Every finding on record at Delhi Rehabilitation and Nursing Center

Based on interviews and record review conducted during the survey, the facility failed to ensure allegations involving injuries of unknown origin were immediately reported by staff to facility management in accordance with facility policy for one of one resident (Resident #2). Specifically, Certified Nurse Aide #1 and Certified Nurse Aide #2 observed bruising to the Resident #2's left eye during care on 03/04/2026 but failed to immediately notify nursing staff because they believed another staff member had already reported the injury. The bruising was not reported until later that evening by another Certified Nurse Aide, delaying nursing assessment, supervisory notification, and initiation of the facility's investigation.Findings include: The facility's policy and procedure revised 07/02/2026 titled Seven Components of a Systematic Approach to Abuse Prohibition documented the facility must submit reports that are accurate, to the best of its knowledge at the time of submission. In the initial report, facility must provide sufficient information to describe the alleged violation and indicate how residents are being protected. A report to the Department of Health must be made immediately, but no later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury; and no later than 24 hours if the alleged violation involves neglect, exploitation, mistreatment or misappropriation of resident property; and does not result in serious bodily harm. Resident #2 was admitted to the facility with diagnoses of cognitive social or emotional deficit following cerebral infarction (impaired emotional processing, personality changes, or a reduced ability to navigate social situations), peripheral vascular disease (a slow, progressive circulation disorder characterized by narrowing, blockage, or spasms in blood vessels outside the heart and brain) and schizoaffective disorder (a chronic mental health condition characterized by a combination of schizophrenia symptoms like hallucinations or delusions and mood disorder symptoms like depression or mania). The Minimum Data Set (an assessment tool) dated 03/09/2026, documented the resident could be understood and could understand others. On a written statement in the Facility Investigation Report dated 03/04/2026, Director of Nursing #1 documented, upon notification in injury of unknown origin, they went up to assess the resident. Resident #2 was noted with a discoloration to the outer area of their left eyebrow. Resident #2 denied pain to the area and neuro check was within normal limits. Resident did not show signs of distress and was resting calmly in bed. Skin Assessment dated 03/04/2026 7:00 PM, Resident noted with purple discolored area to outer left eyebrow 3.0 centimeter x 1.5 centimeter, completed by Director of Nursing #1. During an interview on 6/29/2026 at 1:18 PM, Resident #2 was observed sitting in their chair next to their bed. Resident #2 was asked how they were doing and if they felt safe. Resident #3 nodded their head yes. Resident #2 was asked if they had any complaints and nodded their no. Based on observations, Resident #2 could give yes or no answers and nod their head yes or no to answer questions. During an interview on 06/29/2026 at 12:14 PM, Certified Nurse Aide #2 stated they assisted Certified Nurse Aide #1 with transferring Resident #2 on 03/04/2026 and observed bruising around the resident's left eye prior to the 3 PM shift. Certified Nurse Aide #2 stated they assumed another staff member had already reported the bruising and therefore did not notify nursing staff. Certified Nurse Aide #2 stated Resident #2 initially reported not knowing how the bruise occurred. Later, when asked again, Resident #2 stated a black man hit them. Certified Nurse Aide #2 acknowledged the bruising should have been reported immediately, and stated Administrator #1 later educated them regarding the requirement to immediately report observed injuries. During an interview on 06/29/2026 at 12:46 PM, Certified Nurse Aide #3 stated they observed bruising around Resident #2's left eye during the evening shift on 03/04/2026 and immediately reported the finding to Licensed Practical Nurse, Charge Nurse #1. During an interview on 06/29/2026 at 12:33 PM, Social Worker #1 stated they were notified on the morning of 03/05/2026 by a Licensed Practical Nurse that Resident #2 had sustained bruising to the left eye. Social Worker #1 stated they interviewed Resident #2 regarding the injury, assessed the resident for emotional distress, completed follow-up visits, and documented the findings. During an interview on 06/30/2026 at 11:06 AM, Administrator #1 stated the facility reports injuries of unknown origin, allegations of abuse, resident-to-resident altercations, misappropriation, elopements, and other reportable events to the Department of Health within required timeframes. Administrator #1 stated staff were expected to immediately notify the Director of Nursing #1 or Administrator #1 of any allegation or injury so the required reporting process could begin. 10 New York Codes, Rules and Regulations 415.4(b)(2)

Based on interviews and record review conducted during survey, the facility failed to report reasonable suspicion of a crime committed in the facility to the State Survey Agency and one or more law enforcement entities, within required timeframes for Resident #4 and Resident #5. Specifically, on 03/23/2026, through staff reporting and an investigation, the facility discovered that Licensed Practical Nurse #2 falsely entered medication orders for Resident #4 without provider authorization, discontinued the orders, and diverted (removed) the medication for personal use in December 2025 and attempted to do so again in March 2026 for Resident #5. There was no documented evidence the facility reported the incidents to the Department of Health or local law enforcement, as required. Failure to report suspicion of a crime committed in the facility resulted in Immediate Jeopardy and placed all residents at risk for serious harm, serious impairment, serious injury, or death. Findings Include:Cross reference to F-602 and F-865.The facility's policy and procedure dated 07/02/2026 titled Seven Components of a Systematic Approach to Abuse Prohibition documented the facility must submit reports that are accurate, to the best of its knowledge at the time of submission. In the initial report, facility must provide sufficient information to describe the alleged violation and indicate how residents are being protected. A report to the Department of Health must be made immediately, but no later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury; and no later than 24 hours if the alleged violation involves neglect, exploitation, mistreatment or misappropriation of resident property; and does not result in serious bodily harm.Record review revealed Licensed Practical Nurse #2 entered a medication order for fluoxetine in Resident #5's chart on 03/18/2026 at 8:33 AM for provider approval and the order was discontinued later that day at 7:19 PM by Nurse Practitioner #1.Facility investigation records included a written statement from Licensed Practical Nurse #2 dated 03/24/2026 acknowledging that in December 2025 they entered an order under Resident #4 for fluoxetine 10 milligrams, discontinued it, and took the medication when it arrived. The statement further documented that in March 2026, Licensed Practical Nurse #2 entered an order under Resident #5 for fluoxetine 20 milligrams, discontinued it, and intended to take the medication, but the medication had been removed from the medication cart.On a written statement in the Facility Investigation Report dated 03/24/2026, Licensed Practical Nurse #3 stated Licensed Practical Nurse #2 came over to the mediation cart looking for medication. Licensed Practical Nurse #2 did not respond when Licensed Practical Nurse #3 asked what medication they were looking for. Licensed Practical Nurse #2 stated the medication they ordered did not come in. Shortly after Licensed Practical Nurse #2 walked away, Licensed Practical Nurse #3 recalled fluoxetine was delivered during the overnight shift and Licensed Practical Nurse #3 had moved it to the bottom drawer so they could put it in the pile of medications to return to the pharmacy due to Resident #5 not having an order for it. When Licensed Practical Nurse #3 went back to the orders page, they saw a medication order placed for fluoxetine the morning of 03/18/2026 and discontinued in the afternoon on 03/18/2026. In the written statement, Licensed Practical Nurse #3 recalled a couple months ago Licensed Practical Nurse #2 mentioning they were helping their current partner get a medication (fluoxetine) which raised suspicion that the medication was ordered for Licensed Practical Nurse #2's partner. Licensed Practical Nurse #3 then reported the suspicion to Registered Nurse #1 who was supervising at the time. On a written statement in the Facility Investigation Report, Registered Nurse #1 stated they did confront Licensed Practical Nurse #2, and Licensed Practical Nurse #2 admitted to ordering, discontinuing and giving the medication to her significant other because they were having withdrawals and they were trying to help them. Licensed Practical Nurse #2 admitted they knew they were wrong and that they needed to tell the Director of Nursing and the Administrator.Facility investigation report dated 03/24/2026 concluded that Licensed Practical Nurse #2 took the remaining medication for personal use in December 2025 instead of returning it to the pharmacy for credit.There was no documented evidence in the facility investigation report conclusion that Licensed Practical Nurse #2 falsified orders on Resident #4 and #5 with attempt to (and success for one of two instances) divert medication.During an interview on 07/02/2026 at 10:41 AM, Nurse Practitioner #1 stated resident orders are typically communicated verbally to nursing staff during rounds. Licensed Practical Nurses and Registered Nurses enter the orders into the electronic medical record, and the provider later reviews and signs them. If nursing staff are unavailable, the provider may enter the orders directly. Nurse Practitioner #1 stated that once entered and before signing off, orders become active and are transmitted to the pharmacy for dispensing. Controlled substance orders require provider authentication before being sent to the pharmacy. Orders are reviewed twice daily, and the facility's Nurse Practitioners and Medical Providers are authorized to initiate and discontinue orders. Regarding Resident #4, Nurse Practitioner #1 stated a gradual dose reduction of fluoxetine had been requested but was not appropriate due to the resident's obsessive-compulsive disorder and previous unsuccessful reduction attempts. Regarding Resident #5, Nurse Practitioner #1 stated the resident had been successfully weaned off fluoxetine through a gradual dose reduction. Nurse Practitioner #1 stated they were informed that Licensed Practical Nurse #2 had entered fluoxetine orders under their name on two occasions. They were unaware a different dose had been entered and stated that, due to multiple providers managing residents, nurses may enter routine refill orders under a different provider's name. Nurse Practitioner #1 stated they cannot sign orders entered under another provider's name. To verify verbal orders, providers review orders, resident records, and progress notes and communicate with one another when questions arise. Nurse Practitioner #1 stated the orders involved in this incident were routine fluoxetine renewal orders. They further stated that discontinued medications should be returned to the pharmacy and should not remain available for use within the facility by staff. During an interview on 07/02/2026 at 2:42 PM, Licensed Practical Nurse #2 stated that sometime in December 2025, they created and entered a fraudulent order for Resident #4 for fluoxetine (a medication for depression) and successfully diverted the medication. They explained that after a gradual dose reduction decreased Resident #4's fluoxetine medication from 20 milligrams to 10 milligrams, Licensed Practical Nurse #2 entered an order for the discontinued 10 milligram dose, discontinued the order the same day so it would not appear on the Medication Administration Record, and took the medication home. Licensed Practical Nurse #2 stated that in March 2026, they again entered a fraudulent order for Resident #5 for fluoxetine 20 milligrams and discontinued it the same day with the intent to divert the medication. They stated they knew Resident #5 had stopped taking fluoxetine due to concerns about adverse effects and a gradual dose reduction had been initiated. They intended to take the medication home but could not find it, and another nurse observed them looking for the medication. Licensed Practical Nurse #2 stated they informed the nurse they wanted to speak with Director of Nursing #1 and Administrator #1 to confess what they had done. Licensed Practical Nurse #2 stated they were suspended for several days.During an interview on 07/02/2026 at 1:52 PM, Director of Nursing #1 stated that on 03/24/2026, they were made aware by Registered Nurse #1 there was a situation involving the possible diversion of medication. Registered Nurse #1 reported this to both Director of Nursing #1 and Administrator #1. Director of Nursing #1 stated Licensed Practical Nurse #2 went into the Director of Nursing office on 03/24/2026 and confessed to both Director of Nursing #1 and Administrator #1 that they had entered a medication order into the electronic health record and then discontinued it, with the intention of diverting the medication for personal use. Licensed Practical Nurse #2 stated to Director of Nursing #1 that they had a loved one who was going through issues and remembered that Resident #4 was on fluoxetine and created the order and then discontinued the medication. In addition, Licensed Practical Nurse #2 created an order on 03/18/2026 under Resident #5's electronic medical record for 10 milligrams of fluoxetine and then discontinued the medication the same day. Director of Nursing #1 stated that both incidents were not reported to the Department of Health or Law Enforcement because they did not feel the incident rose to the level of a crime.During an interview on 07/02/2026 at 3:33 PM, Administrator #1 stated they were first made aware of the incident on 03/23/2026 by Registered Nurse #1, and the facility initiated an investigation that same day. Registered Nurse #1 began reviewing medication records and medication supplies for discrepancies involving fluoxetine. Administrator #1 stated Licensed Practical Nurse #2 met with Director of Nursing #1 and #1 and admitted entering an order and diverting the medication for Resident #4 in December 2025 and entered a medication order without provider approval with intention of diverting medication for personal use for Resident #5 in March 2026 but did not get ahold of the medication. Licensed Practical Nurse #2 was immediately suspended pending investigation. Administrator #1 stated they consulted with corporate leadership and determined the incident appeared to be isolated. Administrator #1 stated Nurse Practitioner #1 and Director of Nursing #1 were interviewed on 03/23/2026; however, no documentation of the interview was maintained. Administrator #1 stated the incident was not reported because they did not believe the definition of gross negligence applied. Administrator #1 further stated the incident was not a crime, as the facility determined the medications were taken from facility stock and residents were not billed. Administrator #1 also stated the incident was not brought to the Quality Assurance and Performance Improvement committee due to concerns regarding employee rights and personnel matters.10 New York Codes, Rules and Regulations 415.4(b)(2) Immediate Jeopardy was issued to the Administrator on 07/02/2026. Facility Immediacy Removal Plan submitted on 07/03/2026 was approved. Immediate Jeopardy was lifted effective 07/03/2026. The facility's immediacy removal actions included the following: On 07/02/2026 at 6:38 PM, Administrator #1 called law enforcement and reported stolen medication and falsification of medical orders.On 07/02/2026 at 9:43 PM, facility submitted a report to New York State Department of Education Office of the Professions, detailing theft of the 30-day supply of fluoxetine and falsification of medical orders for fluoxetine.On 07/02/2026, facility indefinitely suspended Licensed Practical Nurse #2.During an interview on 7/07/2026 at 11:15 AM, Administrator #1 stated Licensed Practical Nurse #2 is on indefinite suspension pending legal review. As of 07/03/2026 at 11:59 PM, 159 of 164 staff received education on reporting suspected crimes under the Federal Elder Justice Act, with remaining employees to be educated upon arrival to their next shift.

