Every finding on record at Delmar Center for Rehabilitation and Nursing

Based on record review and interview conducted during a survey, the facility did not ensure licensed nurses and Certified Nurse Aides had the specific competencies and skills necessary to care for resident's need. Specifically, (a.) Resident #63's herpes zoster eye disease (shingles of the eyelid) was resolved and their order for Enhanced Barrier Precautions was discontinued instead of contact precautions; (b.) Licensed Practical Nurse #2 was unaware of medication shortened expiration dates and was not able to demonstrate insulin Kwik pen administration; (c.) Licensed Practical Nurse #1 was unable to identify which resident in a shared room was on Enhanced Barrier Precautions and was unable to verbalize the difference in other types of infection control precautions; and (d.) Infection Control training was not routinely conducted. Licensed Practical Nurse #5 stated they did not have any rosters for staff who attended additional training, or audits. Additionally, there were multiple interviews conducted where staff did not know the difference between Contact and Enhanced Barrier Precautions. This is evidenced by:The Facility Assessment, documented Staff Training/Education and Competencies 3.4 based upon the resident review of the facility assessment it was determined the major diagnoses of the resident population included dementia, diabetes, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF). In addition to the existing facilities, mandatory education of abuse prevention, resident rights, infection control to name a few identified educations have been implemented with competencies. Training topics and competencies may/will change as resident needs are identified. Facility's staff development nurse and directors completed competencies with their staff at least annually.Policies and Procedures3.5 Policies and procedures were reviewed on an ongoing basis by the Director of Nursing/Assistant Director of Nursing, Medical Director, staff development and corporate compliance officer. These policies were reviewed against evidenced based practice for the most current professional standards of practice. When revision and or change was needed the Director of Nursing along with all those involved with the policy need scribes the revision and then was approved through the Quality Assurance process. Policy changes were reviewed with appropriate staff to educate regarding changes and assure competency and professional practice standards.The undated facility policy titled Infection Control Guidelines for All Nursing Procedures, documented staff were required to receive in-service training on infection control, including protocols for standard and transmission-based precautions. It further documented: Standard Precautions were to be used for all residents. Transmission-Based Precautions were to be implemented when indicated. Staff were to perform hand hygiene, including washing hands with soap and water under specified conditions. staff were to wear appropriate personal protective equipment to prevent exposure to infectious materials. Resident #63 Resident #63 was admitted to the facility with diagnoses of rhabdomyolysis (a serious condition characterized by the breakdown of muscle fibers, leading to the release of harmful substances into the bloodstream, which can lead to kidney damage), herpes zoster eye disease (shingles of the eyelid), and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). The Minimum Data Set, dated [DATE], documented the resident had moderate cognitive impairment, could be understood and could understand others.During an observation on [DATE] at 12:23 PM, a Contact Precaution sign was posted outside Resident #63's room. Certified Nurse Aide #4 entered the room, delivered a meal tray, and exited without performing hand hygiene. Certified Nurse Aide #4 then picked up another tray and proceeded into another resident's room.During an interview on [DATE] at 12:23 PM, Certified Nurse Aide #4 stated they had not known the difference between Contact Precautions and Enhanced Barrier Precautions and acknowledged they had not followed the required steps listed on the signage.During an observation on [DATE] at 12:20 PM, Certified Nurse Aide #4 entered and exited Resident #63 room labeled Contact Precautions without personal protective equipment. Certified Nurse Aide #4 used hand sanitizer for hand hygiene although the signage indicated the use of soap and water after contact with residents.During an interview on3.06.2026 at 12:20 PM, Certified Nurse Aide #4 stated they had used hand sanitizer and reported staff usually just used hand sanitizer.A nursing progress note dated [DATE] at 12:48 PM, written by Director of Nursing #1, documented Resident #63's shingles rash resolved, Enhanced Barrier Precautions discontinued, and care plan updated.An order for Enhanced Barrier Precautions (EBP) (wound) every shift for wound was created on [DATE] at 5:27 PM by Licensed Practical Nurse #5 and discontinued on [DATE] at 12:48 PM by Director of Nursing #1.An order for Contact Precautions, shingles, every shift for monitoring, was created on [DATE] at 4:33 PM by Registered Nurse #1 and discontinued on [DATE] at 12:52 PM by Licensed Practical Nurse #5.An order for Enhanced