observation and interviews conducted during the survey, the facility failed to provide effective housekeeping and maintenance services on 2 of 2 resident units. Specifically, floors, walls, ceilings, and furniture were not clean or maintained. The findings include:During observations on 07/09/2026 at 10:00 AM: The window in room [ROOM NUMBER] had a repair with duct tape adhered to the window. Built-in dresser facades were peeling or worn and/or furniture was chipped in rooms [ROOM NUMBER] and the Adirondack and [NAME] unit nurse stations. Faucets were leaking in rooms [ROOM NUMBERS]. The bathroom door was scrapped in room [ROOM NUMBER]. Patches were not painted and/or walls were scrapped in rooms 120,215 and in the Adirondack Bathing Area suite. Old brackets were on the wall in room [ROOM NUMBER] and the [NAME] Unit corridor. Ceilings soiled around supply ventilation ducts throughout the facility. Ceiling tiles were soiled in the physical therapy room. The floor had rust stains around toilets in rooms 121, 215, 217, and in the Adirondack Bathing Area. Floors were soiled in the [NAME] unit oxygen storage room, Janitor Closet andfloor sink as well as the Adirondack unit nurse station. Thecoving base was missing in rooms [ROOM NUMBERS].During an interview on 07/09/2026 at 10:51 AM, Director of Environmental Services #1 stated that they would repair the furniture, window, andfaucet leaks and would clean the areas noted. New York Codes, Rules, and Regulations Title 10 S415.5(h)(4)

Based on record review, and interviews conducted during the recertification and abbreviated survey (Case #2790264) the facility did not ensure that residents were free from accidents and hazards for the facility and two (Residents # 72 and #75) of six residents reviewed. Specifically, (a) the facility did not provide therapeutic diets to prevent choking and aspiration, (b) Resident #72's care plan was not followed resulting in injury, and (c) the facility did not provide adequate monitoring to keep Resident #75 from suffering from frequent falls. Findings include:The policy and procedure titled Diet Orders, revised 12/12/2025, stated diet orders for each resident originate with a physician's written order with it entered into the electronic medical record system. The policy and procedure titled Food and Nutrition Services, revised 12/12/2025, stated food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident. The policy and procedure titled Aspiration Precautions, revised 05/2022, stated prevention included ensuring staff thickened food and provide diet modification of texture as ordered and to ensure residents receive the right consistency and diet with each meal. A facility policy titled Falls and Fall Risk Managing, dated 12/12/2025, documented that according to the Minimum Data Set, a fall was defined as: Unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force (e.g., a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred.The policy titled Certified Nurse Documentation, dated 12/12/2025, stated care will be delivered as per the resident's plan of care/Kardex.FacilityCross-reference F0808 - Therapeutic Diet Prescribed by PhysicianDuring a meal observation in the dining room on 07/07/2026 at 12:45 PM, Resident #52 was noted to have a pickle spear on their lunch tray and a melted sherbet cup. The lunch ticket stated the resident should have received a mechanical soft diet with nectar (mildly thick) liquids. During an observation of meal trays on 07/07/2026 at 12:45 PM, meal trays for Residents #42, 49, and #71 were to have mechanical soft diets. All three trays contained a pickle spear. The pickle spears were noted to have both skin and seeds. The physician's order for Resident #52 dated 05/05/2026 stated regular diet, mechanical soft texture, mildly thick/nectar liquids consistency. The physician's order for Resident #41 dated 01/27/2026 stated regular diet, mechanical soft texture, thin liquids consistency. The physician's order for Resident #49 dated 07/06/2026 stated no added salt diet, mechanical soft texture, thin liquids consistency. The physician's order for Resident #71 dated 06/21/2023 stated regular diet, mechanical soft texture, thin liquids consistency. During an interview on 07/04/2026 at 12:44 PM, Certified Nurse Aide #1 stated they did not believe a pickle spear should be on Resident #71's plate and removed it. During an interview on 07/07/2026 at 12:45 PM, Licensed Practical Nurse #1 stated a pickle is not part of the mechanical soft diet and Resident #52 should not have received sherbet because it was not a thickened liquid. During an interview on 07/07/2026 at 02:17 PM, Director of Therapy #1 stated there were 13 residents prescribed a mechanical soft diet and three with a puree diet. They stated one resident was prescribed pudding thickened liquid and two with nectar thickened liquid. During an interview on 07/07/2026 at 02:20 PM, Dietary Aide #1 stated a mechanical soft diet meant food was ground and chopped. They stated a pickle should not have been on those trays. During an interview on 07/07/2026 at 02:23 PM, Food Service Director #1 stated mechanical soft foods were anything one could mush, was ground, and had no chunks. They agreed that pickles did not belong on a mechanical soft diet tray. During an interview on 07/07/2026 at 02:45 PM, Administrator #1 stated this should not have happened and education would immediately be provided. They stated the Medical Director #1 was made aware and residents were being monitored. During an interview on 07/10/2026 at 11:55 AM, Medical Director #1 stated they would expect a diet order to be followed, and they were made aware of the incident with the pickles. Resident #72esident #72 had diagnoses that included dementia (a condition affecting memory, thinking, and judgment), traumatic brain injury (an injury to the brain that can impair cognition and physical function), and stroke. The Minimum Data Set assessment dated [DATE] documented the resident was rarely understood and was unable to understand others, was always incontinent of bowel, and required dependent assistance for eating, oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, bed mobility, and transfers. The care plan dated 04/19/2026 documented staff would have provided two-person assistance with transfers using a mechanical lift and assistance with eating, dressing, oral hygiene, and personal hygiene. The facility-reported incident documented,on 03/11/2026, a Certified Nurse Aide was providing incontinent care to the resident without assistance. The Certified Nurse Aide rolled the resident onto the left side, at which time the resident tipped over the edge of the bed, struck the head on the bedside stand, and sustained a laceration to the left forehead. Facility documentation indicated the Certified Nurse Aide received disciplinary action and education regarding following the care plan and the requirement of a two-person assist for care. During an observation on 07/09/2026 10:27 AM, Certified Nurse Aide #5 provided incontinent care to the resident without the assistance of another staff member. The Certified Nurse Aide #5 rolled the resident onto the left side and balanced the resident laterally while providing perineal care and changing the incontinent brief. Following the observation, the Certified Nurse Aide #5 stated they were not aware the resident required a two-person assist. During an interview on 07/09/2026 10:39 AM Certified Nurse Aide #5stated they had been unaware the resident required a two person assist. Resident care requirements are identified on the care card located inside the resident's closet; however, they had acknowledged they had not looked at the care card before providing care. During an interview, Graduate Nurse Manager #1 stated the resident had required a two-person assist for care and that all staff were expected to know their specific needs. Certified Nurse Aide #5 did not follow the correct process for the resident and could have caused a recurrence of a fall. All staff were aware the care card specifics are on the inside of the closet and were expected to reference them for updates and changes. Resident #75 Resident #75 was admitted to the facility with the diagnoses of vascular dementia, mild with agitation (a decline in thinking and memory skills caused by conditions that block or reduce blood flow to the brain), dysphagia (difficulty or discomfort in swallowing), and nondisplaced comminuted supracondylar fracture without intercondylar fracture of left humerus (a break in the lower part of the left upper arm bone just above the elbow joint where the bone cracked into multiple pieces but the fragments remain in their proper position). The Minimum Data Set (a resident assessment tool), dated 2/10/2026, documented the resident sometimes understood others, was sometimes able to be understood and was significantly cognitively impaired. Resident #75's hospital Discharge summary, dated [DATE], documented Resident #75 was admitted to the hospital on [DATE] due to agitation and concerns regarding resident safety. Further documented was that Resident #75 suffered a fall in the hospital on [DATE] and suffered a left humeral head fracture, that was determined not to need surgical intervention. Resident #75 was found on the floor again in the hospital on 1/23/2026 and treated for infection to a wound from a prior heart surgery. The facility fall assessment dated [DATE] at 12:29 PM, documented that Resident #75 was at moderate risk for falls with a score of 16. The facility fall assessment dated [DATE] at 8:11 AM, documented that Resident #75 was at moderate risk for falls with a score of 17. The facility fall assessment dated [DATE] at 7:55 AM, documented that Resident #75 was at low risk for falls with a score of 11. A nursing note dated 2/09/2026 at 10:59 documented that Resident #75 had an unwitnessed fall on 2/06/2026, that day they were admitted to the facility, in which no injury was sustained. A nursing note dated 2/12/2026 at 7:43 PM, documented that Resident #75 was lowered to the floor after being found hanging out of the bed with their legs on the floor but their upper body on the bed. No injuries were noted. A nurses note dated 2/15/2026 at 10:51 PM documented that Resident #75 was observed to have exited their bed and was lying on the floor. No injuries were noted. A nurse's note dated 2/23/2026 at 4:52 PM documented that Resident #75 was found lying on the floor. Resident #75 stated that they had rolled out of bed. No injuries were noted. A nurse's note dated 2/25/2026 at 1:30 AM documented Resident #75's bed alarm was heard and upon entering the room, Resident #75 was found on the floor. Resident #75 stated that they were looking for their spouse. An interdisciplinary team note dated 3/10/2026 at 11:34 AM, documented that Resident #75 fell on 3/09/2026 at 9:20 AM, 11:15 AM, and 4:15 PM. A nurse's note dated 3/11/2026 at 11:42 PM documented that Resident #75 was witnessed standing and sitting themselves on the floor. A follow-up note on 3/12/2026 at 8:59 AM documented that Resident #75 was found seated on the floor on 3/11/2025 at 5:30 PM. A nurses note dated 3/19/2026 at 5:19 PM documented that Resident #75 had exited their wheelchair and was lying on the floor in the hallway. A nurse's note dated 4/09/2026 at 8:01 AM documented that Resident #75 was found sitting on the floor next to their bed. No injuries were noted. A nurses note dated 4/12/2026 at 11:59 documented that Resident #75 fell to the floor from wheelchair while sitting near the nurses' station. Resident #75 was unable to be observed as they were discharged from the facility. The comprehensive care plan for being moderate risk for falls related to confusion, deconditioning, gait/balance problems, and history of fall in hospital, psychoactive medication use, date initiated 2/06/2026 and revised 3/05/2026, had the documented goal of the resident will not sustain serious injury through the review date. The documented interventions were dated and documented as follows: Anticipate and meet Resident #75's needs. Date initiated 2/06/2026, date revised 2/08/2026. Be sure Resident #75's call light was within reach and encourage Resident #75 to use it for assistance as needed. Resident #75 needed prompt response to all requests for assistance. Date initiated 2/06/2026, date revised 3/23/2026. Complete Morse Fall Risk assessment quarterly and as needed. Date initiated 2/06/2026. Educate Resident #75/family/caregivers about safety reminders and what to do if a fall occurred, as appropriate. Date initiated 2/06/2026. Encourage Resident #75 to participate in activities that promoted exercise, physical activity for strengthening and improved mobility such as: Bingo, movies, music, conversation in large dining room. Date initiated 2/06/2026, date revised 3/23/2026. Follow facility fall protocol. Date initiated 2/06/2026. Physical therapy and treat as ordered or as needed. Date initiated 2/06/2026. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/interdisciplinary team as to causes. Date initiated 2/06/2026. Resident #75 needed activities that minimize the potential for falls while providing diversion and distraction. Date initiated 2/06/2026, date revised 2/06/2026. The comprehensive care plan for being high risk for falls related to confusion, gait/balance problems, poor communication/comprehension, psychoactive drug use, unaware of safety needs, date initiated 3/16/2026 and revised 4/17/2026, documented the goal of the resident would not sustain serious injury through the review date. The care plan documented the following: 2/23/2026 slid out of bed 2/25/2026 was found on the floor 3/09/2026 lowered to the floor 3/09/2026 unwitnessed fall in bedroom [ROOM NUMBER]/11/2026 lowered self to floor 3/19/2026 fall 4/09/2026 unwitnessed fall no injury 4/12/2026 witnessed fall with fracture The documented interventions were dated and documented as follows: Anticipate and meet the resident's needs. Ensure call bell was in reach. Date initiated 3/16/2026, date revised 2/23/2026. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as walking, or activities provided for the day. Date initiated 4/09/2026. Date revised 4/09/2026. Follow facility fall protocol. Date initiated 3/16/2026, date revised 3/23/2026. Personal items within reach. Date initiated 3/16/2026, date revised 3/23/2026. Review information on part falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/interdisciplinary team as to causes. Date initiated 3/16/2026. The resident needed activities that minimized the potential for falls while providing diversion and distraction. Resident enjoyed playing cards or board games. Date initiated 4/09/2026, date revised 4/09/2026. During an interview on 7/09/2026 at 10:59 AM, Family Member #2 stated that they were not notified by the facility that Resident #75 fell on 4/13/2026. Family Member #2 stated that Resident #75 told them they had fallen and was in significant pain. Family Member #2 stated that they called the facility and the unnamed nurse stated that they did not know about the fall, had heard Resident #75 moaning but did not ask the resident what was wrong. Family Member #2 stated they requested that Resident #75 be sent to the hospital and the unnamed nurse stated they were too busy to call for a hospital transfer. Family Member #2 stated it was only when they threatened to call emergency services themselves did the nurse respond and call for the hospital transfer. Family Member #2 stated that Resident #75 had a broken hip and required surgery as well as a urinary tract infection. During an interview on 7/09/2026 at 3:20 PM Nurse Practitioner #1 stated that the last Medical Director had a much different practice. Nurse Practitioner #1 stated that they would expect physical therapy involvement after a few falls. The interdisciplinary team discussed falls and incidents in morning meeting daily. They came up with interventions at end of morning meeting. During an interview on 7/10/2026 at 10:50 AM, Director of Nursing #1 stated that education would monitoring would be done to ensure improvement process. Care plans should include documentation for every fall, every time. Interventions should be explored every time. Care plans should be revised and updated as needed. Root causes should be looked for. During an interview on 7/10/2026 at 11:42 AM, Medical Director #1 stated that all falls should be told to the provider and a root cause analysis done. Sending a resident to the emergency room should be done by a provider after the provider assessed the resident to see if the situation could be managed in the facility. Medical Director #1 believed that the staff had been given a lot of autonomy to make decisions, and they were adjusting to the new way of doing things. During an interview on 7/10/2026 at 2:15 PM, Administrator #1 stated that a lot of staff were new and that they were changing the way the facility was run prior to being taken over. Administrator #1 stated they wanted best practices from their staff and to follow the regulations. Administrator #1 stated the Director of Nursing #1 was going to be intimately involved with process improvement and monitoring. 10 New York Codes, Rules, and Regulations 415.12 (h)(1)(2)