Based on interview and record review conducted during survey, the facility failed to ensure Resident #s 4 and 5 were free from misappropriation and exploitation in being taken advantage of for personal gain. Specifically, in December 2025, Licensed Practical Nurse #2 entered medication orders using Resident #4's information and without provider authorization, discontinued the orders, and diverted medication for personal use. In March 2026, Licensed Practical Nurse #2 entered and discontinued a medication order for Resident #5 with the intent to obtain the medication for personal use. The residents' personal health information including their name, diagnoses and identifying information, were fraudulently used to facilitate the medication orders.Findings include:Cross reference to F-609, F-865.The facility's policy and procedure titled Abuse-Investigation, Protection and Reporting - Components #5, 6, 7 dated 05/23/2023 under the Procedures Section listed 1. The facility will notify the Department of Health when the reasonable cause threshold has been established; meaning that there is sufficient evidence for a prudent person to believe that abuse, misappropriation of property, involuntary seclusion, neglect and/or exploitation has occurred and 2. The facility will notify the local Law Enforcement Agency if the abuse/occurrence investigation concludes a crime has occurred. Resident #4 was admitted to the facility with diagnoses of depression (a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities), adjustment disorder with mixed anxiety and depressed mood (a short-term mental health condition triggered by a stressful life event), and anxiety (an emotion characterized by apprehension, tension, and worry about future events). The Minimum Data Set (a resident assessment tool) dated 01/13/2026 documented the resident could be understood and could understand others. Resident #5 was admitted to the facility with diagnoses of bipolar disorder (a lifelong mental health condition characterized by dramatic shifts in mood, energy, and activity levels), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest) and schizoaffective disorder (mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania). The Minimum Data Set, dated [DATE] documented the resident could be understood and could understand others. Facility investigation records included a written statement from Licensed Practical Nurse #2 dated 03/24/2026 acknowledging that in December 2025 they entered an order for Resident #4 for fluoxetine 10 milligrams, discontinued it, and took the medication when it arrived. The statement further documented that in March 2026, Licensed Practical Nurse #2 entered an order under Resident #5 for fluoxetine 20 milligrams, discontinued it, and intended to take the medication, but the medication had been removed from the medication cart. In a written statement in the Facility Investigation Report dated 03/24/2026, Licensed Practical Nurse #3 stated Licensed Practical Nurse #2 came over to the mediation cart looking for medication. Licensed Practical Nurse #2 did not respond when Licensed Practical Nurse #3 asked what medication they were looking for. Licensed Practical #2 stated the medication they ordered did not come in. Shortly after Licensed Practical Nurse #2 walked away, Licensed Practical Nurse #3 recalled fluoxetine was delivered during the overnight shift and they had moved it to the bottom drawer so they could put it in the pile of medications to return to the pharmacy because Resident #5 did not have an order for it. When Licensed Practical Nurse #3 went back to the orders page, they saw a medication order placed for fluoxetine the morning of 03/18/2026 and discontinued in the afternoon on 03/18/2026. Licensed Practical Nurse #3 recalled a couple months prior (was unsure of date) Licensed Practical Nurse #2 mentioning they were helping their current partner get a medication (fluoxetine) which raised suspicion that the medication was ordered for Licensed Practical Nurse #2's partner. Licensed Practical Nurse #3 then reported the suspicion to Registered Nurse #1. During an interview on 07/02/2026 at 2:42 PM, Licensed Practical Nurse #2 stated that sometime in December 2025, they created and entered a fake order for Resident #4 for fluoxetine (a medication for depression) and successfully diverted the medication. They gave it to someone they cared about because the other person was struggling with depression. They explained that after a gradual dose reduction decreased Resident #4's fluoxetine medication from 20 milligrams to 10 milligrams, Licensed Practical Nurse #2 entered an order for the discontinued 10 milligram dose, discontinued the order the same day so it would not appear on the Medication Administration Record, and took the medication home. During an interview on 07/02/2026 at 2:43 PM, Licensed Practical Nurse #2 stated that in March 2026, they entered a fake order for Resident #5 for fluoxetine and discontinued it the same day with the intent to divert the medication. They stated they knew Resident #5 had stopped taking fluoxetine due to concerns about adverse effects and a gradual dose reduction had been initiated. They intended to take the medication home but could not find it, and Licensed Practical Nurse #3 observed them looking for the medication who then reported it to Registered Nurse #1 who was the supervisor at the time. Licensed Practical Nurse #2 stated they informed Registered Nurse #1they wanted to speak with Director of Nursing #1 and Administrator #1 to confess what they had done. Licensed Practical Nurse #2 stated they were suspended for several days. During an interview on 07/02/2026 at 1:52 PM, Director of Nursing #1 stated Licensed Practical Nurse #2 told them that they had a loved one who was going through issues and remembered that Resident #4 was on fluoxetine and created the order and then discontinued the medication. On 03/18/2026, Licensed Practical Nurse #2 created an order for 10 milligrams of fluoxetine and then later that day, discontinued the medication. Director of Nursing #1 stated Licensed Practical Nurse #2 was suspended immediately and a facility investigation was started on 03/24/2026. Director of Nursing #1 stated residents' insurances were not billed and neither resident was affected.During an interview on 07/02/2026 at 3:33 PM, Administrator #1 stated they did not believe gross negligence applied, facility determined the medications were taken from facility stock and residents were not billed. 10 New York Codes, Rules and Regulations 415.4(b)

Based on record review and interview during survey, the facility failed to implement its Quality Assurance and Performance Improvement (QAPI) program to address a medication diversion event involving unauthorized medication orders and misappropriation of resident medications. Specifically, the facility failed to present the incident to the Quality Assurance and Performance Improvement Committee for review, identify system failures, develop corrective actions, and monitor the effectiveness of interventions to prevent recurrence.Findings include:Cross reference to F-602, F-609.The facility's policy and procedure titled Quality Assurance and Performance Improvement (QAPI) Program dated 01/13/2026 documented the facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI Program that is focused on indicators of the outcomes of care and quality of life for our residents. The objectives of the Quality Assurance and Performance Improvement (QAPI) Program are to: 1. Provide a means to measure current and potential indicators for outcomes of care and quality of life.Through staff reporting and subsequent investigation, the facility became aware on 03/23/2026 that Licensed Practical Nurse #2 admitted to entering unauthorized medication orders into the electronic medical record under Resident #4's record, discontinuing those orders, and taking the medication for personal use in December 2025. Licensed Practical Nurse #2 also admitted to entering another unauthorized medication order for Resident #5 on 03/18/2026 with the intent to obtain that medication, although the medication was removed from the medication cart before they could take it.There was no documented evidence the facility brought the matter to the Quality Assurance and Performance Improvement committee after the incident.During an interview on 07/02/2026 at 3:33 PM, Administrator #1 stated they consulted with Corporate Administrator #1 and Corporate Regional Registered Nurse #1 regarding the incident. Licensed Practical Nurse #2 was placed on a probationary period, including weekly audits of medication orders and medication cart practices. Administrator #1 stated the incident was not brought to the Quality Assurance and Performance Improvement Committee due to concerns regarding employee rights and personnel matters. 10 New York Codes, Rules and Regulations 415.27

Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for 3 of 3 medication carts, and 2 (Elm and Aspen units) of 3 medication storage rooms reviewed. Specifically, (a.) opened medications had no open and/or expiration dates; (b.) stock medication open and expiration dates were not legible; (c.) personal items were stored in double locked cabinet with controlled substances; (d.) a pre-poured medication cup was noted in medication cart; and (e.) a narcotic was not signed out correctly when administered. This is evidenced by: The facility's Storage -Labeling - Maintenance of Medications Policy effective [DATE], documented all medications maintained in the facility would be properly labeled in accordance with current state and federal guidelines and regulations. Medications with shortened expiration dates (i.e. Insulin's, injections, ophthalmic drops, etc.) must be dated when opened. See Recommended Minimum Storage Parameters for specific information. Only drugs (and supplies necessary for their administration) were to be kept in medicine cabinets and carts. Medication must be checked regularly for expiration dates and deterioration. Medication labels must be legible at all times. The facility's Administration of Medication - General Policy effective ,d+[DATE], documented it was the facility's policy that medications would be administered to residents in a timely and accurate manner by a licensed nurse or physician. Nurse should check expiration dates on packaged containers. Nurse Administers medication at the time it was prepared. Never pre-pours medications. Nurse should immediately chart medications administered in the proper time and date square via initials and identified initials by signature in designated space on the administration record. During an observation on [DATE] at 12:35 PM, the Elm Unit Medication room [ROOM NUMBER] refrigerator contained an open bottle of purified protein derivative (PPD) with no open and or expiration date. During an observation on [DATE] at 1:15 PM, Elm Unit Medication Cart #1 contained a cup of pre-poured medications for Resident #62. Licensed Practical Nurse #2 stated they poured medication for Resident #62, but they were not in their room. Licensed Practical Nurse #2 stated they placed the cup of pills in medication cart and planned to give medications when resident returned. The following had no expiration dates after opening: 2 Humalog insulin Kwik pens, 1 Basaglar insulin Kwik pen, and 1 opened Breo Ellipta inhaler had no open date. During an observation on [DATE] at 10:33 AM, the Aspen Unit medication cart #2 contained: an opened bottle of nitroglycerin pills with no open and or expiration date, 1 bottle of zinc stock medication where the open and expiration dates were not legible. Licensed Practical Nurse #3 discarded the bottle of zinc. The Narcotic count for Resident #19 oxycodone 10 milligrams count was 104, sign out book reflected 103. Licensed Practical Nurse #3 stated Resident #19 was also prescribed oxycodone 5mg as well and they signed medication out on the incorrect page. Oxycodone 5mg count was 11, and book reflects 12. Licensed Practical Nurse #3 made the correction. During an observation on [DATE] at 10:40 AM, the Aspen unit medication #2 room narcotic lock box contained a wallet and $2 cash. Licensed Practical Nurse #3 stated they belonged to a resident and was kept for safe keeping. During an observation on [DATE] at 11:00 AM, the Birch Unit medication cart #1 contained the following with no expiration dates after opening: 1 vial Fiasp insulin; 1 Degludec insulin kwik pen; 1 Humalog insulin kwik pen; 1 Timolol eye drop; and 1 bottle artificial tears. During an interview on [DATE] at 11:00 AM, Licensed Practical Nurse #4 stated, pharmacy placed expiration dates on medication. Insulin expired 30 days after opening and they were not aware of Medications with shortened expiration dates (i.e. Insulin's, injections, ophthalmic drops, etc.). During an interview on [DATE] 11:13 AM, Director of Nursing #1 stated all residents had a locked drawer in their room to keep personal items. There was also a safe to keep valuables. Director of Nursing #1 did not know where the safe or key to the safe was located. Director of Nursing #1 stated Activities generally assisted residents with accessing personal needs account and ordering out when needed. During a subsequent interview on [DATE] at 2:52 PM, Director of Nursing #1 stated nursing staff were to date medications upon opening and check expiration date with each medication pass. Nurses should not pre-pour medications. 10 New York Codes, Rules, and Regulations 415.18(d)

Based on observations, record reviews, and interviews during the recertification and abbreviated (NY00322544) survey, the facility did not ensure that food and drink were palatable and attractive for 19 (Resident #s 1, 11, 12, 23, 26, 60, 62, 63, 65, 66, 71, 74, 76, 78, 108, 127, 131,145, and 150) of 32 residents reviewed for palatable and attractive food and drink. Specifically, residents complained of food being cold, unattractive, and not palatable in general during the resident council meeting. Additionally, 3 units (Aspen, Fir, and Chestnut) of 6 units served food that was not palatable and was not appetizing in appearance. This is evidenced by: A facility policy titled Food and Nutrition Services dated 11/15/2023 documented the facility would provide each resident with a nourishing, palatable, well-balanced diet that met their daily nutritional and special dietary needs, considering each resident's preferences. Resident #11 was admitted with diagnoses of cerebral infarction due to embolism (stroke due to blood clot), mild vascular dementia with other behavior disturbances, and seizures. The Minimum Data Set (an assessment tool) dated 4/22/2024, documented the resident had no cognitive impairment, could be understood, and understood others. During an interview on 7/23/2024 at 9:13 AM, Resident #11 stated that the food was not very good but was edible. Resident #62 was admitted with the diagnoses of morbid obesity due to excessive calories, acute kidney failure dependent on dialysis, and anxiety disorder. The Minimum Data Set, dated dated dated [DATE], documented the resident had minimal cognitive impairment, could be understood, and understood others. During an interview on 7/23/2024 at 12:24 PM, Resident #62 stated the food was not very good, always cold, and had no flavor. They stated that they usually received sandwiches for dinner or ordered out because the food was not very good. Resident #66 was admitted with the diagnoses of end-stage renal disease dependent on dialysis, type 2 diabetes mellitus, and peripheral artery disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). The Minimum Data Set, dated dated dated [DATE], documented the resident had no cognitive impairment, could be understood, and understood others. During an interview on 7/23/2024 at 10:14 AM, Resident #66 stated the food was not appealing and that they were on a dialysis diet. They stated they do not get specialized diet as they were told by staff that they do not have the budget for those items. Resident #74 was admitted with the diagnoses of end-stage renal disease dependent on dialysis, acute, chronic respiratory failure with hypoxia (a condition when the lungs have trouble loading oxygen into the blood or removing carbon dioxide), and type 2 diabetes with neuropathy. The Minimum Data Set, dated dated dated [DATE], documented the resident had no cognitive impairment, could be understood, and understood others. During an interview on 7/23/2024 at 11:25 AM Resident #74 stated that food was good once in a blue moon, and always cold. They stated there was supposed to be an alternate but when asked for the alternate, they were told that they do not have any. During a resident council meeting conducted on 7/23/2024 at 11:50 AM with Residents #'s 1, 26, 62, 78, and 127. Each resident stated that the food at the facility was usually cold, not attractive, or appetizing. Many resident council participants stated they usually would order food out to be delivered because of the unappetizing food. The resident council had a separate food council meeting before the regular meetings. Review of food council minutes from May 2024, June 2024, and July 2024 meetings, documented resident concerns were cold food, under or over-cooked food, inedible food due to cooking and temperatures, and food not matching on menus distributed. During a test trays for temperature and taste performed on multiple units. The following were observed: -A lunch meal test tray was obtained on 7/26/24 at 12:26 PM, on the Chestnut unit. The beef [NAME] was 101 degrees Fahrenheit, the bun was 76.2 degrees Fahrenheit, the cottage cheese and fruit was 46 degrees Fahrenheit, macaroni salad was 49.4 degrees Fahrenheit. The taste of the hotdog was adequate no condiments were provided, and the bun for the hotdog was soft and chewable. The macaroni salad had no seasoning or flavor. -A lunch meal test tray was obtained on 7/29/24 at 12:22 PM, on the Fir unit. The grilled chicken was 114.6 degrees Fahrenheit, the carrots was 99.1 degrees Fahrenheit, the milk was 51.3 degrees Fahrenheit, and the soda was 52.2 degrees Fahrenheit. The tray ticket had designated a fruit cup to be included but was missing. The taste of the chicken was bland, had no flavor, and was very tough to eat. The carrots were hard to chew and no flavor to them. -A breakfast meal test tray was obtained on 7/30/2024 at 8:16 AM, on the Aspen unit. The meal ticket documented biscuits and sausage gravy matched the meal with the exception that cranberry juice was not included. Orange juice was given as a substitute for the cranberry juice. The biscuits were 122 degrees Fahrenheit, and the sausage gravy was 114.3 degrees Fahrenheit. The appearance of the meal was not appealing or flavorful and the biscuits were slightly difficult to chew and cut. 10 New York Code of Rules and Regulations 415.14(d)(1)(2) 48615 48744