Barrier Precaution (EBP) (wound), every shift for wound dated [DATE] at 4:33 PM was created by Licensed Practical Nurse #5. During an observation on [DATE] at 11:45 AM, Licensed Practical Nurse #2 was unaware of medication shortened expiration dates and was not able to demonstrate insulin Kwik pen administration. After obtaining a blood glucose fingerstick on Resident #5, Licensed Practical Nurse #2 administered Novolog insulin 25 units via kwik pen. They did not perform a Safety Test (Priming) per manufacturer insert. Attach the needle, dial 2 units, and press the injection button. Ensure insulin comes out to remove air bubbles. During an interview on [DATE] at 11:50 AM, Licensed Practical Nurse #2 stated they had never primmed insulin kwik pens in the past. They stated they had been a nurse for about one year and were never told to prime insulin pens. Licensed Practical Nurse #2 also stated that insulin expired on the date printed on the bottle or pen. They stated they did not know that there was a list of medications that had shortened expiration dates.During an observation on [DATE] at 4:43 PM, Licensed Practical Nurse #1 and Certified Nurse Aide # 8 were observed providing colostomy care to Resident #10 in a room posted for Enhanced Barrier Precautions. Both staff exited the room wearing gloves and did not perform hand hygiene afterwards.During an interview on [DATE] at 4:43 PM, Licensed Practical Nurse #1 stated they did not know which resident in the room was on Enhanced Barrier Precautions. When asked what Enhanced Barrier Precautions meant, they stated they were not sure. Licensed Practical Nurse #1 stated they thought they received education on the different types of precautions when they were hired. When asked if they knew the difference between Contact Precautions and Enhanced Barrier Precautions, they were unable to describe the difference.During an interview on [DATE] at 12:33 PM, Certified Nurse Aide #1 stated they did not know the difference between Contact Precautions and Enhanced Barrier Precautions and believed all precaution signage required full personal protective equipment.During an interview on [DATE] at 12:38 PM, Certified Nurse Aide #8 stated they were unaware of the difference between Contact Precautions and Enhanced Barrier Precautions and treated both the same.During an interview on [DATE] at 5:50 PM, Certified Nurse Aide #10 stated they had been employed for approximately one month and were not certain of the difference between Contact Precautions and Enhanced Barrier Precautions and were unsure if infection control education was included in orientation.During an interview on [DATE] at 12:25 PM, Licensed Practical Nurse #5 stated they divided their responsibilities between infection control. wound care, and nurse educator and worked remotely for a portion of their schedule. They stated all new staff were trained upon hire and as needed, and the orientation packets were kept in their employee file. They stated nursing staff received instruction during orientation regarding the difference between Contact Precautions and Enhanced Barrier Precautions, and that precaution signage posted outside resident rooms identified the required personal protective equipment. Licensed Practical Nurse #5 stated their tracking system was poor and did not capture who and when training took place. They stated the tracking system for as needed in services consisted of an employee roster with a check mark. They were unable to provide any of these rosters.During an interview on [DATE] at 6:05 PM, Director of Nursing #1stated staff entering rooms with Enhanced Barrier Precautions should wear gloves, and precautions for Contact Precautions depend on the infection. Director of Nursing #1 stated hand sanitizer was acceptable unless otherwise specified on the signage. They further stated the facility had been without a nurse educator.During an interview on [DATE] at 10:00 AM, Director of Nursing #1 stated insulin administration including insulin kwik pens were reviewed and demonstrated during nurse orientation. They stated shortened expiration dates were also covered during nurse orientation and the list of these medications should be posted in the medication room.During an interview on [DATE] at 9:30 AM, Administrator #1 stated all staff received infection control training upon hire and completed annual competency training. Administrator #1 stated initial training was conducted in person, with annual training provided through web-based education and additional training provided as needed by the Nurse Educator. They further stated they were uncertain if the web-based learning was available in other languages apart from English. Precaution signage with pictorial instructions for use of personal protective equipment was posted outside resident rooms and as of this survey was both in English and Spanish. 10 New York Codes, Rules, and Regulations 415.26(c)(2)