Based on record review, interviews and observations, the facility failed to provide food that was palatable and at a preferred temperature according to professional standards. Specifically resident trays were served with flat ginger ale and melted sherbet, as well as food that was bland with no taste at not at a preferred temperature.Findings include: Review of policy titled Food and Nutrition Services dated 12/2025, documents each resident will be provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. During a dining observation on 07/07/2026 at 12:10 PM, a sample tray was observed with the following results: 1) cheeseburger casserole 127.5 degrees, bland, no taste, 2) Raspberry sherbet, melted, 3) ginger ale 58.8 degrees, flat, served in a paper cup. During a dining observation on 07/08/2026 at 1:15 pm, a sample tray was observed with the following results: 1) fruit salad, 71.2 degrees, 2) chicken (109 degrees Fahrenheit) pasta and mushrooms (115 degrees Fahrenheit,) 3) cooked carrots, 106 degrees, 4) coffee, 131 degrees, 5) apple juice 67.2 degrees, 6) cranberry juice, 69.1 degrees. No sugar or condiments noted on the tray and drinks were served in paper cups. During an interview on 07/06/2026 at 1:38 PM, Resident #8 stated that the food in the facility is not very good. Stated that they eat a lot of sandwiches. Stated when the food comes, only the coffee is hot. During an interview on 07/06/2026 at 2:00 PM, Resident #4 stated that the food is not good. During an interview on 07/06/2026 at 2:20 PM, Resident #3 stated that meal portions are too small. Stated they have given their own food, so someone has enough to eat. Stated sometimes people will go to the food trays in the halls to get something to eat from them. During an interview on 07/06/2026 at 2:30 PM, Resident #15 stated the food is horrible and often order out and has food in their room for when they are hungry. During an interview on 07/07/2026 at 8:42 AM, Resident #10 stated their breakfast was cold, the eggs were not very good. During an interview on 07/07/2026 at 9:05 AM, Resident #13 stated the food isn't too good. States that hot foods do not come hot. During an interview on 07/07/2026 at 9:41 AM, Resident #1 stated their diet is wrong so they can't eat the food and what they can eat is cold or overcooked. During an interview on 07/07/0226 at 10:27 AM, Resident #53 stated the food doesn't always taste good. Stated they tend to eat a lot of sandwiches because the main meal isn't very good. During an interview on 07/07/2026 at 11:51 AM, Resident #66 stated that food portions are small and when they ask for second servings, they are not provided. During an interview on 07/07/2026 at 12:01PM, Resident #69 stated the food is horrible. Stated hot food is never hot and the taste is poor. Stated they will often order out for meals. During an interview on 07/09/2026 at 9:26 AM, Resident #69 noted to have breakfast tray on overbed table. Resident eating meal of eggs, toast, coffee. Resident states food and coffee are cold. During an interview on 07/10/2026 at 9:36 AM, Food service Director #1 stated food issues were discussed at resident council, and they attended resident council meetings when the residents discussed the food. They wrote down notes on menu ideas and thoughts during the meeting. They had a menu; they went over with the dietician. There is a regular main meal and then an alternative every day. There was no separate food committee. During an interview on 07/10/2026 at 12:15PM, Administrator #1 stated dining was an ongoing issue. There was a company-wide push for improving food service. 10 New York Codes of Rules and Regulations 415.14(d)(2)

Based on observations, interviews, and record reviews during the survey, the facility failed to provide residents with a therapeutic diet prescribed by a physician. Specifically, residents with physician orders for mechanical soft diets received pickles on their meal tray. Findings include: The policy and procedure titled Diet Orders, revised 12/12/2025, stated diet orders for each resident originate with a physician's written order with it entered into the electronic medical record system. The policy and procedure titled Food and Nutrition Services, revised 12/12/2025, stated food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident. The policy and procedure titled Aspiration Precautions, revised 05/2022, stated prevention included ensuring staff thickened food and provide diet modification of texture as ordered and to ensure residents receive the right consistency and diet with each meal. During a meal observation in the dining room on 07/07/2026 at 12:45 PM, Resident #52 was noted to have a pickle spear on their lunch tray and a melted sherbet cup. The lunch ticket stated the resident should have received a mechanical soft diet with nectar (mildly thick) liquids. During an observation of meal trays on 07/07/2026 at 12:45 PM, meal trays for Residents #42, 49, and #71 were to have mechanical soft diets. All three trays contained a pickle spear. The pickle spears were noted to have both skin and seeds. The physician's order for Resident #52 dated 05/05/2026 stated regular diet, mechanical soft texture, mildly thick/nectar liquids consistency. The physician's order for Resident #41 dated 01/27/2026 stated regular diet, mechanical soft texture, thin liquids consistency. The physician's order for Resident #49 dated 07/06/2026 stated no added salt diet, mechanical soft texture, thin liquids consistency. The physician's order for Resident #71 dated 06/21/2023 stated regular diet, mechanical soft texture, thin liquids consistency. During an interview on 07/04/2026 at 12:44 PM, Certified Nurse Aide #1 stated they did not believe a pickle spear should be on Resident #71's plate and removed it. During an interview on 07/07/2026 at 12:45 PM, Licensed Practical Nurse #1 stated a pickle is not part of the mechanical soft diet and Resident #52 should not have received sherbet because it was not a thickened liquid. During an interview on 07/07/2026 at 02:17 PM, Director of Therapy #1 stated there were 13 residents prescribed a mechanical soft diet and three with a puree diet. They stated one resident was prescribed pudding thickened liquid and two with nectar thickened liquid. During an interview on 07/07/2026 at 02:20 PM, Dietary Aide #1 stated a mechanical soft diet meant food was ground and chopped. They stated a pickle should not have been on those trays. During an interview on 07/07/2026 at 02:23 PM, Food Service Director #1 stated mechanical soft foods were anything one could mush, was ground, and had no chunks. They agreed that pickles did not belong on a mechanical soft diet tray. During an interview on 07/07/2026 at 02:45 PM, Administrator #1 stated this should not have happened and education would immediately be provided. They stated the Medical Director #1 was made aware and residents were being monitored. During an interview on 07/10/2026 at 11:55 AM, Medical Director #1 stated they would expect a diet order to be followed, and they were made aware of the incident with the pickles. 10 New York Codes, Rules, and Regulations 415.14(e)