Based on observation, record review, and interviews during the recertification survey, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the automatic dishwashing machine was not in good repair and did not provide a sanitizing final rinse, and equipment required cleaning. This is evidenced by: During observations on 7/22/24 at 11:19 AM, the thermometer on the automatic dishwashing machine was not functioning, and the concentration of sanitizing chemical in the final rinse of the automatic dishwashing machine final rinse was zero parts per million of available chlorine. The directions on the bottle of sanitizing chemical concentrate state the concentration is to be between 50 and 100 ppm. During observations on 7/22/2024 from 11:19 AM, the following equipment in the Elm Unit, Fir Unit, Birch Unit, Aspen Unit, Chestnut Unit, and/or Dogwood Unit nourishment rooms and servery kitchens were soiled with food particles or food drips: microwave oven K-rated fire extinguisher microwave ovens refrigerators cabinetry During observations on 7/24/2024 at 1:21 PM through 2:31 PM: In the main kitchen, the floor drains were soiled with food debris and/or a black residue, the floor and drain below and behind the dishwashing machine were heavily soiled with a black build-up, and dead insects were found above the suspended ceiling and in ceiling light fixtures. In the Aspen/Birch Servery, dead insects were found above the suspended ceiling, and the floor was caked with a black build-up and food debris along the wall and under the steamtable, worktable, and dishwashing machine. In the Chestnut/Dogwood Servery, food debris and dead insects were found on the floor under the steamtable, worktable, and dishwashing machine. During an interview on 7/22/2024 at 12:22 PM, Food Service Director #1 stated that the vendor would be contacted to repair the automatic dishwashing machine. During an interview on 7/25/2024 at 12:27 PM, Administrator #1 stated that they would speak to the Food Service Director regarding training staff to monitor the dishwashing machine final rinse and maintaining the cleanliness of the nourishment rooms. 10 New York Codes, Rules, and Regulations 415.14(h) Chapter 1 State Sanitary Code Subpart 14-1

Based on observation and interviews during the recertification survey, the facility did not provide adequate outside ventilation by means of windows, or mechanical ventilation, or a combination of the two. Specifically, components of the heating and air conditioning system were not repaired or replaced as necessary. This is evidenced by: During observations on 7/24/2024 from 8:00 AM through 3:00 PM and on 7/25/2024 at 10:25 AM, the air quality in the Family Conference Room was humid and stuffy. During an interview on 7/25/2024 at 10:27 AM, Director of Maintenance #1 stated for about one year, the closed loop air handler servicing the Family Conference Room had a clogged water line which interfered with the functioning of the system. Director of Maintenance #1 stated several air conditioning heat pumps (approximately 10 of 300) were failing and required replacement; the facility had purchased and had onsite, 3 replacement heat pumps that would be installed by facility staff, and in the interim, window air conditioning units were placed in the rooms affected. During an interview on 7/26/2024 at 11:09 AM, Administrator #1 stated the air handling system servicing the Family Conference Room would be diagnosed and repaired if necessary, and all heat pumps not functioning properly would be repaired or replaced as necessary. 10 New York Codes, Rules, and Regulations 415.29(h)

Based on observation, record review, and interviews during the recertification, the facility did not maintain a pest-free environment and an effective pest control program on 2 of 2 resident unit serveries and the main kitchen. Specifically, evidence of insect infestation was found in the main kitchen and resident unit serveries, and the facility did not implement the remediation recommendations of the pest control vendor. This is evidenced by: During observations of the main kitchen on 7/24/2024 at 1:21 PM and again on 7/30/2024 at 9:37 AM: A swarm of small flies were found around the drink preparation area floor drain. A swarm of small flies were found around the drain in and in the corridor just outside of the cart-wash room. 7 of 7 floor drains in the main kitchen were soiled with food debris and/or a black residue. The floor drain in the cart-wash room was heavily soiled with a black build-up. The floor and drain below and behind the dishwashing machine were heavily soiled with a black build-up. Dead cockroaches were found above the suspended ceiling and in ceiling light fixtures in the main kitchen and the main kitchen servery. Door sweeps were not installed on the 3 doors to the main pantry and the door to the snack pantry. Empty boxes and wiring debris was found above the suspended ceiling. During observations of the Aspen/Birch Servery on 7/24/2024 at 1:51 PM: Small flies were found around the floor drain. Dead cockroaches were found above the suspended ceiling. The floor was caked with a black build-up and food debris along the wall and under the steamtable, worktable, and dishwashing machine. During observations of the Chestnut/Dogwood Servery on 7/24/2024 at 2:14 PM: food debris and dead cockroaches were found on the floor under the steamtable, worktable, and dishwashing machine. small flies were found around the floor drain in the serving station. During observations on 7/24/2024 at 2:31 PM, vegetation overgrowth was found around the perimeter of the building, and old equipment and solid waste was found in the receiving area behind the building. The facility pest control sighting log documented that from 7/24/2023 through 7/15/2024, facility staff had sighted cockroaches and/or drain flies on the Chestnut Unit, Birch Unit, main kitchen, and reception area. The document titled [vendor] Service Report and dated 6/17/2024, 5/29/2024, 5/14/2024, 4/19/2024, 10/18/2023, 09/22/2023, 8/23/2023, and 7/11/2023 documented that the pest control vendor advised the facility to clean floor drains and kitchen floors daily, to install sweeps to the kitchen pantry doors, and to clear vegetation from the perimeter of the building. There was no documented evidence that a pest control vendor provided services from 11/2023 through 03/2024. During an interview on 7/24/2024 at 12:14 PM, Director of Maintenance #1 stated that about 11 months ago, the dietary staff reported sightings of cockroaches first in the main kitchen then in the servery kitchens. The pest control vendor was contacted and began treatment to control and overtake the infestation. Treatment was not provided from November 2023 through March 2024 as the vendor canceled their contract with the facility. A sweep was installed on the rear exit door from the main kitchen several years ago, but the pest control vendor had not updated their records. During an interview on 7/25/2024 at 12:14 PM, Administrator #1 stated that the facility was in process of addressing the concerns listed on the pest control vendor reports, such as clearing vegetation from around the building and cleaning and monitoring the cleanliness of kitchens and floor drains; the pest control vendor wouldl be asked to reassess the facility to ensure their recommendations were being followed. 10 New York Codes, Rules, and Regulations 415.29(j)(5)

Based on record review and interviews during a recertification survey, the facility did not ensure the facility conducted initially and periodically comprehensive, accurate, standardized reproducible assessments of each resident's functional capacity and completed not less than once every 12 months for 1 (Resident # 108) of 32 residents reviewed for Comprehensive Resident Assessments. Specifically, for Resident # 108, Comprehensive Resident Assessments was not completed to reflect changes in the resident's physical and medical conditions. This is evidenced by: A facility policy and procedure titled Minimum Data Set (MDS) - Resident Assessments dated 10/2017, documented that the assessment must accurately reflect the resident's status and be reflective of the resident's state at the time of assessment. Resident #108 was admitted with diagnoses including unspecified dementia (a neurological disorder affecting memory), hemiplegia and hemiparesis following cerebral infarction affection left non-dominant side (a clot in the brain causing one side of the body to be weak or nonfunctional), and gastro-esophageal reflux disease with esophagitis, with bleeding. The Minimum Data Set, dated dated dated [DATE], documented the resident was usually understood and could sometimes understand others and required extensive assistance for most activities of daily living. The Minimum Data Set, dated dated dated [DATE] documented Resident #108 did not have any symptoms and behaviors indicative of cognitive incapacity. The Minimum Data Set also did not document the gastro-esophageal reflux disease with esophagitis, with bleeding that the resident experienced which required medications to treat and minimize future similar gastric issues. Physician order dated 4/24/2024 documented Protonix 40 milligrams by mouth once daily for gastrointestinal bleeding prevention. During a telephone interview on 7/29/2024 at 11:50 AM, Minimum Data Set Coordinator #1 stated the assessments were done telephonically. They stated when doing the Minimum Data Sets, the facility would inform them that a resident needed an assessment. Minimum Data Set Coordinator #1 stated if information was needed regarding a resident's assessment, they got assistance from the facility staff to help gather the needed information. They stated that the social work department, the Director of Nursing, and the therapy departments have provided information through emails and or phone calls. The Minimum Data Set Coordinator stated they had never been physically in the nursing home. 10 New York Code of Rules and Regulations 415.11(a)(2)

Based on record reviews and interviews conducted during the recertification survey, the facility did not develop and implemented comprehensive person-centered care plans for each resident that included measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 (Resident #'s 124 and 150) of 32 residents reviewed for care plans. Specifically, (a.) Resident #124 had orders for congestion and fungal cream that were not care planned. (b.) Resident #150 had orders for 5 medications. There was no documented evidence that a comprehensive person-centered care plans was developed and implemented for their medication use. This is evidenced by: A facility policy and procedure titled Comprehensive Care Planning dated 12/05/2020, documented that the comprehensive care plan would include measurable objectives identified from admission assessment and the Minimum Data Set assessment. The interdisciplinary team would review and revised the care plan quarterly following Minimum Data Set completion, with a significant change, return following hospital admission, annually, and as needed. Resident #124 was admitted with diagnoses of unspecified dementia (a degenerative disease of the mind causing confusion and memory loss), toxic effect of methanol, intentional self-harm (intentionally ingested toxic amounts of alcohol- based chemical), type 2 diabetes (an endocrine dysfunction causing uncontrolled blood sugar levels). The Minimum Data Set (an assessment tool) dated 5/13/2024 documented the resident had significant cognitive impairment, could usually be understood, and understand others. The Comprehensive Care Plan initiated 10/31/2022, and last revised on 5/31/2024, did not document the resident's medical conditions of congestion and fungal infection) that required 2 medications, the use of the medications, and the signs and symptoms of adverse reactions to the medications, the adverse effects of the medical issues that required or any signs or symptoms of resolution or abatement of the medical condition requiring the ordered medications. There was no documented evidence that acare plan was developed or implemented for antifungal cream and Claritin medication use. Physician order dated 10/31/2023 at 9:00 AM documented Claritin 10 milligrams by mouth daily for congestion. There was no end date for this medication order. Physician order dated 6/24/2024 at 8:00 PM documented Clotrimazole antifungal cream for an infection on their genitals. There was no end date for this medication order. Resident #150 was admitted with diagnoses of schizoaffective disorder, bipolar type (a mental health disorder causing extreme mood swings), type 2 diabetes (a dysfunction of the endocrine system causing inability to regulate blood sugar), and hypertension (high blood pressure). The Minimum Data Set, dated dated dated [DATE] documented the resident had significant cognitive impairment, could usually be understood, and understand others. The Comprehensive Care Plan initiated 4/23/2024, last revised 6/12/2024, did not document the resident's medical conditions that required 5 medications, the use of the medications, and the signs and symptoms of adverse reactions to the medications, or the adverse effects of the medical issues that required them. Physician orders dated 4/24/2024 documented Hydrochlorothiazide 25 milligrams once daily for hypertension, Aspirin 81 milligrams once daily for coronary artery disease, Protonix 40 milligrams once daily for gastroesophageal reflux disease, Flomax 0.4 milligrams once daily for an enlarged prostate, and Atorvastatin 20 milligrams daily for cholesterol. Review of the Comprehensive Care Plan did not have documented evidence of care plan developed and implemented for Hydrochlorothiazide, Aspirin, Protonix, Flomax, and Atorvastatin use. During an interview on 7/30/2024 at 10:38 AM, Assistant Director of Nursing #1 stated care plans should be updated as things change. Sometimes care plans were updated at care reviews which were done every 3 months. For example, if a resident was receiving antibiotic therapy and the infection was resolved, the care plan should have been updated to read completed or resolved. Care plans should not have outdated therapy or treatments listed on it. During an interview on 7/20/2024 at 10:49 AM, Director of Nursing #1 stated that care plans were supposed to updated at least quarterly and anytime there were changes. They stated when a resident's condition change or medications added or removed, the care plan should be updated to reflect that. When asked why a care plan might not be updated to reflect resident medications or changes. Director of Nursing #1 stated that the facility tries to focus the care plans more on diagnoses and what the diagnoses required, not just medications. 10 New York Codes, Rules, and Regulations 415.11(c)(1) 48744

Based on record review, and interviews conducted during a recertification and abbreviated (NY00344171) survey, the facility did not ensure Comprehensive Care Plans were reviewed and revised to reflect f resident current conditions for 2 (Resident #'s 33 and 108) of 32 residents reviewed. Specifically, for (a.) Resident #33's Comprehensive Care Plan for accidents and abuse was not revised after the resident was involved in a resident-to-resident altercation; (b.) Resident #108's, Comprehensive Care Plan for medications was not reviewed and revised to include completion of treatment and resolution of medical issues. This is evidenced by: Resident #33 was admitted with diagnoses of sensorineural hearing loss (hearing loss in the inner ear), chronic obstructive pulmonary disease, and major depressive disorder. The Minimum Data Set (an assessment tool) dated 5/16/2024, documented the resident had moderate cognitive impairment, could be understood, and could understand others. The Comprehensive Care Plan for Behavior and Aggressive tendencies last updated on 5/13/2024 documented the resident would demonstrate appropriate coping skills. The Comprehensive Care Plan was not updated after an altercation had occurred between Resident #33 and another resident resulting in an injury to Resident #33 on 6/04/2024. During an interview on 7/25/2024 at 12:22 PM, Social Worker #1 stated Resident #33 did not have any issues or problems since the initial altercation on 6/04/2024 and the care plans should have been updated. During an interview on 7/29/2024 at 1:01 PM, Registered Nurse #1 stated the Comprehensive Care Plans should be person-centered and include non-pharmacological interventions and monitoring. The Comprehensive Care Plan should be reviewed and changed as necessary, based on changing goals, preferences, and needs of the resident and in response to current interventions reviewed and revised by the interdisciplinary team after each assessment. Resident #108 was admitted with diagnoses including unspecified dementia (a neurological disorder affecting memory), hemiplegia and hemiparesis following cerebral infarction affection left non-dominant side (a clot in the brain causing one side of the body to be weak or nonfunctional), and gastrointestinal hemorrhage (bleeding in the digestion track, stomach and/or intestines). The Minimum Data Set, dated dated dated [DATE], documented the resident was usually understood and could sometimes understand others. The Minimum Data Set did not document resident's cognition status. The Comprehensive Care Plan for Infection initiated 3/29/2023 and last updated on 4/22/2024 documented the resident had a history of cellulitis to their left hand and required antibiotics twice a day for 10 days. The completion of the antibiotic therapy and resolution of the infection was not documented on the care plan. Physician order dated 3/20/2024 documented Doxycycline 100 milligrams twice a day for 10 days. The Comprehensive Care Plan for infection initiated 4/23/2023 and last revised on 4/26/2024 documented the resident had a history of a urinary tract infection and required antibiotics for 7 days. The completion of therapy and resolution of the infection was not documented on the care plan. Physician order dated 4/23/2024 documented Cephalexin 500 milligrams twice a day for 7 days for Urinary tract infection. There was no documented evidenced on the care plan that the care plan was updated or revised when the resident completed the antibiotic use. During an interview on 7/30/2024 at 10:38 AM, Assistant Director of Nursing #1 stated care plans should be updated as things change. They stated care plans were updated at care reviews which were done every 3 months. For example, if a resident was receiving antibiotic therapy and the infection was resolved, the care plan should have been updated to read completed or resolved. Care plans should not have outdated therapy or treatments listed on it. Assistant Director of Nursing #1 stated that care plans were based more on medical management than individual treatments. 10 New York Codes of Rules and Regulations 415.11(c)(2)(i-iii) 48744