Based on observation, record review, and interviews conducted during survey, the facility did not ensure it established and maintained an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five (5) residents (Residents #63, #82, #106, #10, and #113) reviewed. Specifically, (a.) staff failed to follow posted Contact Precaution and Enhanced Barrier Precaution signage; (b.) staff failed to perform appropriate hand hygiene; and (c.) staff failed to demonstrate knowledge of the differences between Contact Precautions and Enhanced Barrier Precautions. This had the potential to affect residents requiring infection control precautions.This is evidenced by:The undated facility policy titled Infection Control Guidelines for All Nursing Procedures documented staff were required to receive in-service training on infection control, including protocols for standard and transmission-based precautions. It further documented: Standard Precautions were to be used for all residents. Transmission-Based Precautions were to be implemented when indicated. Staff were to perform hand hygiene, including washing hands with soap and water under specified conditions. staff were to wear appropriate personal protective equipment to prevent exposure to infectious materials.Resident #113 was admitted to the facility with diagnoses that included extended spectrum beta-lactamase (ESBL) producing organism (a drug-resistant bacterial infection), type 2 diabetes mellitus (a condition affecting blood sugar control), and high blood pressure. The Minimum Data Set (an assessment tool) dated 01/15/2026 documented the resident was cognitively intact and required substantial assistance with activities of daily living. The resident was identified as requiring Enhanced Barrier Precautions due to risk for transmission of multidrug-resistant organisms.During an observation on 03/05/2026 at 12:07 PM, a Contact Precaution sign was posted outside the resident's room. Licensed Practical Nurse #3 was observed in the room without personal protective equipment while setting up the resident's tray and assisting with the television.During an interview at that time, Licensed Practical Nurse #3 stated the resident was on Enhanced Barrier Precautions, not Contact Precautions, and reported they had not noticed the posted sign was a Contact Precaution rather than Enhanced Barrier Precautions.During an interview on 03/05/2026 at 12:21 PM, Registered Nurse Unit Manager #3 stated Resident #113 was intended to have been on Enhanced Barrier Precautions and was unsure why a Contact Precaution sign had remained posted on the door.Resident #82 was admitted to the facility with diagnoses that included Clostridium difficile infection (a contagious diarrheal infection), high blood pressure, and generalized weakness. The residents' care plan documented the resident required Contact Precautions for Clostridium Difficile infection, which required staff to follow appropriate infection control practices to prevent transmission. The Minimum Data Set, dated [DATE] documented the resident was cognitively intact; was on Enhanced Barrier Precautions; and needed substantial assistance with lower activities of daily living.During an observation on 03/05/2026 at 12:15 PM, an Enhanced Barrier Precaution sign was posted outside the resident's room. Review of the resident's care plan indicated the resident was to have been on Contact Precautions for Clostridium difficile infection.During an interview on 03/05/2026 at 12:21 PM, Registered Nurse Unit Manager #3 stated the resident was no longer infectious and had not required Contact Precautions and the Physician orders and care plan should have been updated to reflect the current precaution status.Resident #63 was admitted to the facility with diagnoses that included herpes zoster of the eye (a contagious viral infection), chronic obstructive pulmonary disease (a lung disease affecting breathing), and atrial fibrillation (an irregular heart rhythm). The Minimum Data Set, dated [DATE] documented the resident had moderate cognitive impairment and required substantial assistance with lower activities of daily living. The resident was on Contact Precautions for herpes zoster and had an active wound requiring Enhanced Barrier Precautions.During an observation on 03/05/2026 at 12:23 PM, a Contact Precaution sign was posted outside Resident #63 room. Certified Nurse Aide #4 entered the room, delivered a meal tray, and exited without performing hand hygiene. Certified Nurse Aide #4 had picked up another tray and proceeded into another resident's room prior to intervention. They stated they had not known the difference between Contact Precautions and Enhanced Barrier Precautions and acknowledged they had not followed the required steps listed on the signage.During an observation on 03/06/2026 at 12:20 PM, Certified Nurse Aide #4 entered and exited Resident #63 room labeled Contact Precautions without personal protective equipment. Certified Nurse Aide #4 used hand sanitizer for hand hygiene despite the boldly written signage specifically indicating a necessity of soap and water after contact with residents.During an interview on 03/06/2026 at 12:20 PM, Certified Nurse Aide #4 stated they had used hand sanitizer and reported staff usually just use hand sanitizer, Certified Nurse Aide #4 despite the posted signage had been unaware with what the sign had indicated.Resident #10 was admitted to the facility with a diagnoses of methicillin-resistant Staphylococcus aureus (MRSA) infection (a drug-resistant bacterial infection), chronic kidney disease (reduced kidney function), and schizophrenia (a mental illness affecting thoughts and behavior). The Minimum