Based on observation, record review, and interviews during the survey, the facility failed to store, prepare, distribute or serve food in accordance with professional standards for food service safety in the main kitchen and unit nourishment station. Specifically, the dishwashing machine final-rinse water pressure was low, equipment was not in good repair, and surfaces were not clean. The findings include:During observations of the main kitchen and unit nourishment station on 07/06/2026 at 12:44 PM:The dishwashing machine final rinse water pressure was 13 pounds per square inch; the dishwashing machine information plated stated that the final rinse water pressure was to be between 15 and 25 pounds per square inch.The bulk food bins were not labeled and the exteriors were soiled with food particles.In the Nourishment Station: the microwave oven interior was rusty & worn, and the refrigerator, ceiling, catch bin below ice machine, and the floor in corners were soiled with food particles and/or dirt. During an interview on 07/06/2026 at 1:11 PM, Director of Food Service #1 stated that they would clean and label the bulk food containers and speak with maintenance about the issues in the Nourishment Station. New York Codes, Rules, and Regulations Title 10 S415.14(h)

Based on observation, interview, and record review conducted during a survey, the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one of one resident (Resident #66) reviewed. Specifically, Resident #66 had seen an orthopedic provider who advised surgical intervention for their decreased range of motion in their right shoulder, the resident reported to the facility they wanted to proceed with surgical procedure and there was no documented evidence the facility made attempts to follow up with the provider or schedule required appointments to proceed with the surgery.Findings include: Facility policy titled Resident Mobility and Range of Motion dated 05/2026 documented, residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. Resident #66 Resident #66 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs), chronic pain, and major depressive disorder (mood disorder that significantly impacts one life). The Minimum Data Set (an assessment tool) dated 04/24/2026, documented that the resident could be understood, could understand others, and was cognitively intact. Orthopedic consult dated 03/20/2026 documented, Resident #66 had a significant decrease in range of motion in their right shoulder. The provider offered the resident two options for treatment, including surgical intervention. The resident stated they would consider surgical intervention and report back to provider. Nursing progress note dated 04/06/2026 by Graduate Nurse #1 documented the resident had decided to proceed with surgery on their right shoulder, writer would call to schedule preoperative appointment. There was no documented evidence of notification to or from the orthopedic provider of surgery approval, scheduled preoperative appointment, or attempts to schedule preoperative appointment. During an interview on 07/07/2026 at 11:30 AM, Resident #66 stated they had needed surgery for a rotator cuff repair and had been asking to schedule the surgery. The surgery had not been scheduled yet. During an interview 07/09/2026 at 10:21 AM, Graduate Nurse #1 stated they were made aware the resident had decided to proceed with shoulder surgery. The orthopedic provider had approved surgery around 04/20/2026. Since then, they had been calling to schedule the resident for a preoperative appointment. The preoperative appointment had been scheduled. During an interview on 07/10/2026 at 11:00 AM, Director of Nursing #1 stated their expectation would be if the resident had decided to proceed with a recommended procedure in April 2026, there should be progress notes indicating follow up and an appointment scheduled for preoperative clearance, the appointment may be months away but still should be scheduled. One note in April with no appointment or follow up is not acceptable. 10 New York Codes, Rules, and Regulations 415.12 (e)(2)

Based on observations, record review, and interviews conducted during the recertification and abbreviated survey (Case #2790264), the facility did not ensure that residents were free from abuse and misappropriation for one (Resident #s 15) of 23 residents reviewed for abuse prevention. Specifically for Resident #15, the facility failed to protect the resident from having their debit card used by staff for personal reasons.The findings include:A facility policy titled Identifying Exploitation, Theft and Misappropriation of Resident Property, dated 3/07/2022, documented in relevant part, that exploitation, theft and misappropriation of resident property was strictly prohibited. It was understood by the leadership in this facility that preventing these occurrences required staff education and training. Exploitation meant taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats or coercion. Misappropriation of resident property meant the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. Examples of misappropriation of resident property included:identity theft;theft of money from bank accounts;unauthorized or coerced purchases on the resident's credit card:coercion to provide gifts in exchange for ongoing care;manipulating the resident into providing monetary support or assistance;drug diversion (taking the resident's medication); andtheft of personal belongings.Staff and providers were expected to report suspected exploitation, theft or misappropriation of resident property. A facility submitted incident dated 2/06/2026 documented that on 2/05/2026 Resident #15 became aware that their debit card had been used while they were in the hospital and reported it to the police. At that time, Resident #15 had stated that they had given their card to a staff member with permission to use it. Human Resource Director #2 admitted that they used Resident #15's debit card and stated they had been given permission to do so by Resident #15. Human Resource Director #2 was suspended pending investigation and then terminated for violating the facility policy of not accepting anything of value from facility residents. On 2/26/2026, Resident #15 retracted that statement and stated that they had not told the accused staff member they could use their card. The incident was reported to New York State Department of Health, and all staff were in serviced on the facility gift policy. Resident #15 Resident #15 was admitted to the facility with the diagnoses of quadriplegia (a partial or total loss of motor function and sensation in all four limbs and the torso), idiopathic progressive neuropathy (nerve damage that gradually worsens over time, where the underlying cause remains unknown even after extensive medical testing), and hypothyroidism (a common condition where the thyroid gland did not produce enough thyroid hormones to meet the body's need). The Minimum Data Set (a resident assessment tool), dated 4/03/2026, documented the resident was able to be understood, understood others and was cognitively intact. During an interview on 7/08/2026 at 8:52 AM, Resident #15 debit card was taken in January 2026 and used by Human Resources Director #2. Resident #15 became emotional and stated that they thought they were friends, which was why they had let Human Resources Director #2 use the card. They did not know that Human Resources Director #2 was going to spend that much money. Human Resources Director #2 was fired, and the facility was supposed to reimburse Resident #15 $215 but had not yet done so. Resident #15 then took a phone call, and the interview was terminated. During an interview on 7/08/2026 at 11:30 AM, Director of Social Work #1 stated that they had followed up with Resident #15 after the debit card incident and did not believe that Resident #15 was stressed about it. Director of Social Work #1 stated they believed that the resident was more upset that Human Resources Director #2 had to suffer consequences. Director of Social Work #1 stated that sometimes employees would purchase items for residents and there would be a receipt and withdrawals signed by both the resident and a witness. This process was started in January 2026. During an interview on 7/08/2026 at 3:14 PM, Administrator #1 stated that Resident #15 had been reimbursed $215 into their resident account. Administrator #1 stated that Resident #15 should know that. Administrator #1 stated that Resident #15 would spend their checks and had not paid their bill with the facility for a period of time. The facility had become Resident #15's representative payee and taken care of their outstanding balance. Administrator #1 stated that they thought Resident #15 had taken issue with having their money managed for them because Resident #15 liked to shop and with the facility running their money, Resident #15 had less freedom to shop as they liked. During an interview on 7/10/2026 at 10:50 AM, Director of Nursing #1 stated that they would be doing a lot of education with the staff and tangibility would be forthcoming. During an interview on 7/10/2026 at 2:15 PM, Administrator #1 stated that a lot of staff were new and that they were changing the way the facility was run prior to being taken over. There should not be a mixing of petty cash and resident funds and there was a new process in place that made it easier for residents to access their funds which would decrease the likelihood of residents asking staff to purchase things for them. Administrator #1 stated they wanted best practices from their staff and to follow the regulations. Administrator #1 stated the Director of Nursing #1 was going to be intimately involved with process improvement and monitoring. 10 New York Code of Rules and Regulations 483.12

Based on record reviews and interviews during the survey, the facility failed to ensure the Preadmission Screening and Resident Review was complete prior to admission for one of 23 residents reviewed. Specifically, for Resident #3, question #23 was left blank and the Level I review for possible mental illness was not completed. Findings include: The policy and procedure titled Pre-admission Screening and Resident Review, dated 12/12/2025, stated all residents should have the required preadmission screen prior to admission to the facility. Resident #3 Resident #3 was admitted to the facility with the diagnoses of malignant neoplasm of the bladder (abnormal growth of cells that starts in the bladder lining), type 2 diabetes mellitus (a chronic metabolic disease characterized by high blood sugar levels), and depression (a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities). The Minimum Data Set (an assessment tool, dated 06/19/2026, documented the could understand others and could be understood by others, and was cognitively intact. The Minimum Data Set documented the resident had a psychiatric/mood disorder. The document titled Screen Form : DOH-695, signed 03/20/2026, was incomplete as question #23 : Does this person have a serious mental illness was left blank. During an interview on 07/10/2026 at 11:30 AM, Admissions #1 stated the blank question should have been caught. They stated they were responsible to scan the documents and send to the team. They stated they would expect the screen to be reviewed but was unable to say who would be responsible for reviewing screens. During an interview on 07/10/2026 at 11:37 AM, Director of Social Work #1 stated they didn't typically review the screens and didn't know who was responsible for reviewing screens prior to admission for completion. 10 New York Codes, Rules, and Regulations 415.11(e)