Based on observations, record review, and interviews conducted during a Recertification and Abbreviated (Case #NY00330031) Survey, the facility did not provide needed care and services that were resident centered and in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for 2 (Resident #'s 24 and 87) of 32 residents reviewed for quality of care. Specifically, for (a.) Resident #24 missed two scheduled specialist appointments. Resident #24 had multiple co-morbid conditions and subsequently underwent amputation of 5 toes. (b.) Resident #87 went on a 3-day Leave of Absence without supplies for daily wound care. Resident returned on day #3, and on day #4 dressings were still unchanged. This is evidenced by: The Facility's Transportation Policy dated July 2023; documented facility would assist residents in arranging transportation to/from outpatient clinic appointments/diagnostic appointments when necessary. In the event that the transportation company canceled transportation for a consult, alternative means of transportation would be made, if possible. If alternate transportation was not available, medical provider would be informed and consult would be rescheduled. A virtual consult or alternative medical review (i.e. In-house provider/contract vendor) would be pursued to the extent possible in the event that alternate transportation arrangements were not available. The Facility's Out on Pass (OOP) Therapeutic Leave Policy effective 7/13/2023, documented Nurse would order necessary medications from pharmacy for Out on Pass as needed. Nurse would provide education to resident/responsible party regarding any medication that is sent Out on Pass. Resident #24 was admitted to the facility with diagnoses of diabetes type 2 (a problem in the way the body regulates and uses sugar as a fuel), diabetic foot ulcers leading to osteomyelitis (inflammation or swelling that occurs in the bone usually as a result of infection), and peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel). The Minimum Data Set (an assessment tool) dated 10/11/2023, documented resident had severe cognitive impairment, could be understood, and understand others. Based on review of complaint NY00330031, the complainant stated Resident #24 had repeated cancellations of appointments related to the nursing home not having transportation. The resident ended up having to have a full amputation. Wound Care progress note dated 10/19/2023 documented Resident #24 was seen on follow up for left 3rd toe wound. Resident had left partial hallux and second digit amputation for presumed infection and osteomyelitis on 8/1/8/2023. Wound status: worsening. Size: Size: 1 centimeter x 1 centimeter x u.1 centimeter. ca1cu1atect area 1s 1 sq centimeter. Exudate: Moderate amount of serous drainage. Wound Care progress note dated 12/19/2023 documented Resident #24 rescheduled for amputation of left 3rd toe on 12/21/2023, secondary to transportation needs. Left 3rd toe showed exacerbation and deterioration. During an interview on 7/25/2024 at 11:28 AM, Licensed Practical Nurse #5 stated Resident #24 was admitted to the facility with diabetic foot ulcers and a history of osteomyelitis. Resident was hospitalized for foot infections in August, September, and October of 2023. Thereafter, Resident was seen by infectious disease in November of 2023, along with orthopedics every two weeks in November of 2023. In December 2023 resident underwent amputation of left 5 metatarsals (toes). Resident had been stable since amputation in 2023. During an interview on 7/25/2024 at 11:54 AM, Transportation Scheduler #1, stated orthopedic appointment on 10/25/2023 for Resident #24 was re-scheduled to 11/08/2023. They stated the facility had two residents with appointments for same day. The facility did not have transportation because both were non-Medicaid and had no transportation benefit. Therefore, the facility was to provide transportation. Transportation Scheduler #1 stated the new admission resident had a post-op appointment which took priority. They stated on 11/16/2023 orthopedic appointment for Resident #24 was re-scheduled due to COVID positive and Resident #24 had an appointment on 11/24/2023 of the following week. During an interview on 7/26/2024 at 11:17 AM, Director of Nursing #1 stated Resident #24 was admitted in July of 2023 with history of gangrene and osteomyelitis. They stated Resident #24 was sent to hospital on the following dates: -8/12/2023 - 8/24/2023 after seen on wound rounds with left great toe red and warm to touch. -9/2/2023 - 9/6/2023 diagnosis of Altered Mental Status, oxygen desaturation and sepsis. -9/13/2023 - 9/14/2023 replaced peripherally inserted central catheter (PICC) line. -10/1/2023 - 10/5/2023 Sepsis -12/21/23 - 12/27/23 Amputation left 5 metatarsals (toes). Director of Nursing #1 stated Resident #24 had scheduled orthopedic appointments. The 10/25/2023 appointment was rescheduled to 11/08/2023 because facility was unable to provide transportation for two residents appointments on the same day. The 11/16/2023 orthopedic appointment was canceled because Resident #24 was COVID positive, and the resident had another scheduled appointment on 11/24/2023. They stated the two appointments were rescheduled at their discretion and the facility physician and or Nurse Practitioner were not notified. they stated moving forward, physician and or Nurse Practitioner would be notified according to facility's policy and procedure. During an interview on 7/29/2024 at 2:34 PM, Nurse Practitioner #1 stated if a resident missed an appointment the protocol was to notify the provider. The provider would then make an assessment and determine what alternative could be done for missed appointments or if appropriate for appointment to be rescheduled. Resident #87 was admitted to the facility with diagnoses of cervical region radiculopathy (inflammation of any of the nerve roots of your cervical spine (neck), contracture left wrist (a deformity caused by injury to the muscles), and adjustment disorder (a group of symptoms, such as stress, feeling sad or hopeless, and physical symptoms that could occur after you go through a stressful life event). The Minimum Data Set, dated dated dated [DATE], documented resident had intact cognition, could be understood, and understand others. During an observation on 7/29/2024 at 12:07 PM, Resident #87 was observed sitting in wheelchair in their room. They were calm and cooperative and stated they were waiting for nurse to change bilateral lower extremity dressings. Resident #87 stated they were Out on Pass from Friday 7/26/2024 and returned Sunday 7/28/2024. They were not provided with any supplies to change bilateral lower extremity dressings while on leave, and dressings had not been changed even after their return on Sunday 7/28/2024. Dressings observed were soiled and sliding down both legs. Review of the Treatment Administration Record dated July 2024 documented the following order : Medihoney Wound/Burn Dressing External Paste (Wound Dressings). Apply to right 1st &5th toe topically as needed for wound care. Cleanse all areas on bilateral feet with Dakin's 0.125% Apply Medihoney & calcium alginate to wound bases and cover with bordered foam dressing. Review of the Treatment Administration Record dated July 2024 documented the following order: Medihoney Wound/Burn Dressing External Paste (Wound Dressings). Apply to right heel topically as needed for wound care, Cleanse wound to right heel with Dakin's 0.125% apply Medihoney & calcium alginate to wound bed, cover with foam dressing. During an interview on 7/29/2024 1:00 PM, Licensed Practical Nurse #5 stated Resident #87 was Out on Pass Friday 7/26/2024 and returned Sunday 7/28/2024. Resident sent with medication for dates out of facility. They stated since request for Out on Pass was last minute, they forgot about sending dressing change supplies and did not enter a nurse note. Licensed Practical Nurse #5 stated whoever took care of resident would be educated on dressing change. During an interview on 7/29/2024 at 2:34 PM, Nurse Practitioner #1 stated residents who were Out on Pass were required to give the facility a 72-hour notice. The facility physician and or Nurse Practitioner would assess if resident was stable to go Out on Pass. If appropriate for Out on Pass, a responsible person, such as a family member, was advised to sign-out resident. The person who signed resident out would be given medications and supplies for dates out on pass; educated on when and how to administer prescribed medications, and on any treatments or dressing changes that were ordered during leave of absence. During an interview on 7/29/2024 at 2:52 PM, Director of Nursing #1 stated Out on Pass policy request required 3 days in advance of leave, pharmacy preferred 5 days notice. The request was discussed during morning meeting. Once approved for Out on Pass, nurse manager would give medications and supplies that would be needed during leave to resident or resident representative upon leaving. An Out on Pass form would be signed by resident or representative upon leaving and then upon return. A progress note would be documented in Point Click Care (an electronic medical record) and Resident would be placed on leave until return. Upon return resident would return to Point Click Care as active, and a nurse should conduct a brief assessment. 10 New York Codes, Rules, and Regulations 415.12

Based on observation, record review, and interviews during a recertification survey, the facility did not ensure the resident environment remained as free of accidents hazards as possible and provided adequate supervision to prevent accidents for 1 (Resident #11) of 32 residents reviewed for accidents and hazards. Specifically, for Resident #11, medications were left in the resident's room unattended without the resident being assessed to independently self- administer their medication. Additionally, Resident #11 was in the bathroom when the medication was left unattended on their lunch tray. This is evidenced by: Resident #11 was admitted with diagnoses including multiple sclerosis (a degenerative muscle disease), bipolar disorder (a mental health disorder causing variable mood swings), and failure to thrive (inability to care for oneself). The Minimum Data Set (an assessment tool) dated 4/22/2024, documented the resident had minimal cognitive impairment, could be understood, and could understand others. The Minimum Data Set, dated dated dated [DATE] did not document that Resident #11 was capable or desired to self-administer their medications. A facility policy and procedure titled Administration of Medications - General dated 9/2020, documented that medications may not be left unattended and medications should be always secured in a locked area or in visible control. The policy also documented that medication should be administered at the time it was prepared and never pre-poured. The policy also documented that medication were never to be left at resident bedside, and if a situation occurred which necessitated that the nurse must step away from the resident prior to administration of all medications, medication must be removed from room and secured in locked medication cart until medications could be administered to the resident. A facility policy and procedure titled Self-Administration of Medications dated 3/2022, documented residents have the right to self-administer medications if the interdisciplinary team had determined that it was clinically appropriate and safe for the resident to do so. Additionally, the policy documented that the staff and practitioner will document an evaluation of decision-making capacity and the resident's ability and desire to self-administer their medications. The Comprehensive Care Plan initiated 5/21/2021 and last updated on 7/03/2024, did not document that Resident #11 was capable or desired to self-administer their medications. During an observation on 7/23/2024 at 9:38 AM, a medication cup with 4 medications i was observed sitting on the Resident #11's lunch tray in room # 107 B, (Aspen unit) unattended. Resident#11 was observed to be in the bathroom [ROOM NUMBER] feet away and not within the site of the medication. A review of all the physician orders on 7/28/2024 did not have documented evidence of a physician orders for the Resident #11 to self-administer their medications. During an interview on 7/25/24 at 1:10 PM, Licensed Practical Nurse #4 stated it was not appropriate to leave medications at the resident's bedside. During an interview on 7/25/2024 at 2:07 PM, Licensed Practical Nurse #3 stated medications could be left at the bedside if the physician indicated the resident could self- administer their own medication. They stated resident's care plan should reflect that they were capable to self- administer their own medication and not cause any harm to roommate by leaving their medication unattended. During an interview on 7/30/2024 at 10:38 AM, Assistant Director of Nursing #1 stated it was never appropriate to leave medications unattended with residents unless they had assessments that allowed the resident to do that. During an interview on 7/30/2024 at 10:50 AM, Director of Nursing #1 stated medications should not be left at the bedside unless the resident was assessed to be able to self-administer their medications. The nursing staff that left the medication sitting on the bedside table of Resident #11 was not available for interview. New York Codes of Rules and Regulations 415.12(h)(1)

Based on record review and interview conducted during a recertification survey, the facility did not ensure that residents who used psychotropic drugs received gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs for 2 (Resident #s108 and #150) of 32 residents reviewed for unnecessary medications. Specifically, for (a.) Resident #108 was ordered 3 psychotropic medications (Seroquel, Mirtazapine, and Zoloft) and (b.) Resident #150 was ordered 3 psychotropic medications (Trileptal, Olanzapine, and Clonazepam). There was no documented evidence that a gradual dose reduction was attempted. The Policy titled Psychotropic Medications -Unnecessary use effective 10/24/2022 documented the faculity would ensure that psychotropic medications were prescribed appropriately and were routinely evaluated and monitored; each resident's drug regimen would be free from unnecessary medications. The Policy further documented Gradual Dose Reduction (GDR) as the stepwise tapering of a dose to determine if symptoms, conditions, or risk could be managed by a lower dose or if the dose or medication could be discontinued. Resident #108 was admitted to the facility with diagnoses of heart failure (dysfunction of the heart muscles to contract properly), unspecified dementia (a degenerative memory disease), post traumatic stress disorder (an emotional disorder caused by a traumatic experience), and depression. The Minimum Data Set (an assessment tool) dated 6/03/2024 documented resident had significant cognitive impairment, could sometimes be understood, and sometimes understand others. A Physician order dated 2/28/2024 at 8:00 PM documented Resident #108 was to receive Seroquel 50 milligrams by mouth twice a day. No end date was documented. A Physician order dated 2/28/2024 at 10:00 PM documented Resident #108 was to receive Mirtazapine 7.5 milligrams by mouth at bedtime. No end date was documented. A Physician order dated 2/29/2024 at 8:00 AM documented Resident #108 was to receive Zoloft 100 milligrams by mouth daily. The Minimum Data Set, section N (Medication), dated 6/03/2024 documented Resident #108 received antipsychotic medication on a routine basis. Section N0450 antipsychotic review documented no gradual dose reduction (GDR) attempted. Review of Resident #108's medical record on 7/25/2024 did not have documented evidence that a gradual dose reduction was attempted for the resident. Resident #150 was admitted to the facility with diagnoses of schizoaffective disorder / bipolar type (a mental disorder causing variable mood swings), depression nspecified, and disruptive mood disorder /dysregulation disorder (a mental disorder that increases the chance of the resident reacting inappropriately to situations). The Minimum Data Set, dated dated dated [DATE], documented the resident had a fluctuating cognitive pattern with disorganized thinking /behavior present, could sometimes be understood, and sometimes understood others. During an observations of the Aspen unit on 7/22/2024 at 12:53 PM, Resident #150 was observed in their room yelling loudly and banging their hand on the bed. A Physician Order dated 4/23/2024 at 8:00 PM documented Resident #150 was to receive Trileptal 600 milligrams by mouth twice a day. No end date was documented. A Physician Order dated 4/23/2024at 8:00 PM documented Resident #150 was to receive Olanzapine 15 milligrams by mouth twice a day. No end date was documented. A Physician Order dated 7/19/2024 at 8:00 AM documented Resident #150 was to receive Clonazepam 0.5 milligrams by mouth daily No end date was documented. The Minimum Data Set, section N (Medication), dated 4/30/2024 documented Resident #150 received antipsychotic medication on a routine basis. Section N0450 antipsychotic review documented no gradual dose reduction (GDR) attempted. Review of Resident #150's medical record on 7/25/2024 did not have documented evidence that a gradual dose reduction was attempted for the resident. During an interview on 7/29/2024 at 7:57 AM, Administrator #1stated a local psychiatric facility sent a large number of residents to the facility prior to the current administrator's hiring. Administrator #1 further stated that the Nurse Practitioner that was used by the facility had just received psychiatric certification 3 weeks ago and would be reviewing the plans for the psychiatrically challenged residents at the facility. During a subsequent interview on 7/30/2024 at 12:25 PM, Administrator #1 stated telehealth psychiatric services were used and residents with psychiatric care were set up with telehealth psych appointments 2 days per week. The psychiatric provider had never been physically in the building. New York Codes of Rules and Regulations 415.12 (1)(2)(ii)