Data Set, dated [DATE] documented the resident was cognitively intact; was on Enhanced Barrier Precautions; and had a colostomy (an external device that collects waste).During an observation and interview, on 03/07/2026 at 4:43 PM, Licensed Practical Nurse #4 and Certified Nurse Aide #9 were observed providing colostomy care in a room with an Enhanced Barrier Precaution signage. Both staff exited the room wearing gloves and did not perform hand hygiene. Licensed Practical Nurse #4 stated they had not known which resident in the room was on Enhanced Barrier Precautions and had not been educated on the difference between Contact Precautions and Enhanced Barrier Precautions. They stated they should have removed their gloves and washed their hands in the resident's room prior to exiting for infection control purposes.Resident #106 was admitted t othe facility with the diagnoses of congestive heart failure (a condition where the heart does not pump effectively), type 2 diabetes mellitus (a condition affecting blood sugar control), and conjunctivitis (infectious disease of the eye). The Minimum Data Set, dated [DATE] documented the resident was cognitively intact and was independent with upper body activities of daily living and dependent with lower body activities of daily living. The resident had an order for contact precautions.During an observation and interview on 03/11/2026 at 12:36 PM, Resident #106 was on contact precautions related to a contagious eye infection. A precaution sign was posted outside the resident's room in English only outlining required infection control measures. During the observation, Certified Nurse Aide # 14 entered the resident's room, performed hand hygiene using hand sanitizer, picked up a meal tray, delivered the tray to the resident, and exited the room. Upon exiting, Certified Nurse Aide#14 removed gloves and again performed hand hygiene using hand sanitizer. The Certified Nurse Aide did not wear the additional personal protective equipment indicated on the posted contact precaution signage. Certified Nurse Aide #14 stated they were aware the resident was on contact precautions; however, they reported that precautions were only required during direct care. They stated it was permitted for staff to enter and exit the room without wearing personal protective equipment unless they were providing care.During an observation and interview at 03/11/2026 1:30 PM, a family member approached Resident #106 s door, stopped, read the sign and began to put on the required personal protective equipment. They had not been educated by the facility about what to do if there was a particular sign on the residents' door, however they had worked in a nursing facility and knew the importance of maintaining the integrity of the precautions.During an interview on 03/05/2026 at 12:33 PM, Certified Nurse Aide #1 stated they had not known the difference between Contact Precautions and Enhanced Barrier Precautions and believed all precaution signage required full personal protective equipment.During an interview on 03/05/2026 at 12:38 PM, Certified Nurse Aide #8 stated they were unaware of the difference between Contact Precautions and Enhanced Barrier Precautions and treated both the same.During an interview on 03/05/2026 at 12:58 PM, Housekeeping Supervisor #1 stated housekeeping staff received training during orientation and on the job from more experienced staff. Housekeeping Supervisor #1 further stated most housekeeping staff primarily spoke Spanish and communication occurred through bilingual staff when available. The staff was unable to utilize their electronic system for education as the version they maintained was only available in the English language. If an area needed a specific cleaning technique or chemical agent, they needed to find a bilingual staff member to translate and educate them.During an interview on 03/05/2026 at 1:30 PM, Infection Control Nurse #1 stated they had served as the Infection Preventionist since 01/2025. They divided responsibilities between infection control and wound care and worked remotely for a portion of their schedule. Staff were educated during orientation regarding infection control practices. Precaution signage was utilized to identification of required personal protective equipment. They had maintained infection tracking through a line list kept with each Unit Manager. Residents with a Clostridium difficile infection were placed on Contact Precautions and could be discontinued from precautions following completion of antibiotics. Housekeeping staff were expected to use a specific product for cleaning rooms of residents with Clostridium difficile; however, they were unable to identify the product or contents needed to have been utilized. Housekeeping staff were notified of cleaning needs through group communication; however, the process for discontinuation of precautions was not clearly defined.During an interview on 03/07/2026 at 5:50 PM, Certified Nurse Aide #10 stated they had been employed for approximately one month and were not certain of the difference between Contact Precautions and Enhanced Barrier Precautions and were unsure if infection control education was included in orientation.During an interview on 03/07/2026 at 6:05 PM, Director of Nursing#1 stated staff entering