Based on interview and record review conducted during a survey, the facility failed to provide or obtain from an outside resource, in accordance with routine and emergency dental services to meet the needs of each resident for one of two residents (Resident #66) reviewed. Specifically, Resident #66 was not offered or provided dental care since 11/2025.Findings include: Facility undated policy titled Availability of Dental Services documented, the facility would assist residents in obtaining routine dental services, routine 24-hour emergency dental care. Dental care shall be provided through the services of a Consultant Dentist. Resident #66 Resident #66 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs), chronic pain, and major depressive disorder (mood disorder that significantly impacts one's life). The Minimum Data Set (an assessment tool) dated 04/24/2026, documented that the resident could be understood, could understand others, and was cognitively intact. Observation on 07/07/2026 at 11:30 AM, Resident #66 was in the main dining area socializing with other residents. They appeared well groomed with their own teeth. Dental consult form documented Resident #66 refused dental care 6/2025 and 11/2025. There was no documented evidence of a follow up plan for the resident. There was no documented evidence of dental care provided prior to 6/2025. During an interview on 07/07/2026 at 11:30 AM, Resident #66 stated they had not seen a dentist in over a year. There was no dentist that had come to the facility since 11/2025. During an interview on 07/08/2026 at 12:50 PM, Administrator #1 stated the facility contracted with Dentist #1 to provide dental care for the residents; and they would provide the contract. Subsequently on 07/10/2026 at 9:30 AM, they provided a phone number for Dentist #1. During an interview on 7/09/2026 at 3:20 PM, Nurse Practitioner #1 stated dental should see residents at least yearly and maybe every six months for cleaning. During an interview on 07/10/2026 at 10:49 AM, Director of Nursing #1 stated dental services should be provided to residents annually and on an as needed basis. If a resident refused dental care, they would expect the resident would be reapproached prior to six months, and refusal documentation would include a plan to follow up with resident. Attempts to interview Dentist #1 were unsuccessful, the office was closed for holiday 07/06/2026-07/10/2026. Emergency phone number on recording for the office indicated to call the covering dental provider in the area. 10 New York Codes, Rules, and Regulations 415.17(a-d)

Based on record reviews and observations conducted during the survey, the facility failed to ensure respiratory care was provided according to professional standards. Specifically, for three (Resident #s 53, 8 and 23) of three residents, the facility failed to ensure the humidifying container attached to the oxygen concentrator and nasal cannula contained water.Findings include: Record review of policy titled Administration of Oxygen dated 03/2022, documents staff is to be sure there is water in the humidifying container and that the water level is high enough that the water bubbles as oxygen flows through. Periodically re-check water level in humidifying container. Resident #53 was admitted to the facility with diagnoses of heart failure (a chronic, progressive condition where the heart muscle becomes weakened or stiff and cannot pump enough blood to meet the body's needs for oxygen and nutrients,) chronic obstructive pulmonary disease (a progressive lung disease that makes it hard to breathe,) and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (partial weakness or total paralysis on the right side of the body, which is the dominant side, caused by a stroke or blood clot in the brain.) The Minimum Data Set (MDS, an assessment tool) dated 05/08/2026, documented the resident could be understood and understood others and was cognitively intact. Resident #8 was admitted to the facility with diagnoses of hemiplegia and hemiparesis following cerebral infarction (complete paralysis and weakness, resulting from damage to the brain's motor pathways following a stroke (a medical emergency that happens when blood flow to the brain is blocked or a blood vessel in the brain ruptures,)) chronic obstructive pulmonary disease (a progressive lung disease that makes it hard to breath,) and schizoaffective disorder, bipolar type (a chronic mental health condition combining the hallmark psychotic features of schizophrenia (like delusions and hallucinations) with the severe mood swings of bipolar disorder (episodes of mania and depression.)) The Minimum Data Set (MDS, an assessment tool) dated 04/03/2026, documented the resident was sometimes understood and sometimes understood others and had moderate cognitive impairment. Resident #23 was admitted to the facility with diagnoses of unspecified combined systolic (congestive) and diastolic (congestive) heart failure (a condition that occurs when the heart muscle both fails to pump with enough force and cannot relax to fill with adequate blood,) Chronic obstructive pulmonary disease (a progressive lung disease that makes it hard to breath,) and hyperlipidemia (a medical term for having too many lipids (fats,) such as cholesterol and triglycerides, in the blood.) The minimum data set (MDS, an assessment tool) dated 05/08/2026 documented the resident could be understood and understood others and was cognitively intact. During an observation on 07/07/2026 at 10:37 AM, Resident #53 observed in bed, with oxygen on via nasal cannula. Nasal cannula date 07/06/2026 observed to be connected to oxygen concentrator via humidifier bottle. Observed concentrator running at one liter per minute, with humidifier bottle empty, no water observed in bottle. During an observation on 07/07/2026 at 11:17 AM, Resident #8 observed resting in bed, dressed in clean clothing, wearing oxygen cannula. Oxygen cannula date 07/06/2026 attached to oxygen concentrator via humidifier bottle. Humidifier bottle noted to be empty, contained no water, concentrator running at two liters per minute. During an observation on 07/08/2026 at 9:53 AM, Resident #53 observed in bed, dressed for the day, nasal cannula in place with oxygen running at one liter per minute. Observed nasal cannula attached to concentrator via empty, undated humidifier bottle. Observed no water in humidifier bottle. During an observation on 07/09/2026 at 9:36 AM, Resident #53 observed in room, resting in bed, wearing nasal cannula. Nasal cannula observed attached to oxygen concentrator via empty humidifier bottle. Observed concentrator running at one liter per minute. During an observation on 07/09/2026 at 11:04 AM, Resident #8 observed in room, laying down in bed. Resident #8 observed wearing oxygen cannula attached to concentrator via empty humidifier bottle. Concentrator observed to be running at two liters per minute. During an observation on 07/09/2026 at 11:14 AM, the oxygen concentrator of Resident #23 was observed in room at bedside. Noted to have oxygen cannula date 07/06/2026 draped over concentrator, attached via humidifier bottle. Observed humidifier bottle did not contain any water at that time. Record review of Resident #53 orders shows active order for Oxygen: run one liter via nasal cannula every shift for chronic obstructive pulmonary disease. Record review of Resident #53 orders shows active order to change oxygen tubing and clean filter every week on Tuesday night, night shift for Oxygen maintenance, date and initial tubing. Record review of Resident #53 care plan titled impaired respiratory status related to chronic obstructive pulmonary disease and hypoxemia documents interventions of oxygen at one liter per minute via nasal cannula. Record review of Resident #8 orders shows active order for supplemental humidified oxygen at two liters per minute via nasal cannula, every shift for chronic obstructive pulmonary disease. Record review of Resident #8 orders shows active order to change oxygen tubing and clean filter every week on Tuesday night, night shift for oxygen maintenance, date and initial tubing. Record review of Resident #8 care plan titled Impaired respiratory status related to chronic obstructive pulmonary disease, smoker documents intervention of oxygen via nasal cannula at two liters per minute. Record review of Resident #23 orders shows active order to apply oxygen at two liters via nasal cannula at hour of sleep and as needed for chronic obstructive pulmonary disease. Record review of Resident #23 orders shows active order to change oxygen tubing and clean filter every week on Tuesday night, night shift for oxygen maintenance, date and initial tubing. Record review of Resident #23 care plan titled Cardiovascular and Respiratory status documents intervention of Oxygen two liters via nasal cannula at hour of sleep and as needed. During an interview on 07/08/2026 at 9:37 AM, Graduate Nurse #1 stated that any resident with a concentrator that had a humidifier bottle on it should have water in the humidifier bottle. Stated oxygen tubing and the humidifier bottles are changed and filled weekly and as needed. 10 New York Codes, Rules, and Regulations 415.12(k)(6)

Based on observation, interview, and record review conducted during a survey, the facility failed to label and store drugs and biologicals according to professional standards for one of one medication storage room (Adirondack unit) reviewed and one of one medication cart reviewed ([NAME] unit). Specifically, one stock medication had expired in the medication room, one resident medication in stock medication storage, the refrigerator in the medication room containing medications was not monitored for appropriate temperature, and nine loose pills were found in the medication cart. Findings include: The facility policy titled Storage -Labeling - Maintenance of Medications dated 12/12/2025 documented, medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The refrigerator must maintain a proper temperature of 36-46 degrees Fahrenheit. Medication must be checked regularly for expiration dates and deterioration. Medication carts and cabinets shall be kept in well-lit areas and be of sufficient size to permit storing without undue crowding. The medicine preparation area is to be maintained in a clean and organized manner. Expired medications are removed from use and returned to the pharmacy. During an observation on 07/08/2026 at 10:44 AM, Adirondack medication room contained one expired bottle labeled stool softener. The stock bottle of stool softener had a manufacture expiration date of 02/2026. The stock medication cabinet contained one medication with a pharmacy label for Resident #7. The refrigerator containing resident medication had a daily shift monitoring log labeled June 2026. Five signatures for the month of June 2026 were present. There was not a temperature monitoring log for July of 2026. During an observation on 07/08/2026 at 11:00 AM, [NAME] medication carts second draw contained nine loose unidentified pills; one round yellow pill, one oblong yellow pill, two small pink round pills, one round orange pill, three round white pills in various sizes, and one half of a blue oblong pill. During an interview on 07/08/2026 at 10:44 AM, Licensed Practical Nurse #2 stated there should not be expired medication in the medication carts or the medication storage room, andit is every nurse's responsibility to ensure the expired medications are removed and disposed of. There should not be resident specific medication in with the stock medication. They believed Resident #7's medication was placed in the stock medication area because the resident was not currently using the medication. The temperature monitoring for medication room refrigerator should be monitored daily at minimal, although they were supposed to document every shift. During an interview on 07/08/2026 at 11:00 AM, Licensed Practical Nurse #1 stated they could not identify loose medications found in the second draw of medication cart. They stated loose tablets should not be in the medication cart; the medication cart was so full they were not able to see the loose pills in the cart. During an interview on 07/10/2026 at 10:49 AM, Director of Nursing #1 stated their expectations were the refrigerators temperatures in the medication rooms were to be monitored and documented on the temperature log daily. There should be no expired medications in the medication carts or medication rooms. 10 New York Codes, Rules, and Regulations 415.18(d)