Based on record review and interviews during an abbreviated survey (Case #s NY00321796, NY00320120, NY00320846, and #NY00322090), the facility did not ensure each resident received adequate supervision to prevent accidents for 3 (Resident #s 2, 5 and #3) of 5 residents reviewed. Specifically, for Resident #2, who had severe cognitive impairment, the facility did not ensure adequate supervision was provided when the resident left the Aspen Unit where they resided to visit a friend on the Fir Unit on 7/1/2023. Resident #2 entered Resident #1's room on the Fir Unit and Resident #1 alleged they were sexually abused by Resident #2, and when on 7/14/2023, Resident #2 entered Resident #6's room on the Fir Unit and the resident alleged that Resident #2 stole their wallet; For Resident #5 who had severe cognitive impairment and was assessed as high risk for elopement, the facility did not ensure the resident was provided with adequate supervision on 7/26/2023, when the resident left the facility undetected by staff at approximately 1:08 PM; and for Resident #3 who had severe cognitive impairment, the facility did not ensure the resident was provided with adequate supervision on 8/12/2023, when the resident wandered into Resident #2's room and staff witnessed an incident of sexual abuse. This was evidenced by: Refer to F600 The Policy and Procedure (P&P) titled Resident Safety and Accident Prevention effective 6/2020, documented the facility had a commitment to resident safety and implemented an accident prevention plan to identify, assess, and prevent accidents. The facility would ensure that each resident received adequate supervision to prevent accidents. It documented an accident referred to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. Supervision/adequate supervision referred to an intervention and means of mitigating the risk of an accident. It documented facilities were obligated to provide adequate supervision to prevent accidents. Adequate supervision was determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and the frequency of the supervision needed. This determination was based on the individual residents' assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident. An interdisciplinary approach that included individualized resident needs, resident population as a whole, and environmental considerations would be implemented. The Policy and Procedure (P&P) titled Safety and Supervision of Residents effective 6/7/2023, documented the strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents were facility-wide priorities. It documented resident supervision was a core component of the systems approach to safety. The type and frequency of resident supervision was determined by the individual resident's assessed needs and identified hazards in the environment. The P&P titled Safety Checks and Purposeful Rounding effective 3/2018, documented the facility believed that appropriate services and care should be provided to assist each resident in attaining or maintaining his/her highest level of physical, mental, and psychological well-being. To ensure the above, the following procedure was to be followed: routine direct visual contact with residents on your assignment, taking note of resident's physical environment; face to face visual verification of resident's whereabouts should be noted; eye contact if the resident is awake. The P&P titled Elopement revised 4/30/2023, documented the goal of the facility was to prevent elopement from the facility to extent possible. Prior to admission, potential residents would be evaluated for the risk of elopement and the ability of the facility to provide for their safety needs. On admission, readmission and with any significant change residents would be evaluated for the risk of elopement. Residents identified to be at risk for elopement would have their picture taken and placed in the elopement binders in the facility. Resident #2: Resident #2 was admitted to the facility with diagnoses of schizoaffective disorder, dementia without behavioral disturbance, and bipolar disorder. The Minimum Data Set (MDS - an assessment tool) dated 6/10/2023, documented the resident had severe cognitive impairment. The CCP for resident has been going into other resident's rooms, last revised 6/14/2023, documented CCP interventions to intervene as necessary to protect the rights and safety of others; divert attention; remove from the situation and take to alternate location as needed. The CPP for Activities last revised 6/14/2023, documented the following risks: impaired thought processed related to mild neurocognitive disorder, schizoaffective disorder, bipolar, and history of alcohol, heroin, cocaine, and cannabis use. The CCP interventions documented the resident could act inappropriately at times but was easily redirected and was able to independently ambulate to and from activities and ambulated through the entire building, going unit to unit. The CCP for the resident has the potential to become physically aggressive related to psychiatric diagnosis, last revised on 8/12/2023, documented on 7/1/2023, the resident reached into a female resident's shirt and fondled their right breast and on 8/12/2023, the resident was fondling a female resident's breast. On 7/1/2023, the CCP interventions documented the resident was placed on 1:1 supervision until further notice. The intervention was resolved on 7/6/2023. On 8/12/2023, the CCP documented 1:1 staff supervision until further notice. The facility Investigation Form dated 7/1/2023 documented a resident-to-resident incident. Resident #1 reported Resident #2 was rubbing their shoulders and then placed their hand in their shirt and grabbed their right breast. Resident #2 was placed on 1:1 supervision immediately. The investigation conclusion documented it was inconclusive if Resident #2 touched Resident #1's right breast. Resident #2 was confirmed on video going into Resident #1's from 2:25:16 PM to 2:25:27 PM. The Nurse's Note dated 7/1/2023 at 9:03 PM, documented Resident #2 was placed on 1:1 supervision due to behaviors. The resident made frequent request to hug/kiss staff throughout the shift and asked to leave the unit to go for walks repeatedly. The Nurse's Note dated 7/3/2023 at 4:00 PM, documented the resident was removed from 1:1 supervision on 7/3/2023. It documented no issues with inappropriateness towards staff or residents. The facility Investigation Form dated 7/14/2023 documented a missing wallet. Resident #6 reported that Resident #2 took their wallet off the bedside table. Investigation conclusion documented Resident #2 did have a wallet, but the wallet was not a billfold, it was a trifold wallet with none of the items that Resident #6 reported were in their wallet. The handwritten investigation notes by the Director of Nursing (DON) documented for camera #48 on 7/14/2023, Resident #2 was noted to open Resident #6's door an enter their room at 7:24:48 AM. Resident #2 was noted leaving the room at 7:25:28 with a black wallet in their left hand. The facility Investigation Form dated 8/12/2023, document an incident of sexual abuse. The CNA noted Resident #2 was standing over Resident #3, who was laying in Resident #2's bed. The CNA saw Resident #2 rubbing Resident #3's breasts over their shirt. Resident #3 was placed on 1:1 supervision immediately until further notice. The Nurse Practitioner Note dated 8/12/2023 at 8:33 AM by NP #1, documented the assigned supervisor, LPNM #1, reported to NP #1 that a male resident was observed touching the breast of a female resident (#3), who was laying on the male resident's bed. NP #1 gave an order for the male resident to be placed on strict 1:1 supervision until seen by a psychiatrist. On 8/12/2023, the CCP documented 1:1 staff supervision until further notice. During an observation on 8/14/2023 at 12:32 PM, there was no staff outside or inside Resident #2's room providing 1:1 direct supervision. During an interview on 8/14/2023 at 12:41 PM, Resident #2's assigned Certified Nurse Aide (CNA) #6 stated they did not know who was providing the 1:1 supervision for the resident. CNA #6 stated that right now they were watching the door and would check on the resident every 10 to 15 minutes. During an interview on 8/14/2023 at 1:27 PM, the Director of Nursing (DON) stated staff put the resident on 1:1 supervision and then CCP is updated. The DON stated 1:1 supervision meant that the staff member was watching the resident and they did not take their sights off the resident. They did not have to be in the room if the resident was the only one in the room. Once the resident left the room staff needed to follow them. The DON stated Resident #2 had gone on the Fir unit on 7/1/2023 specifically to see their friend and then went into Resident #1's room. The DON stated that after the incident, they had Resident #2 meet their friend at the fish tank to eliminate their need to go onto the Fir unit. During an interview on 8/14/2023 at 3:25 PM, Registered Nurse Manager (RNM) #2 of the Aspen unit stated they had only been a nurse manager for three months and was the manager of the Elm, Aspen, and Fir units prior to 7/7/2023, and now managed the Dogwood, Chestnut, and Aspen units. RNM #2 stated this was the first time they heard about the incident with Resident #2 on 7/1/2023. RNM #2, stated they never put Resident #2 on 1:1 supervision or knew they were supposed to be. During an interview on 8/14/2023 at 3:43 PM, Certified Nurse Aide (CNA) #4 on the Aspen stated they provided care to Resident #2 regularly and did not hear anything about any incidents with Resident #2 and residents on the Fir unit. CNA #4 stated they were not aware that Resident #2 was to have 1:1 supervision. CNA #4 stated 1:1 supervision meant the 1:1 CNA would sit with the resident for the whole shift to keep an eye on them. During an interview on 8/14/2023 at 3:45 PM, CNA #5 on the Aspen unit stated they heard about an accusation of Resident #2 stealing a resident's wallet and then Resident #2 ended up being moved to Dogwood unit, which is a locked unit. CNA #1 stated they did not hear anything about an allegation of sexual abuse and to their knowledge, Resident #2 was never on 1:1 supervision on the Aspen unit. CNA #5 stated 1:1 supervision meant having a staff person there 24/7 to watch over and supervise them; to watch them at all times. During an interview on 8/15/2023 at 11:38 AM, LPN Manager (LPNM) #1 stated they managed the Chestnut, Aspen, and Dogwood units and Registered Nurse Manager (RNM) #2 oversaw them. LPNM #1 stated they were called to the Fir unit on 7/1/2023. LPN #2 reported that Resident #1 had been screaming that they did not want Resident #2 in their room and then told LPN #2 what had happened. LPNM #1 stated Resident #2 resided on the Aspen unit at the time of incident. LPNM #1 stated Resident #2 would go down to the Fir unit and would visit a friend who resided in a room that was almost directly across from Resident #1's room. LPNM #1 stated any resident was able to visit another resident and stated if they were not locked up they could go anywhere they wanted. LPNM #1 stated that after the incident on 7/1/2023, Resident #2 was placed on 1:1 supervision, was no longer allowed on the Fir unit, and had to meet their friend at the fish tank in the lobby. LPNM #1 stated that not too long after the incident on 7/1/2023, Resident #2 entered a resident's room on the Fir unit and was accused of taking a wallet. Resident #2 was then moved to the Dogwood unit. LPNM #1 stated that on the Dogwood unit on 8/12/2023, Resident #3 wandered into Resident #2's room. LPNM #1 stated it was a locked unit and all the residents wandered into other resident rooms. LPNM #1 stated that after the incident with Resident #3, Resident #2 was put on 1:1 supervision and was then moved to the Chestnut unit on 8/13/2023. LPNM #1 stated that the staff member assigned to do the 1:1 supervision today, did not do it and it was reported to the DON and the staff member got in trouble. They then assigned someone else. During an interview on 8/15/2023 at 12:17 PM, LPN #2 stated they worked fulltime on the Fir unit, which was Resident #1's unit. LPN #2 stated that on 7/1/2023, they heard Resident #1 yell Don't touch me. Do you want me to kill you? LPN #2 stated that by the time they got to the resident's room, staff from the Elm unit had already gotten to the resident. LPN #2 identified the male resident as Resident #2, who was cognitively impaired and resided on the Aspen unit. LPN #2 stated Resident #2 would visit a friend on the Fir unit and would also just pass through all of the units. LPN #2 stated they did not see Resident #2 on the unit after the incident and believed the resident was moved to the Dogwood unit. During an interview on 8/16/2023 at 11:32 AM, NP #1 stated the facility called them about the incident on 7/1/2023 and ordered for Resident #2 to be put on 1:1 supervision. NP #1 stated they ordered 1:1 supervision on a patient-specific basis, so that they could make an assessment to see if the incident was because of a cognitive or physical concern. NP #1 stated they ordered lab tests and there was no medical reason for Resident #2's change in behavior. NP #1 stated Resident #2 had dementia, depression, and schizophrenia, which altogether made it schizoaffective disorder. NP #1 stated the resident had no sexual tendencies prior to 7/1/2023. NP #1 stated that on 8/12/2023, Resident #2 had a behavior opportunity because someone wandered into their bed. NP #1 stated Resident #2 did not have the propensity to seek someone out. NP #1 stated Resident #2 was visiting their friend on 7/1/2023 and then went into Resident #1's room. NP #1 stated Resident #2 did not recall the incident with Resident #1 because of dementia and other diagnoses. NP #1 stated when they were called about the second incident on 8/12/2023, they ordered strict 1:1 supervision and not to release until seen by the Psychiatrist. NP #1 stated the reason they ordered for the 1:1 supervision after the first incident was because they were concerned it would happen a second time and wanted the resident to be supervised until seen by the Psychiatrist. NP #1 stated Resident #2 was seen by the Psychiatrist and there are plans to have the resident relocated. NP #1 stated all residents need some level of supervision and stated Resident #2 needed strict supervision. During a subsequent interview on 8/17/2023 at 2:53 PM, the DON stated Resident #2 had no history of sexual abuse prior to the incident on 7/1/2023. The DON reviewed the electronic medical record (EMR) and stated there was a CCP intervention for 1:1 supervision that was initiated on 7/1/2023, following the incident with Resident #1. The DON then stated Resident #2 was on 15-minute safety checks from 7/1/2023 to 7/3/2023. The DON stated the 1:1 supervision was resolved on 7/6/2023 because the resident had no signs of being sexually inappropriate. The DON stated Resident #2 was moved to the Dogwood unit, which was a locked unit, because the resident wanted to leave and was going into other resident rooms. The DON stated Resident #2 was put on strict 1:1 supervision following the incident with Resident #3. During an interview on 9/7/2023 at 9:51 AM, the physician/Medical Director (MD) #1 stated Resident #2 resided on the Aspen unit on 7/1/2023 and was allowed to roam around the facility. MD #1 stated Resident #2 had been moved to other units. MD #1 stated other than just moving problem residents from one unit to the next, the facility had to protect all the residents, especially residents who were on the Dogwood unit. MD #1 stated that on the Dogwood unit, the supervision was poor and residents go into other's rooms. MD #1 stated the unit was locked but the rooms were not, and staff needed to ensure they were supervising all residents to keep them safe. MD #1 stated Resident #3 who resided on the Dogwood unit, was cognitively impaired, nonverbal, and did not know what they were doing when they wandered into Resident #2's room. Resident #5: Resident #5 was readmitted to the facility with diagnoses of schizophrenia, bipolar disorder, and recurrent major depressive disorder. The Minimum Data Set (MDS - an assessment tool) dated 6/19/2023, documented the resident had severe cognitive impairment. The Comprehensive Care Plan (CCP) for resident was at High Risk for Elopement related to mental illness, last revised 8/9/2023, documented on 7/26/2023 the resident went out the front door and returned two minutes later. The CCP interventions documented the resident had a history of taking off the wander guard bracelet. An intervention for 1 hour safety checks was initiated on 11/10/2022 and resolved on 4/4/2023. A CCP intervention initiated on 2/16/2023 and resolved on 8/9/2023, documented a wander (bracelet) was in place per elopement evaluation on 2/16/2023, and 15- minute safety checks if the resident removed the bracelet. On 7/26/2023, CCP interventions documented 1:1 supervision to be maintained and was resolved on 8/9/2023. The elopement risk evaluation titled PHC- Elopement Risk Evaluation-V2 dated 5/24/2023, documented the resident was fully ambulatory, had a prior elopement history or had made one or currently exit seeking, wandered aimlessly, voiced desire to leave or discontent with placement, had behavior symptoms of agitated/restlessness/substance abuse history with substance seeking behavior, and exhibited hallucinations/delusional thinking/confusion/paranoia/unpredictable. The resident's total assessment score was 39. It documented if the score was 10 or greater the resident should be considered high risk for Elopement Prevention Protocols. Should be followed and documented on the Care Plan. The MDS Section P Restraints and Alarms dated 6/19/2023 documented a wander/elopement alarm was not used. The Resident Accident/Incident (A/I) Report for Resident #5 on the Aspen unit dated 7/26/2023 at 1:10 PM, documented an elopement. The resident was noted to have gone out the front door and returned to the building two minutes later by activities personnel. The Resident's Version of the event documented, I wanted to see the sun. The Supervisor's investigation documented the resident left the building wanting to go see the sun and when they met the activities personnel outside, the resident stated they had to use the bathroom and came back into the building two minutes later. The Nurse's Note dated 7/26/2023 at 1:30 PM by the Registered Nurse Educator (RNED), documented the resident was noted by the aide and receptionist to be coming back into the facility from the doors in the main lobby. Upon further investigation, it was noted that the resident went out the doors and was outside for two minutes before returning to the building. When asked why they went out, they stated I wanted to see the sun. RN assessment was done and there were no injuries. A wander guard bracelet was attempted to be placed but was refused on multiple attempts. The resident remained on 1:1 supervision for safety until further notice. The facility Investigation Form for Resident #5 on the Aspen unit dated 7/27/2023, documented an elopement on 7/26/2023. Resident #5 was sitting in the lobby area when the front door opened for a visitor. Resident #5 quickly went around the corner and went out the front door. Resident #5 was returned to the facility within 2 minutes by activities personnel. Review of video footage labeled ch25_20230726130814 (2:17 minutes in length) showed the following: -A camera view of the lobby and the front door to the facility, which was closed. -Then simultaneously, a resident in a wheelchair presented at the receptionist's desk in the lobby; a food delivery person entered the vestibule and rang the doorbell; and Resident #5, who was in the corner of the common area of the lobby, started walking towards the door. -The Receptionist (RECEP), entered the common area of the lobby from a back office, walked behind their desk, and opened the front door. -As the delivery person was walking through the front door and into the lobby, Resident #5 was seen standing a few feet away from them and close to front door. -As the delivery person approached the desk, Resident #5 walked out of the facility undetected through the open front door, into the vestibule and then exited the building. -The food delivery person gave the resident who was in the wheelchair their food and then left the building. -Shortly after, Resident #5 entered the vestibule accompanied by the Activities staff member and was brought back into the facility. During an interview on 8/15/2023 at 10:02 AM, the Administrator (ADMIN) stated Resident #5 had a history of removing the wander guard bracelet and the facility has made consistent efforts to put it on the resident. The ADMIN stated they tried to move the resident to the locked unit, but they refused, and the resident was put on 1:1 supervision. The ADMIN stated that shortly after the elopement, the resident was sent out to the hospital and when they came back, they went to the locked unit. During an interview on 8/17/2023 at 11:39 AM, Registered Nurse Manager (RNM) #2 on the Aspen unit, stated Resident #5 had negative behaviors, was easily agitated, and was high risk for elopement. RNM #2 stated the resident did not have a wander guard bracelet on at the time of the elopement and stated to try to get one on them was undoable because the resident managed to take it right off. RNM #2 stated 1:1 supervision was the only intervention that could be used for a resident who refused the wander guard bracelet and was high risk for elopement. RNM #2 stated they did not believe Resident #5 was on 1:1 supervision and stated everyone knew they were high risk and kept at least one eye on the resident. RNM #2 stated everyone had to be hypervigilant because of their refusal of the wander guard bracelet and stated all residents needed supervision. RNM #2 stated Resident #5 was difficult to redirect. RNM #2 stated they did not where in the facility the resident would wander the most and usually saw them in the Aspen hallway. RNM #2 stated there were always a lot of people congregating in the reception area and stated the facility made it less inviting for the residents who liked to sit on the couches/chairs that were there for people coming in for an interview. During an interview on 8/17/2023 at 11:54 AM, Certified Nurse Aide (CNA) #3 stated they provided care to Resident #5 on the Aspen unit. CNA #3 stated Resident #5 was at risk for elopement and would not wear the wander guard bracelet. CNA #3 stated the facility had been trying to move the resident upstairs to the locked unit because of their mental condition, but the resident refused. CNA #3 stated Resident #5 did not belong on the Aspen unit because the door to the unit was always open, and the resident did not have a wander guard bracelet on. During a subsequent interview on 8/17/2023 at 12:15 PM, the ADMIN stated there was an issue with supervision in the facility. The ADMIN stated the pizza delivery person came in and Resident #5 who was sitting in the reception area, walked out through the open door. The ADMIN stated the facility made changes to the reception area and moved furniture that residents would frequently use in that area. The ADMIN stated staff education was started immediately after the incident. During an interview on 8/17/2023 at 2:36 PM, the DON stated Resident #5 had an order on 2/23/2023 for 15-minute safety and there was no stop date on the order. The DON stated the order was active at the time of the elopement. The DON stated the receptionist had a collage with residents' photos at the desk for residents who were at risk. The DON stated the RNED did the investigation for the elopement. During an interview on 9/6/2023 at 2:55 PM, the RECEP stated that a few minutes prior to the elopement, they saw Resident #5 heading toward the Aspen unit, and then several residents and staff swarmed their desk. The RECEP stated they did not see Resident #5 sitting in the common area of the lobby. The RECEP stated the food delivery person came in and Resident #5 who did not have a wander guard bracelet on, went out of the building through the open door. The RECEP stated they had a total freak out because they were the one who was supposed to be watching the door to ensure residents did not leave unsupervised. The RECEP stated they had an elopement list with photographs at the desk. The RECEP stated Resident #5 resided on the Aspen unit which was not locked and regularly walked around the facility. The RECEP stated the resident currently resided on the Dogwood unit which was locked. During an interview on 9/7/2023 at 9:51 AM, the physician/Medical Director (MD) #1 stated they were not aware that Resident #5 had eloped on 7/26/2023. MD #1 stated the resident had a lot of psychiatric issues and had been in and out of psychiatric hospitals. During an interview on 9/8/2023 at 10:22 AM, the RNED stated they were covering for the DON on 7/26/2023. The RNED stated they were with the Administrator (ADMIN) when they were notified of the elopement. The RNED stated Resident #5 had psychiatric diagnoses, was at high risk for elopement, and refused to wear the wander guard bracelet. The RNED stated that following the incident, the resident continued to refuse the wander guard bracelet and refused to be moved to the Dogwood unit, which was a locked unit, where residents at high risk for elopement would reside. The RNED stated the resident was immediately put on 1:1 supervision and now resides on the Dogwood unit. Resident #3: Resident #3 was admitted to the facility on [DATE], with diagnoses of personal history of traumatic brain injury (TBI), anxiety disorder, and history of falling. The Minimum Data Set (MDS - an assessment tool) dated 7/6/2023, documented the resident had severe cognitive impairment. The CCP for Resident #3 had the potential to be physically abused related to dementia and wandering, last revised 8/12/2023, documented the resident's breast were fondled by a male resident. The Nurse Practitioner Note dated 8/12/2023 at 8:33 by NP #1, documented the Supervisor notified NP #1 that Resident #2 was observed by a CNA, touching a female resident's breast inappropriately. NP #1 ordered for the resident to be placed on strict 1:1 supervision until seen by a psychiatrist. The facility Investigation Form dated 8/12/2023, document an incident of sexual abuse. The CNA noted Resident #2 was standing over Resident #3, who was laying in Resident #2's bed. The CNA saw Resident #2 rubbing Resident #3's breasts over their shirt. Resident #3 was placed on 1:1 supervision immediately until further notice. During an interview on 8/15/2023 at 11:38 AM, LPNM #1 stated that on 8/12/2023, Resident #3 wandered into Resident #2's room. LPNM #1 stated it was a locked unit and all the residents wandered into other resident rooms. LPNM #1 stated that after the incident with Resident #3, Resident #2 was moved to the Chestnut unit. During an interview on 8/17/2023 at 2:53 PM, the DON stated Resident #2 was put on strict 1:1 supervision following the incident. 10 NYCRR 415.12(h)(1)