rooms with Enhanced Barrier Precautions should wear gloves, and precautions for Contact Precautions depend on the infection. Director of Nursing #1 stated hand sanitizer was acceptable unless otherwise specified on the signage. They further stated the facility had been without a nurse educator. Director of Nursing#1 identified Registered Nurse #3 as the Infection Control Nurse. The previously identified Infection Control Nurse, Licensed Practical Nurse #5, was the wound care nurse rather than the Infection Control Nurse. Director of Nursing #1stated they believed they themselves to have been the Infection Control Nurse and admitted they were uncertain of who was the actual infection control nurse was.During an interview on 03/09/2026 at 10:29 AM, Director of Nursing #1 stated they believed they were serving as the Infection Preventionist since starting in the role on 12/19/2025 and reported they assumed responsibility for infection control when Licensed Practical Nurse #3 was not present. Director of Nursing #1 later stated Licensed Practical Nurse #3 served as the Infection Preventionist and had transitioned from the Assistant Director of Nursing role effective 01/23/2026. Director of Nursing #1 was unable to explain why infection control activities were not consistently managed by Licensed Practical Nurse #3. Director of Nursing #1 stated no audits had been conducted for Enhanced Barrier Precautions and reported staff would likely be noncompliant.During an interview on 03/10/2026 at 9:30 AM, Administrator #1 stated all staff received infection control training upon hire and completed annual competency training. Administrator #1 stated initial training was conducted in person, with annual training provided through web-based education and additional training provided as needed by the Nurse Educator. Administrator #1 stated they were uncertain if the web-based learning was available in other languages apart from English. Precaution signage with pictorial instructions for use of personal protective equipment was posted outside resident rooms and as of this survey was both in English and Spanish. They further stated Licensed Practical Nurse #5 served as the Nurse Educator since 01/2025, and although Licensed Practical Nurse #5 submitted a resignation in 12/2025, the resignation was rescinded following an agreement for a flexible work schedule.During an interview on 03/10/2026 at 10:40 AM, Medical Doctor #1 stated they had been working at the facility since 01/12/2026 and were present two days per week. The physician stated approximately 80 percent of residents had signage posted for Enhanced Barrier Precautions or Contact Precautions, which was higher than typically observed in other facilities. The physician stated they had not been aware of an increase in resident infections or hospitalizations during their time at the facility. They had completed mandatory infection control training to maintain licensure in New York State and reported they read the individual specifications and followed precaution signage prior to entering resident rooms.10 New York Codes, Rules, and Regulations 415.19(a)(b)(1-3)

Based on record review and interviews conducted during a survey, the facility did not ensure that comprehensive care plans were developed and implemented for residents according to professional standards for three (3) residents (Resident #'s 2, 6, and 111) of 23 residents reviewed. Specifically, (a.) Resident #2's care plan for impaired cognition did not have person-centered interventions and the interventions listed were not included on the resident's Kardex; (b.) Resident #6 did not include person-centered approaches/interventions to managing the resident's disruptive behavior; and (c.) Resident #111 did not have a care plan that indicated the resident was at risk for aspiration, although the resident had a history of aspiration pneumonia. This is evidenced by: The facility policy titled Care Planning reviewed 9/2023, documented an individualized comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs was developed for each resident. Each resident's comprehensive care plan was designed to: (a.) incorporate identified problem areas; (b.) incorporate risk factors associated with identified problems; (c.) build on resident's strengths; (d.) reflect resident's wishes regarding care and treatment goals; (e.) reflect treatment goals, timetables and objectives in measurable outcomes; (f.) identify professional services; (g.) aid in reducing declines in resident's functional status/levels; (h.) enhance the optimal functioning of the resident by focusing on a rehabilitative program; and (i.) reflect currently recognized standards of practice for problem areas and conditions. It further documented identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident required an interdisciplinary approach. Resident #2 Resident #2 was admitted to the facility with diagnoses of dementia (a group of conditions that cause a progressive decline in cognitive abilities), depression (a mental health condition characterized by persistent sadness, loss of interest, and other symptoms that significantly impair daily life), and hip fracture (a serious, often life threatening break in the upper femur). The Minimum Data Set (an assessment tool) dated 1/12/2026, documented