Based on record review and interviews during a survey, the facility failed to maintain acceptable parameters of nutrition status, such as usual body weight, or desirable body weight range and recognized, evaluated, and addressed the needs of a resident at risk of or already experiencing impaired nutrition and hydration for one (Resident #64 ) of two residents reviewed. Specifically, Resident #64 had a care plan with focus of having a nutrition problem or potential nutrition problem that was initiated on 07/21/2025. When Resident #64 demonstrated a severe weight loss (7.4 pounds) between 04/09/2026 and 05/04/2026, the loss was not evaluated or addressed by a provider. In addition, there was no documented evidence of a nutritional assessment for Resident #64 between 10/20/2025 and 04/17/2026. Findings include: Facility policy titled Food and Nutrition Services effective 12/2025 documented each resident was provided with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs. The multidisciplinary staff, including nursing staff, attending physician, and the dietician would assess each resident's nutritional needs, food likes, dislikes, and eating habits, as well as physical, functional and psychosocial factors that affect eating and nutritional intake utilization. A resident-centered diet and nutrition plan would be based on this assessment. Facility policy titled Management of Hydration and Nutrition effective 11/10/2022 documented it was facility policy to ensure adequate fluids were available and offered for resident consumption, that a therapeutic diet was offered and ordered if there were any nutritional issues, and to monitor the residents at risk for malnutrition and dehydration, and that interventions were established to address these potential issues. Procedure included the dietician would assess all residents for hydration as part of the comprehensive assessment, at least quarterly, and more often as necessary per resident need. All staff were to be vigilant to monitor/recognize potential indicators of inadequate nutrition/hydration which included unintentional weight loss. Resident #64 was admitted to the facility with the diagnoses of displaced intertrochanteric fracture of the right femur (a break in the upper part of the thigh bone, just outside the hip joint capsule), unspecified dementia, unspecified severity ( when a person clearly has cognitive decline and memory loss, but the exact underlying cause cannot be definitively determined), and chronic obstructive pulmonary disease (a progressive, incurable lung disease that restricts airflow and makes breathing difficult. The Minimum Data Set (MDS, an assessment tool) dated 04/17/2026 documented the resident could make theirself understood, understood others, and had severe cognitive impairment. Comprehensive Care Plan with focus Nutrition: Resident has nutritional problem or potential nutritional problem related to dementia, hypertension, and chronic obstructive pulmonary disease initiated 07/21/2025, revised 04/05/2025 documented as goals Weight will remain stable +/- five percent of 113 pounds initiated 04/18/2026 and Resident will continue to feed their self initiated 04/18/2026. Interventions initiated on 07/21/2025 included: Keep upright 30-60 minutes after meals (revised 03/12/2026), monitor meal intake, Registered Dietician to evaluate and make diet change recommendations, regular diet as ordered (revied 08/06/2026), weigh weekly and as requested (revised 03/12/2026).Resident #64's weight was documented in their electronic medical record as follows:On 04/09/2026, the resident weighed 112.6 pounds. On 05/04/2026, the resident weighed 105.2 pounds. This was a negative 6.57 percent loss, which was considered severe.On 06/04/2026, the resident weighed 104.4 poundsFrom 04/09/2026 to 06/04/2026, the resident lost 8.2 pounds and demonstrated a 7.28 percent body weight loss. Dietary progress note dated 10/20/2025 documented Resident #64's weight was stable this quarter and they remained on a regular diet, was feeding theirself after set-up, and goals were being met this quarter.Quarterly Nutritional Progress note dated 04/17/2026 documented Resident #64's current weight was 113 pounds. Body mass index (BMI, a screening tool used to estimate body fat based on a person's height and weight) was 19.9 which indicated the low end of healthy weight range, however stable. Resident #64's current diet was regular solids with thin liquids. Physician orders, diagnoses and progress notes were reviewed and there were no additional changes to the plan of care at this time. There was no documented evidence in Resident #64's electronic medical record of a nutritional assessment between 10/20/2025 and 04/17/2026. There was no documented evidence of interventions put in place to address Resident #64's weigh loss from 04/09/2026 through 06/04/2026. During a telephone interview on 07/09/2026 at 12:54 PM, Registered Dietician #1 stated dietary assessments were completed for residents upon initial admission and readmission to the facility, quarterly, annually, and with any significant change. They stated they completed a nutritional assessment for Resident #64 on 04/17/2026, but they could not locate the previous quarterly assessment in the resident's electronic medical record. They were providing remote coverage for the facility since March of 2026 as the facility's Registered Dietician was on medical leave. They stated when they have recommendations, they email or speak over the phone with the providers. They stated there were no new interventions put into place when Resident #64 demonstrated the weight loss from 04/09/2026 through 06/04/2026. They would expect to see new intervention(s) on the care plan to address the weight loss. During an interview on 07/09/2026 at 1:44 PM, Nurse Practitioner #2 stated if a resident had a severe weight loss in a month, they needed to investigate the cause so appropriate interventions could be put into place. They stated they wanted to make sure residents were getting the nutrition they needed, and if they were not getting it from foods, they may be able to get it from supplements. They stated they would expect to be notified if a resident had a seven pound weight loss within a month. Upon reviewing Resident #64's electronic medical record during this interview, they did not see any new interventions put into place after this weight loss. During a telephone interview on 07/09/2026 at 3:18 PM, Nurse Practitioner #1 stated if there was a three or five percent weight loss in a 30-day period for a resident, the Registered Dietician would reach out and send an email to notify them. The Registered Dietician may recommend some kind of nutritional supplement or appetite stimulant. For the weight loss that Resident #64 demonstrated, they would expect to be notified and new interventions to address the loss should be on their care plan. They could not recall if Resident #64 had a weight loss. During an interview on 07/10/2026 at 10:02 AM, Director of Nursing #1 stated if a resident had a significant weight loss in a month, the expectation would be to identify the root cause and put interventions in place to address the weight loss. During an interview on 07/10/2026 at 11:43 AM, Medical Director #1 stated they would expect to be notified if a resident had a significant weight loss in a month as there were many etiologies that could have caused the weight loss. They would expect an assessment to be done to figure out why the weight loss occurred. 10 New York Codes, Rules, and Regulations 415.12(i)(1)

Based on observation, record review, and interview during a survey, the facility failed to ensure residents received complete activities of daily living care by failing to provide oral care for three of four residents observed during activities of daily living care.(Resident #5. 27, #28 and #72 reviewed) This deficient practice had the potential to adversely affect residents' oral hygiene, comfort, nutritional status, and overall health. Specifically, for Resident #5, hygiene assistance was not provided for the resident over consecutive days. Findings include: The facility policy, Activities of Daily Living, revised 10/2020, documented, based on the comprehensive assessment and consistent with the resident's needs and choices, care and services would be provided to maintain the resident's current activities of daily living status. The policy identified hygiene, including oral care, as a required activity of daily living. The policy further stated an individualized plan of care would identify the specific activities of daily living requiring assistance, the frequency and level of assistance, and that care would be documented. The facility policy Maintaining Resident Respect and Dignity, revised 02/27/2026, documented, the facility would provide care in a manner that maintained each resident's dignity, respect, compassion, sensitivity, and concern. The policy stated staff would respect residents' care needs by honoring personal appearance preferences, providing grooming, assuring residents were aware of care before care was provided, and treating residents with dignity and respect during all care interactions. Resident #28 had diagnoses that included neurocognitive disorder with Lewy bodies (a progressive form of dementia affecting thinking, movement, and behavior), severe vascular dementia (decline in cognitive function caused by reduced blood flow to the brain), and repeated falls (a history of recurrent falls placing the resident at increased risk for injury). The Minimum Data Set assessment dated [DATE] documented the resident was rarely understood and was unable to understand others, required supervision for eating, oral hygiene, and personal hygiene, and extensive assistance with toileting hygiene, bathing, dressing, and putting on and taking off footwear. The care plan dated 03/07/2025 documented the resident would have been checked for incontinence every two to three hours and as needed, provide routine incontinence care, toilet the resident every two to three hours and as needed, cleanse the perineal area after each incontinent episode, and provide assistance with activities of daily living according to the resident's assessed needs. Resident #72 had diagnoses that included dementia (a condition affecting memory, thinking, and judgment), traumatic brain injury (an injury to the brain that can impair cognition and physical function), and stroke. The Minimum Data Set assessment dated [DATE] documented the resident was rarely understood and was unable to understand others, was always incontinent of bowel, and required dependent assistance for eating, oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, bed mobility, and transfers. The care plan dated 04/19/2026 documented staff would have provided two-person assistance with transfers using a mechanical lift and assistance with eating, dressing, oral hygiene, and personal hygiene. The cognitive care plan dated 12/30/2025 documented staff would reorient and supervise the resident as needed due to impaired cognitive function and inability to fully express needs and understand others. On 07/09/2026 at 10:21 AM, activity of daily living care was observed for Resident #28. Certified Nurse Aide #3 stated this was the first care provided to the resident during the shift. Resident #28 was observed in bed, completely saturated with identifiably urine, and stated they were freezing. There was also a full urinal at the bedside. Certified Nurse Aide #3 provided a bed bath and changed the resident; however, upon completion of care, oral care was not offered or provided. During an interview on 07/09/2026 at 10:31 AM, Certified Nurse Aide #3 stated it had been the first time Resident #28 was changed during their shift. Certified Nurse Aide #3 stated the resident had likely last been changed by the previous shift at approximately 6:20 AM. Certified Nurse Aide #3 acknowledged that, if the resident had been changed at appropriate intervals, they would not have leaked through to their clothing. During an observation on 07/09/2026 at 10:44 AM, activity of daily living care was observed for Resident #72. Certified Nurse Aide #5 performed a complete bed bath and identified the bed bath as the resident's morning care. During the latter portion of care, Certified Nurse Aide #5 recognized the resident's care plan required the assistance of two certified nurse aides and requested assistance from Certified Nurse Aide #6, who assisted with completion of the care. Following completion of the activity of daily living care, oral care had not been provided. During an interview on 07/09/2026 at 11:00 AM, Certified Nurse Aide #5 stated the resident often had become combative during oral care and resisted the care being performed. Certified Nurse Aide #5 stated they had usually documented that the resident refused oral care because it was difficult to obtain the resident's cooperation. They maintained they would report the lack of oral care to the charge nurse when it occurred. During an interview on 07/09/2026 at 11:02 AM, Certified Nurse Aide #6 stated they had been unfamiliar with the resident's combative behavior during oral care but acknowledged oral care had not been completed. They described the importance of oral care to a resident's health and wellness. During a review of Resident #72's June 2026 Activity of Daily Living Oral and Personal Hygiene documentation log revealed oral hygiene was consistently documented as provided, with the oral hygiene component primarily coded dependent, indicating staff completed the care. No documentation was identified during the June 2026 review indicating resident refusal of oral hygiene. During an interview on 07/09/2026 at approximately 12:30 PM, Nurse Manager #1 stated they had been unaware of Resident #72 not receiving oral care. Staff were expected to document all refusals and/ or behaviors as a part of their daily documentation. Nurse Manager #1 stated oral care was very important to a resident's overall health and expected staff to report any resident who became combative during care so appropriate interventions and approaches could have been implemented. Nurse Manager #1 stated the resident should receive oral care and all certified nurse aides were expected to report refusals or difficulty providing care to prevent adverse health outcomes. Nurse Manager #1 further stated residents should receive care as indicated in their care plans. Resident #28 had occasional resistive behaviors but was not aware of any behavior documentation on 07/09/2026. Nurse Manager #1 also stated it was not appropriate for a resident to be saturated with urine. Timely incontinence care should have been provided in accordance with the residents' care plan. During an interview on 07/09/2026 at approximately 12:45 PM, Assistant Director of Nursing #1acknowledged the importance of the staff following the care cards and remarked they were conveniently placed inside the resident's closet for quick access. The documentation was crucial to drive the care of the resident for best outcome. Residents should be checked for incontinence, and care provided every two to three hours or sooner if needed. All refusals should have been documented, and everyone should receive oral care daily. 10 New York Codes, Rules, and Regulations: 415.12(c)