Based on record review and interviews during an abbreviated survey (Case #s NY00321796 and NY00322090) the facility did not ensure the resident's right to be free from abuse for 2 (Resident #s 1 and #3) of 5 residents reviewed. Specifically, for Resident #1, the facility did not ensure Resident #1 was free from non-consensual sexual contact by Resident #2 on 7/1/2023. Resident #2, who was cognitively impaired and care planned for the potential to become physically aggressive and for going into other residents' rooms, entered Resident #1's room and slipped their hand inside Resident #1's shirt and grabbed their right breast. For Resident #3,the facility did not ensure Resident #3, who was cognitively impaired, was free from non-consensual sexual contact on 8/12/2023, when Resident #3 wandered into Resident #2's room and was observed by CNA #1 laying in Resident #2's bed and Resident #2 was standing over Resident #3 and was touching the resident's breast. This is evidenced by: Refer to F689 The facility's Abuse Prevention Manual revised 5/23/2023, documented the following policies and procedures (P&Ps): -The P&P titled The Seven (7) Components of a Systematic Approach to Abuse Prohibition effective 5/23/2023, documented the facility was committed to providing residents an environment that was free from verbal, mental, and physical abuse. The P&P documented forms of abuse. Sexual abuse was non-consensual contact of any type with a resident; including but not limited to the use of sexual coercion, sexual harassment, or sexual assault. -The P&P titled Abuse Prevention - Component #3 effective 5/23/2023, documented it was the policy of the facility to not use nor permit sexual abuse of residents. The P&P's prevention strategies documented identification, ongoing assessment, care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict, abuse or neglect, such as wandering into other's rooms/space. -The P&P titled Abuse Identification - Component #4 effective 5/23/2023, documented the following indicators of possible abuse: a statement that abuse had occurred, visual or auditory observation of an act or condition of abuse, and extreme changes in behavior, including aggressive or disruptive behavior toward a specific person. The clinical indicators of possible sexual abuse documented resident verbalizations indicating sexual abuse. Resident #1: Resident #1 was readmitted to the facility with diagnoses of chronic obstructive pulmonary disease (COPD), anxiety disorder, and recurrent major depressive disorder. The Minimum Data Set (MDS - an assessment tool) dated 4/21/2023, documented the resident was cognitively intact. The Comprehensive Care Plan (CCP) for Resident #1 had the potential to be physically abused related depression, documented on 7/1/2023, a male resident fondled the resident's right breast. The Resident Accident/Incident (A/I) Report for Resident #1 on the Fir Unit, dated 7/1/2023 at 2:25 PM, documented an unwitnessed resident altercation. The resident's version of the event documented Resident #1 was in the doorway of their room when they yelled, I'm going to fucking kill you. Nursing staff went down the hallway and a resident (identified as Resident #2) kept apologizing, stating, I'm sorry, I'm sorry. Staff then told Resident #2 to go back to their unit. Nursing staff asked Resident #1 what happened, and the resident stated they felt someone rubbing their shoulders and they turned around and saw that it was a male resident. Resident #2 then slipped their hand into Resident #1's shirt and grabbed their right breast. The A/I Report for Resident #2, Resident #2's version of the event, documented I'm sorry, I'm sorry. The Nurse's Note dated 7/1/2023 at 4:01 PM, written by Licensed Practical Nurse (LPN) #2, documented a male resident went into the resident's room, started to rub their shoulders, and grabbed their right breast. The incident was unwitnessed. Staff intervened and separated the two residents. The Supervisor, Registered Nurse (RN) on call, Director of Nursing (DON), Administrator (ADMIN), and family were notified. The Nurse Practitioner (NP) Note dated 7/1/2023 at 5:30 PM, written by NP #1, documented NP #1 was notified by the assigned nurse that Resident #1 reported that a resident went into their room and allegedly started rubbing their shoulders and then touched their breast. The incident was not witnessed by any staff. Staff reportedly intervened and redirected the male resident back to his unit. It documented the male resident had a history of dementia and schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder such as mania or depression) with confusion. The facility Investigation Form dated 7/1/2023 documented a resident-to-resident incident. Resident #1 reported Resident #2 was rubbing their shoulders and then placed their hand in their shirt and grabbed their right breast. The investigation conclusion documented it was inconclusive if Resident #2 touched Resident #1's right breast. Resident #2 was confirmed on video going into Resident #1's from 2:25:16 PM to 2:25:27 PM. During an interview on 8/9/2023 at 3:45 PM, Resident #1 was asked if something had happened to them in their room. Resident #1 appeared to be very upset and stated, They grabbed my boob, and I took care of it. It totally scared the shit out of me. Resident #1 stated at the time of the incident they were sitting exactly as they currently were, in their wheelchair facing the bedside table with their back to the door. Resident #1 stated there was a gap in the side of their shirt and the male resident reached in and grabbed their entire right breast. Resident #1 stated their whole breast was in the resident's hand and it hurt. Resident #1 stated they told the resident, Are you crazy? Do you want me to kill you? Resident #1 stated the male resident then said I'm sorry, I'm sorry. I didn't do it. Resident #1 stated they then said What do you mean you didn't do it? You did do it. Resident #1 was asked about the pain in their breast. Resident #1 then stated, It wasn't the pain so much that bothered me. It was that I got violated like that. Resident #1 stated they did not know the a resident personally but had seen them on the unit going into other resident's rooms. Resident #1 stated they did not want the police involved because they knew the resident was not right in the head. During an interview on 8/14/2023 at 3:25 PM, Registered Nurse Manager (RNM) #2 stated they had only been a nurse manager for three months and was the manager of the Elm, Aspen, and Fir units prior to 7/7/2023, and now managed the Dogwood, Chestnut, and Aspen units. RNM #2 stated this was the first time they heard about the incident with Resident #2 on 7/1/2023. RNM #2 stated Resident #2 was cognitively impaired but could be very with it at times, was very social, and usually socially appropriate. During an interview on 8/15/2023 at 11:38 AM, LPN Manager (LPNM) #1 stated they managed the Chestnut, Aspen, and Dogwood units and RNM #2 provided oversight for them. LPNM #1 stated they were called to the Fir unit on 7/1/2023, and LPN #2 reported that Resident #1 had been screaming that they did not want Resident #2 in their room and then told LPN #2 what had happened. LPNM #1 stated Resident #2 resided on the Aspen unit at the time of incident and would go down to the Fir unit and to visit a friend who resided in a room that was almost directly across from Resident #1's room. LPNM #1 stated any resident was able to visit another resident and could go anywhere they wanted to if they were not in the locked unit. LPNM #1 stated that after the incident on 7/1/2023, Resident #2 was no longer allowed on the Fir unit, and had to meet their friend at the fish tank in the lobby. During an interview on 8/15/2023 at 12:17 PM, LPN #2 stated they worked fulltime on the Fir unit, which was Resident #1's unit. LPN #2 stated that on 7/1/2023, they heard Resident #1 yell Don't touch me. Do you want me to kill you? LPN #2 stated that by the time they got to the resident's room, staff from the Elm unit had already gotten to the resident. LPN #2 stated Resident #1 said they were sitting in their wheelchair, facing their bed and their back was toward the door. Resident #1 stated they felt someone rub their shoulders and turned around and saw that it was a male resident and then the male resident slipped their hand in Resident #1's shirt and touched their breast. LPN #2 identified the male resident as Resident #2, who was cognitively impaired and resided on the Aspen unit. LPN #2 stated Resident #2 would visit a friend on the Fir unit and would also just pass through all of the units. LPN #2 stated Resident #1 was alert and oriented. LPN #2 stated they did not see Resident #2 on the unit after the incident and believed the resident was moved to the Dogwood unit. Resident #3: Resident #3 was admitted to the facility on [DATE], with diagnoses of personal history of traumatic brain injury (TBI), anxiety disorder, and history of falling. The Minimum Data Set (MDS - an assessment tool) dated 7/6/2023, documented the resident had severe cognitive impairment. The CCP for Resident #3 had the potential to be physically abused related to dementia and wandering, last revised 8/12/2023, documented the resident's breast were fondled by a male resident. The Resident A/I Report for Resident #3 on the Dogwood unit, dated 8/12/2023 at 6:45 AM, documented touch (inappropriate). The resident's version of the event documented the resident was unable to give a statement. CNA (#1) observed Resident #3 laying in Resident #2's bed. Resident #2 was standing over Resident #3 and was touching the resident's breast. It was documented Resident #3 was at high risk for A/I due to poor decision making. The A/I Report for Resident #2, Resident #2's version of the event, documented the resident was unable to explain. The Nurse's Note dated 8/12/2023 at 7:15 AM, written by LPNM #1, documented Resident #3 was laying in other resident's bed. Resident #2 was standing over Resident #3 and was touching their breast. The Nurse Practitioner Note dated 8/12/2023 at 8:33 AM, written by NP #1, documented the assigned supervisor, LPNM #1, reported to NP #1 that a resident was observed touching the breast of a female resident (#3), who was laying on the male resident's bed. NP #1 gave an order for the male resident to be placed on strict 1:1 supervision until seen by a psychiatrist. The facility Investigation Form dated 8/12/2023, documented an incident of sexual abuse. The CNA noted Resident #2 was standing over Resident #3, who was laying in Resident #2's bed. The CNA saw Resident #2 rubbing Resident #3's breasts over their shirt. Resident #3 was placed on 1:1 supervision immediately until further notice. The investigation conclusion documented Resident #3 was noted to enter Resident #2's room at 6:33:02 AM. Resident #2 entered the room at 6:33:09 AM. CNA #1 entered the room at 6:34:40 AM. CNA #1 re-enacted the incident and reported Resident #2 had open hand placement on Resident #3's left breast and left upper abdomen area. Both residents were fully clothed. During an interview on 8/14/2023 at 1:16 PM, the Administrator stated Resident #3 was found in Resident #2's bed when the incident occurred. During an interview on 8/14/2023 at 3:25 PM, RNM #2 stated apparently something happened over the past weekend with Resident #2, but they did not know the details. During an interview on 8/14/2023 at 5:21 PM, CNA #1 stated that they worked on the Dogwood Unit, which was a secure unit for residents with cognitive impairment. CNA #1 stated they were not aware of the incident with Resident #2 on 7/1/2023, and stated they were only told by the nurses and the aides to watch Resident #2 because they liked going into resident rooms. CNA #1 stated that on 8/12/2023, they were sitting at the nurse station doing their charting and heard Resident #3 making noises. CNA #1 stated there were times when Resident #3 would not talk and only made little noises with their voice. CNA #1 stated the resident was not in their room and was not in the common area. CNA #1 stated Resident #2 was also not in the common area, and they decided to check the resident's room. CNA #1 entered Resident #2's room and saw Resident #3 laying on their back in the resident's bed and Resident #2 standing over Resident #3 with their hands on both breasts, over the top of their shirt. CNA #1 stated that once they told Resident #3 to come out of the room, Resident #2 moved their hands away. CNA #1 stated Resident #3 did not appear to be upset or agitated. CNA #1 stated they moved Resident #2 to the Chestnut Unit following the incident. During an interview on 8/15/2023 at 11:38 AM, LPNM #1 stated that on the Dogwood Unit on 8/12/2023, Resident #3 wandered into Resident #2's room. LPNM #1 stated it was a locked unit and all the residents wandered into other resident rooms. LPNM #1 stated that after the incident with Resident #3, Resident #2 was moved to the Chestnut Unit. During an interview on 8/17/2023 at 2:53 PM, the DON stated that on 8/12/2023, CNA #1 did not notice Resident #3 in the common area and went looking for the resident. CNA #1 told them and demonstrated how they saw Resident #3 laying on Resident #2's bed and Resident #2 was standing at the head of their bed. Resident #2's hands were open, and one hand was on Resident #3's left breast and the other was on Resident #3's left side. CNA #1 told them that Resident #3 was not in any distress. Both residents were fully clothed. The DON stated Resident #2 was put on strict 1:1 supervision following the incident. Resident #2: Resident #2 was admitted to the facility with diagnoses of schizoaffective disorder, dementia without behavioral disturbance, and bipolar disorder. The Minimum Data Set (MDS - an assessment tool) dated 6/10/2023, documented the resident had severe cognitive impairment. The CCP for Resident has been going into other resident's rooms, last revised 6/14/2023, documented CCP interventions to intervene as necessary to protect the rights and safety of others; divert attention; remove from the situation and take to alternate location as needed. The CPP for Activities last revised 6/14/2023, documented the following risks: impaired thought process related to mild neurocognitive disorder, schizoaffective disorder, bipolar, and history of alcohol, heroin, cocaine, and cannabis use. The CCP interventions documented the resident could act inappropriately at times but was easily redirected and was able to independently ambulate to and from activities and ambulated through the entire building, going unit to unit. The CCP for the Resident has the potential to become physically aggressive related to psychiatric diagnosis, last revised on 8/12/2023, documented on 7/1/2023, the resident reached into a resident's shirt and fondled their right breast and on 8/12/2023, the resident was fondling a resident's breast. On 7/1/2023, the CCP interventions documented the resident was placed on 1:1 supervision until further notice. The intervention was resolved on 7/6/2023. On 8/12/2023, the CCP documented 1:1 staff supervision until further notice. The Nurse's Note dated 7/3/2023 at 4:00 PM, documented the resident was removed from 1:1 supervision on 7/3/2023. It documented no issues with inappropriateness towards staff or residents. The Nurse Practitioner Note dated 8/12/2023 at 8:33 AM, written by NP #1, documented the Supervisor notified NP #1 that Resident #2 was observed by a CNA, touching a resident's breast inappropriately. NP #1 ordered for the resident to be placed on strict 1:1 supervision until seen by a psychiatrist. The Social Service Note dated 8/14/2023 at 1:42 PM, written by the Director of Social Work (DSW), documented the DSW visited Resident #2 in their room. It documented that during discussion the resident voiced understanding of keeping their hands to themselves. The Psychiatric Evaluation dated 8/14/2023, documented staff reported that Resident #2 was involved in a sexually related incident with a resident who wandered into their room. It documented Resident #2 was able to recall the incident with the female resident. Resident #2 struggled to answer questions and had difficulty engaging in meaningful conversation. Brief interventional therapy was provided related to this incident and the resident stated understanding. Past psychiatric history documented several psychiatric hospitalization s. During an interview on 8/14/2023 at 12:32 PM, Resident #2 stated they did not touch anyone's breasts. Resident #2 then asked why they would make that allegation. Additional Interviews: During an interview on 8/15/2023 at 3:35 PM, the DSW stated that prior to 7/1/2023, Resident #2 did not have a history of being sexually inappropriate. The DSW stated that on 8/14/2023, Resident #2 told the DSW and the Psychiatrist that they had their hands on Resident #3's breast. The DSW stated the resident would wander into other resident rooms. The DSW stated they did not do an abuse survey of the residents in the facility at the time of the incidents on 7/1/2023 and 8/12/2023. The DSW stated a survey was done this morning and no one reported they were touched inappropriately. During an interview on 8/16/2023 at 10:39 AM, the Administrator (ADMIN) stated Resident #2 saw Psychiatry on 6/28/2023. The ADMIN stated Resident #2 did not have a Psychiatry consult in July after the incident on 7/1/2023 because the facility was in the process of changing providers. During an interview on 8/16/2023 at 11:32 AM, NP #1 stated the facility called them about the incident on 7/1/2023 and ordered for Resident #2 to be put on 1:1 supervision. NP #1 stated they ordered 1:1 supervision on a patient-specific basis, so that they could make an assessment to see if the incident was because of a cognitive or physical concern. NP #1 stated they ordered lab tests and there was no medical reason for Resident #2's change in behavior. NP #1 stated Resident #2 had dementia, depression, and schizophrenia, which altogether made it schizoaffective disorder. NP #1 stated the resident had no sexual tendencies prior to 7/1/2023. NP #1 stated that on 8/12/2023, Resident #2 had a behavior opportunity because someone wandered into their bed. NP #1 stated Resident #2 did not have the propensity to seek someone out. NP #1 stated Resident #2 was visiting their friend on 7/1/2023 and then went into Resident #1's room. NP #1 stated Resident #2 did not recall the incident with Resident #1 because of dementia and other diagnoses. NP #1 stated when they were called about the second incident on 8/12/2023, they ordered strict 1:1 supervision and not to release until seen by the Psychiatrist. NP #1 stated the reason they ordered for the 1:1 supervision after the first incident was because they were concerned it would happen a second time and wanted the resident to be supervised until seen by the Psychiatrist. NP #1 stated Resident #2 was seen by the Psychiatrist and there are plans to have the resident relocated. NP #1 stated all residents need some level of supervision and stated Resident #2 needed strict supervision. During an interview on 9/7/2023 at 9:51 AM, the physician/Medical Director (MD) #1 stated NP #1 told them the surveyor was in the facility and about the incidents with Resident #2 and the allegations of sexual abuse. MD #1 stated they were surprised by the allegations because they had known Resident #2 for over a year and prior to July 2023, there was no history of sexual abuse. MD #1 stated Resident #2 resided on the Aspen Unit on 7/1/2023 and was allowed to roam around the facility. MD #1 stated Resident #2 had been moved to other units. MD #1 stated other than just moving problem residents from one unit to the next, the facility had to protect all the residents, especially residents who were on the Dogwood Unit. MD #1 stated that on the Dogwood Unit, the supervision was poor and residents go into other's rooms. MD #1 stated the unit was locked but the rooms were not, and staff needed to ensure they were supervising all residents to keep them safe. MD #1 stated Resident #3 who resided on the Dogwood Unit, was cognitively impaired, nonverbal, and did not know what they were doing when they wandered into Resident #2's room. 10 NYCRR 415.4(b)(1)(i)