the resident had severe cognitive impairment, could be understood, and could understand others. Resident #2's comprehensive care plan for Impaired Cognition, initiated 9/11/2025, documented the resident had impaired cognition related to dementia in other disease classified elsewhere mild with other behavioral disturbance. The goal documented that the resident would maintain current level of functioning through next review date. The interventions included: communicate with the resident and/or resident representative regarding resident's capabilities, engage the resident to participate in simple, structured activities, present just one thought, idea, question, or direction at a time, and provide a safe, clutter-free environment. The interventions included in the care plan were not-person centered as the care plan did not indicate what the structured activities consisted of. The Kardex (tool used by staff that lists resident care needs/interventions from the care plan) documented: provide a safe, clutter-free environment. The other interventions listed in the care plan were not included on the Kardex. Resident #6 Resident #6 was admitted to the facility with diagnoses of Schizophrenia (a chronic, severe brain disorder, characterized by distortions in thinking, perception, emotions, and behavior), depression, and anxiety (mental health condition characterized by excessive fear or anxiety that interferes with daily activities). The Minimum Data Set, dated [DATE], documented the resident could be understood, sometimes understand others, and had moderate cognitive impairment. Resident #6's comprehensive care plan for Behavior symptoms initiated 10/21/2025 documented the resident exhibited behavior symptoms such as hallucinations, delusions, paranoia, anxiety, depressed mood, difficulty sleeping, agitations, displacement of anger, accusatorial comments, homicidal ideations, homicidal threats, and using racial slurs. The goal indicated that the resident would not harm self or others through the review day. Interventions included: administer psychoactive medications as ordered, check for thirst/hunger and provide snack/food/drink as indicated per diet orders, distract resident with preferred activities, initiate psychiatric evaluation as needed, initiate psychology evaluation as needed, redirect behaviors as needed, redirect resident with preferable television shows, reorient to surroundings as needed, staff to approach the resident in a slow and calm manner, staff to offer emotional support. During an observation on 3/04/2026 at 7:52 AM, Resident #6 was overheard yelling and screaming. It was unclear what they were saying. During an observation on 3/04/2026 at 8:29 AM, Resident #6 was still yelling and screaming. During an observation on 3/04/2026 at 10:34 AM, Resident #6 was heard yelling out and using derogatory language. Staff entered the room and the resident calmed down for a few minutes. Resident began yelling a few minutes after staff exited the room. Resident #6's comprehensive care plan did not include the resident's behavior of yelling/screaming and its disruption to the environment. The interventions did not include Resident #6's preference for male caregivers or use of [lip balm] as a tool to redirect the resident's behavior. The interventions did not include what the resident's preferred activities or televisions shows were. During an interview on 3/11/2025 at 11:14 PM, Registered Nurse #3 stated Resident #6 was followed by both psychiatry and psychology. They stated when Resident #6 had episodes of yelling, screaming, or cursing they tried to reorient the resident. They stated sometimes Resident #6 could be swayed with coffee or snacks. They also stated the resident responded better to men than women, so if they had a male staff member working, they would have them approach Resident #6 and attempt to redirect. During an interview on 03/13/2026 9:34 AM, Licensed Practical Nurse #8 stated sometimes they could redirect Resident #6 with a beverage if they were having behaviors of yelling/screaming. They also stated Resident #6 could sometimes be redirected with [lip balm} for their dry lips. During an interview on 3/13/2026 at 12:24 PM, Director of Nursing #1 stated care plans were a work in progress and that they were lacking within the facility. They stated the purpose of the care plan was to guide staff members on how care should be provided for the resident. They further stated resident care plans should be individualized. Resident #111 Resident #111 was admitted to the facility with diagnoses of pneumonitis due to inhalation of food and vomit (also known as aspiration pneumonia, an acute lung inflammation caused by inhaling foreign material, typically food, vomit, or saliva into the airway), dysphagia (difficult swallowing), and encephalopathy (a broad term for brain dysfunction, damage, or disease, characterized by an altered mental state. The Minimum Data Set, dated [DATE], documented the resident was cognitively intact, understood others, and was usually understood by others. Resident #111's Comprehensive Care Plan for Self-Care and Mobility dated 8/30/2024 documented the resident required assistance with self-care and mobility related to stroke with weakness to (1) side, traumatic brain injury, ventriculoperitoneal