Based on record review, observation, and interviews, the facility failed to file and resolve grievances according to professional standards. Specifically, the facility failed to ensure that residents and staff understood the grievance process and knew how to file a grievance within the facility.Findings include: Facility policy titled Grievance Policy dated 12/2025, documents grievance forms will be readily accessible on each unit or designated common areas within the facility. These items will be available in a location that is discreet and easily visible to all residents and families. Record review of Welcome Book and the Concern/Complaint or Suggestions Policy and Procedure states all residents have the right to voice concerns, complaints or suggestions which affect their lives at this Facility without fear of reprisal or discrimination. You may lodge a complaint with the Facility's Director of Social Services, (our grievance official) who will take the information and follow up through resolution. Residents will be provided with a copy of our grievance form upon admission. The facility has anonymous grievance lock box(es), with forms readily available next to them. This allows grievances to be made anonymously at any time. The Director of Social Services (or their designee) will check the box(es) daily on all business days. Within this document the location of the locked boxes is left blank. During an observation on 07/07/2026 at 11:38 AM, grievance paperwork and a lock box was hanging on the wall in lobby. The box was noted to be at chest height to standing Surveyor. During a surveyor-led Resident Council [NAME] on 07/07/2026 at 11:00 AM, four out of four residents stated they did not know how to file a grievance and they did not know where grievance forms were located. They stated they would speak to activities or nursing about their complaints. During an interview on 07/09/2026 at 12:19 PM, Director of Social Work #1 stated residents were made aware of the grievance process on admission. They let them know there were grievance forms in the lobby and available on each unit for them to fill out. If they have a grievance or complaint; they can get assistance filling out a form. They stated they believed the grievance process was discussed in Resident Council. The grievance box was checked Monday through Friday for new forms. The forms were reviewed immediately with an investigation completed within10 days. The resident was verbally updated on the result of the investigation and offered a copy of the grievance for their records. They stated they follow up every few days to see if the resident was satisfied. During an interview on 07/09/2026 at 1:10 PM, Certified Nurse Aide #3 stated if a resident did come to them with a grievance, they then ask their nurse what the process is for filing it. They stated they did not know where grievance forms were in the facility. During an interview on 07/09/2026 at 1:15 PM, Licensed Practical Nurse #2 stated they had never been approached by a resident with a grievance. They stated they were unable to locate grievance forms and would have to go to the unit manager or the Director of Nursing to ask them the process for filing a grievance for a resident. During an interview on 07/09/2026 at 1:18 pm, Certified Nurse Aide #6 stated if a resident came to them with a grievance they would take it to the supervisor. They stated they were not aware of where the grievance forms were and they stated they would have to ask their supervisor. 10 New York Codes of rules and regulations 415.3(d)(1)(i)

Based on observation, interview, and record review conducted during a survey, the facility failed to ensure that its medication error rate did not exceed five percent for three (Resident's #17, and #56, and #57) of 10 residents observed during a medication pass for a total of 25 observations. This resulted in a medication error rate of 60 percent. Findings include: Facility provided audit titled Medication Audit dated 06/24/2026-07/08/2026 for Residents #17, #56, and #57. All three residents collectively received 281 medications over one hour beyond ordered times. Resident #17 Resident #17 was admitted to the facility with diagnoses of schizoaffective disorder, bipolar type (a mental health condition with symptoms such as hallucinations and delusions, and mood disorder symptoms, such as depression and mania), gastro-esophagus reflux disease (when stomach acid flows back up into the esophagus), and constipation (difficulty passing stool). The Minimum Data Set (an assessment tool) dated 04/24/2026, documented that the resident could be understood, could understand others, and was cognitively intact. Review of Electronic Medication Administration Record dated 07/08/2026 documented Resident #17 was to receive: Aspirin 81 (used as a blood thinner) oral tablet chewable 81 milligrams give one tablet by mouth one time a day at 8:00 AM. Fluoxetine (used to treat mood disorders) oral tablet 10 milligrams give one tablet by mouth one time a day at 9:00 AM. Protonix (used to treat gastro-esophagus reflux disease) oral tablet delayed release 40 milligrams give one tablet by mouth one time a day at 8:00 AM. Benztropine mesylate (used to treat excess salvation) oral tablet 0.5 milligram give one tablet by mouth two times a day at 9:00 AM. Miralax (used to treat constipation) oral packet 17 grams, give 17 grams by mouth every 24 hours as needed for constipation. During an observation on 07/08/2026 at 10:40 AM, Licensed Practical Nurse #3 reviewed Resident #17's Medication Administration Record and stated Resident #17 was to receive fluoxetine oral tablet 10 milligrams, aspirin 81 milligrams tablet delayed release, protonix oral tablet delayed release 40 milligrams, and benztropine mesylate oral tablet 0.5 milligram. Licensed Practical Nurse #3 prepared medications, noting that the Fluoxetine was not present in the medication cart for the resident. They entered the resident's room, placed the medication on the resident's bedside table and asked if the resident wanted Miralax. The Resident responded yes, the nurse then went back to the medication cart leaving the medication with the resident and prepared the Miralax 17 grams without opening the residents electronic record and reviewing the medication administration order. The nurse did not contact the practitioner at that time to advise them the fluoxetine was not available for the resident or that the resident's medications were given over one hour late. Resident #56 Resident #56 was admitted to the facility with diagnoses of hyperlipidemia (excess amount of fats in your blood), diabetes mellitus type two (the body cannot use insulin correctly and sugar builds up in the blood), and essential primary hypertension (most common type of high blood pressure). The Minimum Data Set (an assessment tool) dated 04/24/2026, documented that the resident could be understood, could understand others, and was cognitively intact. Review of Medication Administration Record dated 07/08/2026 documented Resident #56 was to receive: Atorvastatin calcium (used to treat high cholesterol) oral tablet 80 milligrams give one tablet by mouth one time a day at 8:00 AM. Lisinopril (used to treat hypertension) oral tablet 40 milligrams give one tablet by mouth one time a day at 8:00 AM. Metformin (used to treat diabetes) oral tablet 1000 milligrams give one tablet by mouth one time a day at 8:00 AM. Doxycycline hyclate (used to treat bacterial infections) oral tablet 100 milligrams give one tablet by mouth two times a day for seven days at 9:00 AM and 9:00 PM. Lactobacillus (used for prevention of gastrointestinal upset) oral capsule give one capsule by mouth two times a day for seven days at 9:00 AM and 9:00 PM. During an observation on 07/08/2026 at 10:50 AM, Licensed Practical Nurse #3 reviewed Resident #56's Medication Administration Record and stated Resident #56 was to receive Atorvastatin calcium oral tablet 80 milligrams, Lisinopril 40 milligrams oral tablet, Metformin oral tablet 1000 milligrams, Doxycycline Hyclate oral tablet 100 milligrams, and Lactobacillus oral capsule. Licensed Practical Nurse #3 prepared medications, removing the lactobacillus capsule from the top drawer in a medication cup that had the resident's initials and date on it. The nurse did not contact the practitioner at that time to advise them that the resident's medications were given over one hour late. Resident #57 Resident #57 was admitted to the facility with diagnoses of diabetes mellitus type two (the body cannot use insulin correctly and sugar builds up in the blood) chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs), and major depressive disorder (mood disorder that significantly impacts one life). The Minimum Data Set (an assessment tool) dated 04/21/2026, documented that the resident could be understood, could understand others, and was mildly cognitively impaired. Review of Electronic Medication Administration Record dated 07/08/2026 documented Resident #57 was to receive: Basaglar kwikpen subcutaneous (used to treat diabetes) solution Pen-injector 100 unit/milliliter inject 22 units subcutaneously one time a day, contact provider if blood sugar is less than 60 and higher than 380 at 9:00 AM. Daliresp (used to treat chronic obstructive pulmonary disease) oral tablet 250 micrograms give one tablet by mouth one time a day at 9:00 AM. Furosemide (used to treat heart failure) oral tablet 40 milligrams give one tablet by mouth one time a day at 9:00 AM. Potassium Chloride extended release (used as a supplement) oral tablet 10 milliequivalents give one tablet by mouth one time a day at 9:00 AM. Sertraline (used to treat depression) oral tablet 100 milligrams give one tablet by mouth one time a day at 9:00 AM. During an observation on 07/08/2026 at 11:00 AM, Licensed Practical Nurse #3 reviewed Resident #57's Medication Administration Record and stated Resident #57 was to receive Basaglar 22 units, Daliresp 250 micrograms oral tablet, Furosemide oral tablet 40 milligrams, Potassium Chloride 10 milliequivalents, and Sertraline 100 milligrams. The nurse did not contact the practitioner at that time to advise them that the resident's medications were given over one hour late. During an interview on 07/08/2026 at 11:00 AM, Licensed Practical Nurse #3 stated medications were late on a consistent basis because of workload. The morning medication pass was extensive; they had asked the providers and administration multiple times if the medication times could be changed. They had gotten into a routine at that point and did not notify anyone their medication passes were late. They should not leave medications with residents, however there were some residents they knew well, and they liked to take their medications on their own time so they would leave them with the residents. They stated they did pre pour the refrigerated medication and labeled it prior to placing it in the medication cart. They were unsure how to complete the medication pass on time without pre pouring the medication. They acknowledged they should not per pour any medications. For Resident #17, they planned to check the emergency medication supply box and let Nurse Practitioner #1 know if the medication was unavailable once they completed their morning medication pass. During an interview on 07/08/2026 at 11:20 AM, Administrator #1 stated they were unaware medications were being given late. During an interview on 07/10/2026 at 10:49 AM, Director of Nursing #1 stated their expectation was medications would be administered timely. If a nurse could not administer medications timely, they would expect the nurse to make a supervisor aware, and additional nursing support would be given. When medications were given late it was the nurses' responsibility to contact the provider to make them aware and follow any orders for monitoring. During an interview on 07/09/2026 at 3:10 PM, Nurse Practitioner #1 stated their expectation for medications given over one hour late was that they or another provider would be notified to assure there was no risk for harm to the resident. They had not been made aware of any late medications given for Resident #'s 17, 56, or 57 over the past two weeks. During an interview on 07/10/2026 at 11:42 AM, Medical Director #1 stated late medication was unacceptable and was brought to their attention prior to the start of survey. Medical Director #1 expected that staff that were falling behind would ask for assistance and that the facility should have a chain of command that would allow for someone else to come and take over if a nurse was tied up in an emergency or while giving care. 10 New York Codes, Rules, and Regulations 415.12(m)(1)