Based on record review and interviews during an abbreviated survey (Case #s NY00305838 and NY00309068), the facility failed to ensure that an alleged violation involving abuse was reported immediately, but not later than 2 hours after the allegation was made, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (Resident #s 1) of 3 residents reviewed. Specifically, on 11/21/2022 at 9:05 AM, Resident #1 reported an allegation of sexual abuse to the Licensed Practical Nurse (LPN) and the Administrator was made aware of the incident on 11/21/2022 at 9:10 AM. The facility did not report to the New York State Department of Health (NYSDOH) until 11/21/2022 at 3:44 PM, over 6 hours after the Administrator was notified. This is evidenced by: Refer to F Tag 600 The facility's Abuse Prevention Manual effective 10/24/2022, documented the following policies and procedures (P&Ps): -The P&P titled The Seven (7) Components of a Systematic Approach to Abuse Prohibition effective date 8/2020, documented an alleged violation of abuse would be reported immediately but not later than two (2) hours if the alleged violation involved abuse. The facility would notify the DOH when the reasonable clause threshold had been established; meaning that there was sufficient evidence for a prudent person to believe that abuse had occurred. Resident #1: Resident #1 was readmitted to the facility with diagnoses of sepsis, cerebral infarction (stroke), and major depressive disorder. The Minimum Data Set (MDS - an assessment tool) dated 11/9/2022, documented the resident had severe cognitive impairment, was able to make themselves understood, and was able to understand others. The Nursing Home Facility Incident Report submitted by the facility on 11/21/2022 at 3:44 PM by anonymous, documented the Director of Nursing (DON) as the contact person at the facility. The incident occurred on 11/21/2022 at 1:55 AM. Staff was first made aware of the incident on 11/21/2022 at 9:05 AM, and the Administrator was made aware on 11/21/2022 at 9:10 AM. Resident #1 reported to the Licensed Practical Nurse (LPN) that Resident #2 entered their room at approximately 2:00 AM. Resident #1 was awoken by Resident #2 attempting to put their hands down the front of their brief. Resident #1 told Resident #2 to leave the room, and Resident #2 left. The facility notified the law enforcement agency. During an interview on 2/27/2023 at 2:59 PM, the former Administrator (ADMIN) #2, stated that the facility had to verify that the abuse occurred and stated, You have to validate something before you can report it. During an interview on 3/16/2023 at 3:41 PM, the DON stated they knew abuse reporting to the NYSDOH had to be within 2 hours of the time the allegation was made. The DON stated tADMIN #2 was made aware at 9:10 AM. The incident was not reported within the timeframes because they and the ADMIN #2 were personally interviewing the residents and then were reviewing the video footage, when they were made aware of the allegation. 10 NYCRR 415.4(b)(2)