shunt placed. The goal was: resident's self-care and mobility status would improve through the review date. Interventions included: alternate solids and liquids with by mouth intake; encourage resident to get out of bed for all meals; resident to remain upright for 30 minutes after meals; ensure oxygen was greater than 92% during by mouth intake; monitor for changes in status, notify interdisciplinary team as needed Resident #111's Comprehensive Care Plan for Activities of Daily Living initiated 3/08/2026, documented the resident was dependent on staff daily in meeting activities of daily living. Goal was resident would maintain current self-care and mobility status through the review date. Some interventions included: offer out of bed daily, eating, dependent assist of one (1), encourage resident to get out bed for meals due to dysphagia, monitor turn and reposition. There was no documented evidence that Resident #111 had an aspiration related care plan although they had a history of pneumonitis due to inhalation of food and vomit or aspiration pneumonia. During an observation on 3/06/2026 at 12:08 PM, Certified Nurse Aide #13 was observed assisting Resident #111 with their lunch meal. The resident remained in bed for the duration of the meal. During an interview on 3/06/2026 at 12:08 PM, Certified Nurse Aide #13 stated they did not know if Resident #111 usually got out of bed for lunch and they were told to go feed the resident. They stated they were not aware of any reason that Resident #111 needed to be up and out of bed. Certified Nurse Aide #13 was not aware of Resident #111's history of aspiration or of any directives for feeding Resident #111 such as alternating liquids and solids. During an interview on 3/13/2026 at 9:20 AM, Occupational Therapist #1 stated Resident #111 was on aspiration precautions. During an interview on 3/11/2026 at 2:18 PM, Registered Nurse #4 stated that aspiration risk should be included in Resident #111's care plan due their history. They stated Certified Nurse Aides should know a resident's condition/history, including aspiration risk prior to assisting with feeding. They stated Certified Nurse Aide #13 should have been instructed on the Resident #111's care needs prior to assisting them with feeding. During an interview on 3/13/2026 at 12:36 PM, Director of Nursing #1 stated if a resident had a history of pneumonitis related to inhaling food, such as Resident #111, an aspiration-related care plan should be in place. They further stated that residents with the condition should be monitored during meals to reduce the risk of aspiration, optimally out of bed. During an interview on 3/13/2026 at 11:52 AM, Regional Clinical Coordinator #1 stated Resident #111 should have had an aspiration care plan due to their history of aspiration and since they were on aspiration precautions since admission. 10 New York Code of Rules and Regulations 415.11(c)(1)

Based on observations, record review, and interviews during a survey, the facility did not ensure that each resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for three (3) (Resident #'s 4, 111, and 130) of four (4) residents reviewed. Specifically, (a.) Resident #4 was not provided with feeding assistance as indicated per the resident's plan of care, (b.) Resident #111 was not assisted out of bed for meals and positioned upright for meals as indicated in their care plan and staff did not know interventions listed in the resident's care plan for feeding Resident #111 who had a history of aspiration (accidental breathing of food, liquid, or foreign material into the airway on lungs, rather than the stomach, often caused by swallowing difficulties); and (c.) Resident #130 was dependent on staff for care and was not provided with toileting assistance when requested. This is evidenced by: The undated facility policy titled Activities of Daily Living (ADL) Total Care Policy documented the facility aimed to ensure that each individual's basic needs were met while promoting dignity, independence, and comfort. The policy applied to all caregivers, nurses, and staff involved in the direct care of residents who required assistance with activities of daily living, which included but was not limited to: bathing, dressing, toileting, eating, mobility and transferring, and personal hygiene. Caregivers and nursing staff provided direct assistance with activities of daily living, monitoring resident needs, and documented care provided. Supervisors/manager oversaw implementation of care plans, ensured compliance with activities of daily living policy, and provided training to staff. Under activities of daily living procedures for eating it was documented to assist with feeding if a resident was unable to eat independently, ensure that residents are seating in a comfortable, safe position for eating. For mobility and transferring it was documented provide assistance with walking, using mobility aids, or transferring from bed to char or wheelchair and encourage residents to participate in mobility activities as much as possible to maintain their physical abilities. The undated facility policy titled Activities of Daily Living, documented it was the policy of the facility to provide activity of daily living care to all residents based on assessment of needs. Activity of