Based on observation, interview, and record review conducted during a survey, the facility failed to assure that menus are developed, followed, and prepared to meet resident choices including their nutritional needs while using established national guidelines. Specifically, on 07/06/2026 the menu indicated the lunch meal would be Italian sausage on a bun with onion and peppers the residents were served taco salad and on 07/09/2026 the menu indicated breakfast meal was apple pancakes the residents were served scrambled eggs, the residents were not notified of the changes in the menu. Findings include: Facility policy titled Food and Nutrition Services dated 12/2025 documented, each resident was provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Menu for Spring/Summer week #4 documented on 07/06/2026 the lunch meal would include Italian sausage on a bun, sauteed onions and peppers, macaroni salad and seasonal melon. On 07/09/2026 the breakfast meal would include apple topped pancakes, syrup, and sausage links. During an observation on 07/06/2026 at 12:40 PM, the main dining room was observed during the lunch meal. The residents were served taco salad. During an observation on 07/09/2026 at 9:30M, the main dining room was observed during the breakfast meal. The residents were served a combination of scrambled eggs, English muffin, cold cereal, and oatmeal. During an interview on 07/06/2026 at 11:30 AM, Resident #15 stated they frequently ordered food to be delivered or ate what they had in their room provided by their family. They could never be sure of what would be served each meal and did not even look at the menu because it was not accurate. During an interview on 07/07/2026 at 11:30 AM, Resident #66 stated they were unsure what lunch would be, it generally was a surprise and did not follow the menu. They frequently had to request an alternative or ate food they had in their room provided by their family. During an interview on 07/10/2026 at 9:36 AM, Food service Director #1 stated food issues were discussed at resident council, and they attended resident council meetings when the residents discussed the food. They wrote down notes on menu ideas and thoughts during the meeting. They had a menu; they went over with the dietician. There is a regular main meal and then an alternative every day. There was no separate food committee. During an interview on 07/10/2026 at 12:15PM, Administrator #1 stated dining was an ongoing issue. There was a company-wide push for improving food service. 10 New York Codes, Rules, and Regulations 415.14(c)(1-3)

Based on observation and interviews conducted during the survey, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Specifically, the exterior of the facility building and grounds were not clean and maintained. This is evidenced by:During observations of the facility grounds on 07/06/2026 at 1:10 PM:The area around the dumpster was littered.Vegetation overgrowing around the enclosed pad-mounted electrical transformer.At the building entrance, resident courtyard, and resident patio, tree saplings and weeds were growing in the garden beds, and the ornamental shrubs were overgrown and not trimmed.The sign with the former name of the facility was in place at the main entrance. During an interview on 07/08/2026 at 1:57 PM, Administrator #1 stated that they would remove the outdated sign, landscape the garden beds, trim the ornamental shrubs, and clean up the litter. New York Codes, Rules, and Regulations Title 10 S415.5(h)(4)

Based on observations, record review, and interviews during an abbreviated survey (Case #NY 291), the facility did not ensure that the resident environment remains as free of accident hazards as is possible for 1 (Resident #1) of 11 residents reviewed for accident hazards. Specifically, the facility did not ensure Resident #1's bed was positioned away from the heating unit. The length of the resident's bed was beside (parallel) the heating unit. Subsequently, the resident was found by Certified Nursing Assistant (CNA) #1 with the left side of their head lying on the heating unit. Resident #1 sustained a second-degree thermal burn (a burn caused by heat that damaged the first 2 layers of the resident's skin) to their left ear, and a burn on their scalp above their left ear. This resulted in actual harm not immediate jeopardy for Resident #1. This was evidenced by: Resident #1 Resident #1 was admitted to the facility with diagnoses of dementia, paranoid [CONDITION(S)], and [CONDITION(S)] (an abnormal rhythm of the heart). The Minimum Data Set (MDS-an assessment tool) dated 10/21/2022, documented the resident had severe cognitive impairment, was usually understood, and could sometimes understand others. The Policy and Procedure (P&P) titled, Impaired Skin Integrity Prevention and Care Protocol dated 7/2021, documented second-degree [CONDITION(S)] would be cleansed with normal saline or wound wash, patted dry and [MEDICATION(S)] applied. The P&P documented the MD (medical doctor) must be notified within 24 hours of the burn's discovery. During an observation on 11/15/2022 at 10:36 AM, the heater in Resident #1's room measured 12.5 inches high from the floor to the top of the heater. The resident's bed that was in the lowest position, measured 18.5 inches from the floor to the top edge of the mattress. The top of the resident's heater was very warm to the touch. During an observation on 11/15/2022 at 11:09 AM, Resident #1's left ear had some open areas, was dark purple, and swollen. The scalp above Resident #1's left ear was dark red. The resident's bed was against the wall with the headboard facing the heater and the bed facing the door. During an observation on 11/16/2022 at 11:01 AM, Resident #1's left ear was reddened and there was less swelling; however, there were 2 areas on the resident's ear where the tissue was very dark. There was a moderate amount of bloody and clear drainage on the dressing that covered Resident #1's ear. The Comprehensive Care Plan for Trauma Informed Care revised on 10/25/2022, documented the resident was burned as a child and needed skin grafts. The scars caused embarrassment. There was no documentation of an intervention or of a care plan for the burn. The CNA (certified nursing aide) Care Card as of 11/17/2022, documented Resident #1's bed was not to be positioned near heaters in their room. A Nursing Note dated 11/12/2022 at 3:09 PM, documented Resident #1 was found around 7:00 AM that morning with the left side of their face on the heat duct. An injury was noted. It was nursing judgement to change the location of the resident's bed. The bed was now positioned against the wall with the head of the bed facing the doorway. A Nursing Note dated 11/12/2022 at 1:55 PM, documented Resident #1 was found with an unknown injury to the helix (the edge of the ear that extends from the scalp to the earlobe) of their left ear. The area was deep red with peeled skin and scant serosanguineous (pink tinged fluid secreted by an open wound in response to tissue damage) drainage. It was noticed by a Licensed Practical Nurse (LPN) there was hair and dried drainage on the heater. The thermostat was set to 75-80 degrees which the CNA turned off. The CNA reported to the LPN they did not see anything out of the ordinary with the resident's face. The area on the ear was cleaned with wound wash, A&D ointment (a skin protectant) was applied, and the area covered with gauze. A Nursing Note dated 11/12/2022 at 9:13 PM, documented the resident's left ear was red, swollen, and painful. The resident was administered Tylenol with good effect. A Nursing Note dated 11/13/2022 at 2:00 AM, documented the Director of Nursing (DON) assessed the resident's left ear and scalp above the ear. The ear was red and open along the helix. The scalp above the top of the left ear was red with several small open areas. Two of the areas had dry yellowish material. There was serosanguinous drainage on the dressing. The DON documented the reddened areas on the scalp were related to the burn. A Nursing Note dated 11/13/2022 at 11:55 PM, documented the MD was notified regarding Resident #1 having been found with the left side of their face on the heating element in their room with injuries noted. The MD mentioned they would come to the facility on [DATE] to assess the resident if necessary or requested. An MD order dated 11/13/2022, documented to clean Resident #1's left ear with wound wash or normal saline, apply [MEDICATION(S)] ointment and cover with a gauze pad every shift for wound to left ear helix. An Administration Note dated 11/13/2022 at 12:13 PM, documented the resident received Tylenol for pain. Resident #1 was teary on and off, observed to be uncomfortable, and in pain. At 2:36 PM, the Note documented the Tylenol was effective. A Health Status Note dated 11/14/2022 at 11:20 AM, written by the MD, documented the resident was seen after they apparently fell against a heating unit in their room and remained in place for an unknown amount of time. The examination showed [CONDITION(S)] (redness) of the left ear [NAME] (the cup shaped area of the ear) and some [CONDITION(S)] posteriorly from the [NAME] on the scalp. There was no other injury on examination. The resident's vital signs were normal, and the resident did not have a fever. The resident seemed alert. The MD documented the furniture in the room was rearranged so that this type of incident could not happen again. A Nursing Note dated 11/14/2022 at 2:45 PM, documented the LPN noticed after the MD saw Resident #1, they had increased respirations (was breathing faster) and was crying. The RN and MD were notified. The MD ordered Ibuprofen to be administered with Tylenol. The medication was administered with good effect for about an hour. The resident was sitting near the nurses' station with tears in their eyes. An MD order dated 11/15/2022, documented to give the resident Juven (a supplement that can promote wound healing) 2 times a day for ear and scalp [CONDITION(S)]. A Physician Visit Progress note dated 11/16/2022 at 8:50 AM, documented Resident #1 was nonverbal and had a second-degree thermal burn to their left ear (the Physician Assistant (PA) saw the resident). During an interview on 11/15/2022 at 10:45 AM, Registered Nurse (RN) #1 stated when they were called to the resident's room on 11/12/2022, they observed 2-3 strands of hair the color of Resident #1's and a small spot of dried yellowish drainage on the heater. RN #1 stated when they assessed the resident's left ear, there was some redness and a strand of peeling skin that looked like a blister had popped. There was redness on the resident's scalp, but at the time, they thought it was a flare up of the resident's [CONDITION(S)] (a skin rash that causes redness). Later on, they learned it was a burn, not [CONDITION(S)]. RN #1 stated the resident made no verbalization of pain and held completely still while a Licensed Practical Nurse (LPN) did the initial wound care. They applied A and D ointment and a gauze dressing. During an interview on 11/15/2022 at 12:11 PM, the Director of Maintenance (DOM) stated the facility was heated primarily by rooftop heaters that had duct heaters that were all electric. The rooms had electric baseboard heaters in addition to the roof top units. All of the baseboard heaters worked. The DOM stated they were controlled by a thermostat so the room temperature could be adjusted by anyone. The DOM stated some rooms had protective covers on the heaters, but they became hot when the heat was on. They were mainly to protect the heater and did not protect the residents from the heat of the baseboard units. The DOM stated they had never checked the temperatures of the units themselves, but when the units were on, they were hot. During an interview on 11/15/2022 2:23 PM, CNA #1 stated they walked into Resident #1's room and the left side of their head was positioned on the heater. The CNA stated they held the resident's shoulders and positioned them back on the bed. They checked their head and did not see anything out of the ordinary but reported the incident to the nurse in case any injury appeared later on. CNA #1 stated they checked the thermostat in the room, and it was set between 75 and 80 degrees, so they shut it off. During an interview on 11/15/2022 at 2:27 PM, the DON #1 stated they went into work on 11/12/2022 about 10:50 PM. The RN on duty reported that Resident #1 was found with their face laying on the heater in their room. CNA #1 found the resident about 7:00 AM and told the LPN. At that time, there was no visible injury. About 1:00 PM they noticed injury to the resident's left ear and the nurse put A&D ointment on it. The DON stated the RN who gave them report told them that they thought the area on the resident's scalp was a skin condition. The DON stated when they saw the resident's scalp, they disagreed it was a skin condition. It was a burn. The DON stated when they assessed the resident's left ear, it was reddened, swollen, and had what looked like a blister that had opened. The DON #1 told RN #1 to call the MD. RN #1 did not call the MD when the injury was first noticed. The DON stated the resident wiggled around in the bed, so they were sleeping with their head at the foot of the bed. That was why they were found with the left side of their face on the heater. The DON stated when staff made safety rounds that night, they observed from the doorway of the resident's room the resident sleeping with their back to the door. They did not see anything out of the ordinary. During an interview on 11/15/2022 at 3:00 PM, the Administrator stated they were made aware of the incident at 8:00 am on 11/13/2022. They were told the resident was found with their head against the heater and they had [CONDITION(S)]. The resident was independent with bed mobility. The Administrator stated the resident's thermostat was set at 75-80 degrees and one of the nurses asked them how that temperature could cause a burn. The Administrator stated they explained that the heating unit had to pump out enough heat to warm the whole room, so the unit would get very warm. During an interview on 11/16/2022 at 10:37 AM, the Medical Director stated they were notified of Resident #1's 11/12/2022 injury on 11/13/2022 and saw the resident on 11/14/2022. The Medical Director stated at that time, the left ear was reddened, but there no blisters at the time they saw the resident. They stated initially, it looked like it was going to be a deep first or second-degree burn. The Medical Director stated the PA was going to be examining the resident on this date. They stated the heating unit in the resident's room would be hotter than the 75-80 degrees the thermostat was set at because the unit needed to heat the entire room. The Medical Director stated following the incident, Resident #1's bed had been moved from beside the heater to along a wall. The facility needed to look carefully at bed placement in each room. The process had been started. During an interview on 11/16/2022 at 10:52 AM, Registered Nurse Manager (RNM) #2 stated they learned of Resident #1's burn when they arrived at work on 11/14/2022. RNM #2 stated today, when the PA saw the resident, they mentioned to the PA, they thought it was odd the resident did not move their head off the heater and wondered if the resident had some sort of medical event. The PA stated there would be no way to determine that unless the resident was sent out for testing. RNM #2 stated the PA instructed them to continue with the [MEDICATION(S)] ointment to keep the burn moist, to prevent infection, and the resident may need a consult with a plastic surgeon. During a subsequent interview on 11/18/2022 at 9:00 AM, the Medical Director stated they examined the resident this AM. The Medical Director stated the resident's left ear had a deep 2nd degree burn with a darker area of tissue. The Medical Director stated it was difficult to determine if the dark tissue was necrotic, but they stated it could progress to that. The Medical director stated the resident's treatment for the burn had been changed to [MEDICATION(S)] cream. During a subsequent interview on 11/21/2022 at 10:55 AM, RN #1 stated the burn was brought to their attention by a CNA and LPN between 10:00 and 10:30 AM. It was after breakfast was finished and before lunch began. RN #1 could not recall exactly when the MD was notified. It was on 11/13/2022 and RN #1 stated it was sometime between 9:00 AM and 10:30 AM. RN #1 stated they did an internet search for treatment of [CONDITION(S)], and on several sites, it documented to put Vaseline on a burn. They did not have Vaseline in the facility. They had A&D ointment and [MEDICATION(S)] on hand, so they used the A&D ointment. RN #1 stated when they called the MD to report the burn, the MD ordered [MEDICATION(S)] and a dressing to the burn (on the resident's left ear). 10 NYCRR 415.12(h)(1)