Based on record review and interviews during an abbreviated survey (Case #NY00305838), the facility did not ensure the resident's right to be free from abuse for 1 (Resident #1) of 5 residents reviewed. Specifically, the facility did not ensure Resident #1 was free from non-consensual sexual contact during the night of 11/20/2022, when Resident #2, who was cognitively intact, entered Resident #1's room while they were asleep and placed their hand inside Resident #1's incontinence brief. The facility did not ensure that when Resident #2's care plans reactivated from a previous admission titled Psychosocial/Mood/Behavior for the resident's behavior of entering other resident rooms without their permission and the care plan titled Little Involvement Related to Disinterest for Resident #2 inappropriate sexual advances towards female residents included interventions to prevent Resident #2 from entering other resident rooms without permission and making inappropriate sexual advances towards female residents. This was evidenced by: Refer to F609 The facility's Abuse Prevention Manual effective 10/24/2022, documented the following policies and procedures (P&Ps): -The P&P titled The Seven (7) Components of a Systematic Approach to Abuse Prohibition effective date 8/2020, documented the facility was committed to providing residents an environment that was free from verbal, mental, and physical abuse. The P&P documented forms of abuse. Sexual abuse included but was not limited to the use of sexual coercion, sexual harassment, or sexual assault. -The P&P titled Abuse Prevention - Component #3 effective 8/2020, documented it was the policy of the facility to not use nor permit sexual abuse of residents. The P&P's prevention strategies documented the facility would identify residents whose personal histories and diagnoses render them at risk for abusing other residents; develop strategies to prevent occurrences and monitor for changes that would trigger abusive behavior; and systematically reassess these interventions to monitor effectiveness. -The P&P titled Abuse Identification - Component #4 effective 8/2020, documented the following indicators of possible abuse: a statement that abuse had occurred and visual or auditory observation of an act or condition of abuse. The clinical indicators of possible sexual abuse documented physical signs, symptoms and evidence, and resident verbalizations indicating sexual abuse. Resident #1: Resident #1 was readmitted to the facility with diagnoses of sepsis, cerebral infarction (stroke), and major depressive disorder. The Minimum Data Set (MDS - an assessment tool) dated 11/9/2022, documented the resident had severe cognitive impairment. The resident had clear speech, was able to make themselves understood, and was able to understand others. The Resident Accident/Incident (A/I) Report for Resident #1on the Birch unit, documented an incident of sexual abuse occurred on 11/21/2022 at 1:55 AM. Resident #1 reported to the Licensed Practical Nurse (LPN) #1, inappropriate physical contact by a male resident. The facility investigation document titled Statement from Resident #1 dated 11/21/2022 at 9:05 AM, documented that at approximately 1:00 AM to 2:00 AM, Resident #1 woke up and felt something strange. Resident #1 stated His hand was going down my brief towards my vagina. If I hadn't woke up, he would not have stopped. Resident #1 stated they told the resident to get out of there and to go back to their room. Resident #1 stated the resident slowly left the room without saying a word. A Progress Note dated 11/21/2022 at 4:18 PM, written by Nurse Practitioner (NP) #1, documented NP #1 was asked to conduct a skin assessment and clinical evaluation of Resident #1 regarding an incident last night in which the resident alleged that a male resident entered their room and attempted to put their hand inside Resident #1's incontinence brief. The Nursing Home Facility Incident Report submitted by the facility on 11/21/2022 at 3:44 PM, documenterd Resident #1 reported to the Licensed Practical Nurse (LPN) that a male resident (#2) entered their room at approximately 2:00 AM. Resident #1 was awoken by Resident #2 attempting to put their hands down the front of their brief. Resident #1 told Resident #2 to leave the room, and Resident #2 left. The facility notified the law enforcement agency. Resident #2: Resident #2 was readmitted to the facility with diagnoses of type 2 diabetes, unspecified intellectual disabilities, and depression. The MDS dated [DATE], documented the resident was cognitively intact. Review of the Resident #2's Comprehensive Care Plan (CCP) for January 2020, documented the following: -CCP for Psychosocial/Mood/Behavior initiated on 1/6/2020 and reactivated 11/15/2022, documented Resident #2 would go into other's rooms without permission and had stated they were just looking for companionship. The CCP interventions did not include interventions for the prevention of Resident #2 from going into other resident rooms without permission. -CCP for Little Involvement Related to Disinterest initiated on 1/31/2020 and reactivated on 11/15/2022, documented Resident #2 displayed inappropriate sexual advances towards female residents. The CCP did not include interventions to prevent Resident #2 from making inappropriate sexual advances towards female residents. A Progress Note (Amended) dated 11/21/2022 at 3:14 PM, written by Nurse Practitioner (NP) #1, documented NP #1 was asked to assess and evaluate Resident #2 who was reportedly escorted out of another patient's room last night after they wandered in there and allegedly attempted to put their hand on a female patient's incontinence brief while they were sleeping. The female resident explained to NP #1 and Registered Nurse Supervisor RNS/Registered Nurse Manager (RNM) #1 that they observed Resident #2 attempting to put their hand inside the female resident's incontinence brief. Interviews During an interview on 2/7/2023 at 2:17 PM, the DON stated they reviewed video footage of the Birch unit from the 11/20/2022 night shift. The video showed Resident #2 went into Resident #1's room and Resident #2 was in there for about five minutes. The DON stated that no staff saw Resident #2 enter or leave Resident #1's room. During an interview on 2/8/2023 at 11:04 AM, RNM #1 stated they were responsible for all care plan implementations and changes and did not develop or revise Resident #2's care plan. RNM #1 stated that as far as they knew, the incident with Resident #1 was Resident #2's first and only occurrence with a resident. RNM #1 stated they were not aware that Resident #2 had any previous sexual aggression until after the incident on 11/21/2022, when they were told about it. RNM #1 stated that following the incident on 11/21/2022, they immediately put Resident #2 on one-to-one supervision and moved Resident #2 from the Birch unit to Chestnut. During a subsequent interview on 2/24/2023 at 3:28 PM, the DON stated that when Resident #2 was admitted on [DATE], they were not aware that the resident had a prior admission at the facility. The DON stated the facility staff was not aware of Resident #2's prior behaviors or their care plan and did not care plan the resident for being at risk for sexually aggressive behaviors until after the incident on 11/21/2022. During an interview on 2/27/2023 at 2:59 PM, the former Administrator (ADMIN #2) stated that they were made aware of the allegation and called the police. 10 NYCRR 415.4(b)(1)(i)

Based on observation, record review and interviews during the recertification survey the facility did not ensure to respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for 2 (Resident #'s 29, and 143) of 2 residents reviewed for right to privacy. Specifically, the facility did not ensure that Resident #29 and #143's, mail was delivered unopened. This was a repeat deficiency from the recertification survey dated 11/13/2019. This was evidenced by: The Policy & Procedure (P&P) titled Resident Mail dated 1/2021, documented mail will be delivered to the residents within 24 hours of receipt into the facility unopened/untampered. Resident #29: Resident #29 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 11/15/2021, documented the resident was cognitively intact and was able to understand others and make self understood. Resident #143: Resident #143 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 01/08/2021, documented the resident was cognitively intact and was able to understand others and make self understood. During the Resident Council Meeting on 01/27/2022 at 11:12 AM, with six (6) (Resident #'s 29, 40, 70, 132, 138 & #143) residents in attendance, resident rights regarding residents' receiving their mail unopened was discussed. Resident #29 stated that their mail is sometimes delivered opened. Resident #143 stated they have received bank statements that have been opened prior to their delivery. During an interview on 02/02/2022 at 09:48 AM, the Front Desk Receptionist stated when the mail comes in the receptionist sorts the mail. The mail is seperated by the unit the resident resides and placed in the unit mailbox. All mail that is addressed to a resident that has a return address for the Social Security Administration, the Treasury Department, or the County Social Security Office will be placed into the Finance Office mailbox. In addition, mail addressed to a resident that appears to be a bill, such as those from the transportation company, or a hospital will be placed in the Finance Office mailbox. The remainder of resident mail goes to the Activity Department to be distributed to the residents. During an interview on 02/02/2022 at 10:09 AM, the Finance Office (FO) staff member stated when the resident mail comes to the finance office, if it is from the county, it may be a NAMI letter (Net Available Monthly Income, is the amount of a nursing home resident's income that is expected to contribute toward the cost of the nursing home stay) and the FO opens it. If it comes from Medicaid, it may be a needs letter and the FO would open it. The letters would be scanned into the finance office system and the FO would talk to the resident about the letter. If something comes from a bank and is addressed to a resident it was either a 5 year look back or a statement, the FO will open it and scan it into the system, unless the resident had communicated that they wanted to see it first. If a bill addressed to a resident is from the transportation company or a hospital, the FO opens it and scan it into the system. The FO stated they were not aware that mail addressed to a resident could not be opened without resident permission. The FO stated if the resident did not have Chronic Care Medicaid coverage, their mail would not be opened by finance. During an interview on 02/02/2022 at 01:17 PM, the Administrator stated they were not aware that resident mail was being opened without resident permission. The mail addressed to the resident should not opened and should be delivered to the resident unopened. 10NYCRR415.3(d)(2)(i)

Based on observations, record review, and interviews during a recertification survey the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #42) of six residents reviewed for medications. Specifically, the facility did not ensure that the resident, who had severe [MEDICAL CONDITION] (an eye disease that is a leading cause of [MEDICAL CONDITION] in people over 60) and [MEDICAL CONDITION] sicc (inflammation and dryness of the cornea and conjunctiva), and a pseudophakia of right eye (an artificial lens implant) received eye drop medication per the physician's (MD) orders and the resident's Comprehensive Care Plan (CCP), which resulted in an increase in redness and swelling of his eyes. This resulted in actual harm that was not immediate jeopardy. This is evidenced by: Resident #42: The resident was admitted to the nursing home on 6/6/18, with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 6/10/19, assessed the resident as having [MEDICAL CONDITIONS], or [MEDICATION NAME] degeneration. The resident was alert and answered questions appropriately (MDS cognition section was not assessed). A facility policy titled, Non-Availability of Medications, dated 1/2018, documented that if medications are not available during medication administration, the nurse would notify the pharmacy and obtain an appropriate order from the attending physician (MD). The MD would order alternate medication, order medication to be administered at a later time, or authorize use of the emergency kit. The Comprehensive Care Plan for Impaired Visual Function, dated 6/24/19, documented to administer medications per MD order. An instruction sheet from the ophthalmologist given to the facility on [DATE], documented to use medications exactly as prescribed and continue to use them at all times, even if traveling or hospitalized . An ophthalmology consult dated 7/25/19, documented the resident had severe stage primary open angle [MEDICAL CONDITION] of both eyes, [MEDICAL CONDITION] sicc, bilateral dry eyes, and a pseudophakia of right eye. Start Refresh [MEDICATION NAME] one to two drops in both eyes four times a day. A Nurse Practitioner (NP) progress note dated 7/25/19, documented the resident was seen that day by ophthalmology and had longstanding [MEDICAL CONDITION] and dry eyes; the resident stated his eyes felt dry, but had no other complaints. Review of MD Orders dated 7/25/19 documented: -Refresh [MEDICATION NAME] Gel 1 %; instill 2 drops in both eyes four times a day at 12:00 AM, 6:00 AM, 12:00 PM and 6:00 PM. A Progress Note dated 8/3/19, written by the Nursing Supervisor, documented that the writer went to discuss the resident's concern regarding receiving his eyedrops on time. The resident reported that at his recent eye appointment the MD told him his vision had declined due to not receiving his eye medications as they had been ordered. She will audit to make sure this is carried out to the resident's satisfaction. The Medical Record did not include any further documentation of any follow-up (audit) on the resident's concerns. Review of the Medication Administration Record [REDACTED]. Progress Notes documented the following: 8/02/19 at 05:59 AM, [MEDICATION NAME] not found, pharmacy faxed. 8/04/19 at 10:46 AM, The resident's eyes were swollen, with mild redness. 8/04/19 at 10:34 PM, The resident's eyes remain red and swollen. 8/05/19 at 10:07 PM, swelling to eyelids; the resident was encouraged to wear goggles at night. 8/07/19 at 08:04 AM, Redness and swelling to both eyes continues to resolve. 8/07/17 at 07:39 PM, Eyes appear puffy, red and draining. 8/10/19 at 11:50 AM, No redness, but mild swelling to both eyes. 8/11/19 at 11:33 PM, Mild swelling and mild redness to eyes. 8/18/19 at 7:07 AM, [MEDICATION NAME] not available from pharmacy 8/19/19 at 5:31 AM, [MEDICATION NAME] not available, waiting for pharmacy delivery. 8/19/19 at 6:15 AM, Pharmacy is closed [MEDICATION NAME] not available. 8/20/19 at 5:25 & 5:55 AM, [MEDICATION NAME] not available. 8/21/19 at 5:29 AM, [MEDICATION NAME] not available from pharmacy. 8/21/19 at 1:08 PM, [MEDICATION NAME] on order from pharmacy. The medical record did not include documentation that the supervisor, and MD were contacted regarding the missed doses of eyedrops or the increased redness, swelling, or drainage. A MD note dated 8/5/19, documented the resident has [MEDICAL CONDITION], and was seen by ophthalmology who prescribed eye drops with some improvement in his condition, but he continues to have swollen eyelids. The MAR for the dates of 9/4/19 - 9/19/19, documented the resident received 24 of 47 ordered dosed of Refresh [MEDICATION NAME] gel. Progress Notes documented the following: 9/06/19 at 6:28 AM, 5:49 PM, and 11:11 PM, [MEDICATION NAME] was on order. 9/09/19 at 5:07 PM, [MEDICATION NAME] was on order. 9/10/19 at 5:18 PM and 11:01 PM, [MEDICATION NAME] was on order. 9/11/19 at 5:52 AM, [MEDICATION NAME] on order. 9/14/19 at 6:25 AM and 5:00 PM, [MEDICATION NAME] was not available. 9/15/19 at 1:09 AM - [MEDICATION NAME] was not available. 9/15/19 at 5:35 AM, [MEDICATION NAME] were not available from pharmacy on the weekend. 9/15/19 at 11:51 AM, [MEDICATION NAME] unavailable waiting for arrival from pharmacy. The medical record did not include documentation that the pharmacy, supervisor, and MD were contacted regarding the missed doses. During an interview on 9/17/19 at 12:14 PM, with Resident #42, the resident stated they often run out of his eye drops. During an interview on 9/17/19 at 8:52 AM, Licensed Practical Nurse (LPN) #4 stated nurses were supposed to contact the pharmacy when medications were not on the medication cart; the nursing supervisor was supposed to be called to see if medications were available in the emergency kit, and the MD contacted for further orders. During an interview on 09/17/19 09:34 AM, the Nurse Practitioner stated she would expect notification to the provider that the resident's eye drops were not available. During an interview on 09/17/19 at 1:20 PM, Licensed Practical Nurse Manager (LPNM) #3, stated the resident had [MEDICAL CONDITION] and [MEDICAL CONDITION] sicca. He is on multiple eye drops and is followed by ophthalmology. She was not aware that all his eye drops were not being given but she should have. If they were not available a call should have been placed to pharmacy, the MD notified, and it should have been documented in the chart that all these things were done. During an interview on 09/18/19 at 8:51 AM, the MD stated he was not aware of the missed doses of eye drops. He would expect a phone call and documentation of such in the resident's chart; he can't do anything if he does not know. When the surveyor showed the MD the missed doses he stated that was a lot of time to miss the medication and it absolutely could have caused the eye redness and swelling. 10 NYCRR 415.12