Based on medical record review and interviews during an abbreviated survey (Case #NY 538) it was determined for one (Resident #1) of two residents reviewed, that the facility did not ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, for one (Resident #1) of two residents reviewed, the facility did not evaluate the resident for swallowing difficulty or adjust the resident's care plan after the resident choked, necessitating the [MEDICATION NAME] maneuver and transport to the hospital. Approximately six weeks later, the resident choked again, once again necessitating the [MEDICATION NAME] maneuver and transport to the hospital. This resulted in isolated actual harm that is not immediate jeopardy. This is evidenced by the following: Resident #1: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident to have severe cognitive impairment, and requires extensive assistance of one for eating. A facility form titled "Resident History" dated 8/29/14 documented by the Social Worker (SW) that the information received was from the daughter. Under the section titled "Dentures" it was documented "upper and lower" and "unsure when last seen by the dentist." Under the section "any dental or oral problems" it was documented "dentures may not fit right." Under the section "special utensils/splints", it was documented "needs food chopped", needs assistance and encouragement. A physician's orders [REDACTED]. The Dietary Care Plan dated 9/7/14 documented regular diet and contained no documentation regarding the 9/5/14 order to "cut meat in small pieces." A comprehensive care plan (CCP) dated 9/8/14 titled "Activities of Daily Living" (ADL) documented compromised ability to complete ADLs as a problem with an approach "set up tray for all meals; encourage feeding by self and assist as needed. The resident Care Card (CC / used by the caregivers who provide personal care and refer to for instruction) under the section of diet had documented regular diet and consistency, and on 9/11/14 the resident was changed to "feed". No other changes were noted. There was no documented evidence that the physician's orders [REDACTED]. Nurse's notes on 9/16/14 at 6:05 pm documented that the resident choked at suppertime, on pasta with ham (cut in cubes) and broccoli. Resident had weak cough and was unable to clear on his own. [MEDICATION NAME] maneuver started right away. Unable to clear or remove foreign materials. Resident did not lose consciousness. 911 was called. Tried to suction with no success. Oxygen started and mouth sweep to illicit gag reflex with no success. Resident coughing was very weak. Resident facial color red from coughing, to hospital at 6:15 pm. Documentation from the emergency room dated 9/16/14 documented the resident was evaluated due to choking. The recommendations that were made were to have the resident's swallowing ability evaluated, and/or to consider a downgrade to the diet. No changes were made to the resident's care plan. There was no documented evidence that these recommendations from the hospital were addressed. Nurse's note on 9/16/14 at 8:40 pm documented the physician from the hospital called that the chest x-ray showed haziness. A new order was received to administer [MEDICATION NAME] (antibiotic) 250 milligrams (mg.) for ten days for aspiration pneumonia [MEDICATION NAME]. The facility form titled Resident Event Report (RER) dated 10/25/14 at 8:30 am documented that the resident choked during breakfast. The resident became blue and unresponsive. The [MEDICATION NAME] maneuver, abdominal thrusts and suctioning was provided. The resident was sent to the emergency room for evaluation. Nurse's notes dated 10/25/14 documented at 8:30 am the resident was choking. The [MEDICATION NAME] was being done, the resident's color was ash and the resident was not alert and not responding to the [MEDICATION NAME]. The resident was transferred to the floor and abdominal thrusts were done. Resident was turned to side and a small piece of toast was noted on the floor. The resident's eyes were open but not very responsive. An additional note at 11:10 am documented that the resident is being returned and the hospital is recommending a pureed diet. Documentation from the emergency room dated 10/25/14 documented the resident was evaluated due to choking. The recommendations were made to have the resident's swallowing ability evaluated, and to consider a downgrade to the diet. Interview with the Director of Nursing (DON) on 10/29/14 at 2:00 pm who stated that after the first episode of choking, the supervision of the resident was increased; The DON was not able to show documented evidence of the increased supervision on the CCP or the resident CC. When asked why the resident did not have a speech or swallow evaluation after choking the first time, the DON stated that there was no need to get a speech evaluation because of the increased supervision. Interview on 10/29/14 at 3:00 pm with the aide who was assigned to the resident when he choked on 10/25/14. The aide stated that she was unaware that the resident had choked before. She stated another aide had set the resident up for breakfast, and asked her if the resident was able to eat independently, to which she replied yes. The aide stated that usually when resident's are at risk for choking they are supervised for meals. Interview with the physician on 11/12/14 at 3:00 pm who stated that on 9/5/14 the nurse updated him that the resident was having difficulty eating or feeding himself, and the diet was changed to "cut meat in small pieces". The physician stated he was unable to find documentation as to specific problems which warranted this change. The physician stated that after the 9/16/14 choking incident, the hospital emergency department sent boiler plated emergency room instructions back with the resident and "at the time it did not seem like a big deal". The physician stated after the second incident of "alleged" choking there was a recommendation from the hospital emergency department for a swallowing evaluation. The physician stated in retrospect, it would have been reasonable to obtain a swallowing evaluation after the 9/16/14 incident. 10 NYCRR 415.12