daily living consisted of but was not limited to: bathing, dressing, eating, transfers, toileting, bed mobility, and ambulation on and off the unit. Resident #4 Resident #4 was admitted to the facility with diagnoses of cerebral infarction (a medical condition where blood flow to the brain is interrupted, leading to brain tissue damage), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (a neurological condition causing paralysis or weakness on the left side of the body, stemming from right brain damage, and dysphagia (difficulty swallowing). The Minimum Data Set (an assessment tool) dated 1/07/2026, documented the resident was cognitively intact, sometimes understood others, and was sometimes understood by others. Resident #4's comprehensive care plan for Activities of Daily Living initiated 11/04/2025 documented the resident was dependent on staff daily in meeting activity of daily needs. The goal was: the residents' needs would be met by staff as evidenced by being well groomed, appropriately dressed daily. An intervention included: eating: substantial assistance initiated on 10/07/2025. On 3/11/2026, the intervention for eating was updated to supervision/touching assistance. During an observation on 3/05/2026 at 9:00 AM, Resident #4 was observed in bed attempting to feed himself. The tray table with breakfast tray was not directly in front of the resident. The resident attempted to use a fork to bring food to their mouth, but they were too shaky. A Rehabilitation Recommendation and Communication form dated 3/11/2026, completed for Resident #4, documented self-performance for eating was supervision or touching assist. During an observation on 3/13/2026 at 9:18 AM, Resident #4 was heard calling out for something to drink. Resident #4 was observed in bed sitting upright with tray table and breakfast tray placed in front of them. The resident had eaten the toast, but the eggs were untouched. There was a fork observed in the resident's cream of wheat. Resident #4 stated they had a hard time seeing. Certified Nurse Aide #10 brought the resident a nectar thickened juice and placed it on their tray. The resident was unable to locate it. There were several observations of staff entering the resident's room to check if they were done with their meal. There were no observations made of staff providing cues or assistance to the resident with their meal during a 15- minute timeframe. During an interview on 3/11/2026 at 10:48 AM, Licensed Practical Nurse #9 stated someone had to feed Resident #4. During an interview on 3/11/2026 at 10:59 AM, Certified Nurse Aide #9 stated Resident #4 did not require assistance with meals. They needed cues to feed themselves and supervision. During an interview on 3/11/2026 at 11:40 AM, Certified Nurse Aide #1 stated they looked at the kiosk to find out if a resident required assist with feeding themselves. Substantial max assist meant they had to feed the resident/do everything for the resident. During an interview 3/11/2026 1:16 PM, Registered Nurse #3 stated Resident 4 did not require assistance with eating. After review of Resident #4's care plan, they stated the resident needed substantial assistance for feeding. They further stated Certified Nurse Aides reviewed the resident's Kardex at the kiosk or the laptop at the desk to find a resident's care needs. During an interview on 3/12/2026 at 12:28 PM, Dietitian #1 stated Resident #4 had significant weight loss. They stated Resident #4's feeding tube was recently stopped. They stated speech therapy which recommended Resident #4 be switched to consuming food by mouth rather than the feeding tube and it was a very slow and gradual process. They stated weight loss for Resident #4 was favorable and that their intake was adequate. During an interview on 3/13/2026 at 10:04 AM, Rehabilitation Director #1 stated Resident #4's feeding status was upgraded a few days prior. They stated Resident #4 had trouble with their vision. Rehabilitation Director #1 stated supervision meant the resident needed to be provided with cues during the meal. The staff should set up the tray so that everything was in the right area so the resident could see and reach everything. They stated they were not sure why they would need touching assistance for eating. They stated maybe the staff would provide hand over hand assistance or put the drink in the resident's hand. Rehabilitation Director #1 stated if Resident #4 was eating in their room, someone should be in the room to set up their tray and supervision could be offered intermittently. During an interview on 3/13/2026 at 12:24 PM, Director of Nursing #1 stated supervision/touching assist was the new equivalent to limited assist. They stated staff may need to guide the resident's hand to their mouth or guide their hand to an item on their tray. They stated staff were not actually picking up the fork and doing it for them. Director of Nursing #1 stated if a resident required supervision/touching assist with feeding and ate in their room, they expected staff to check on the resident intermittently and provide assist as needed. They stated they would encourage a resident to eat out of their room. They stated substantial assist meant staff would feed the resident most of their meal. Director of Nursing #1 stated they would be concerned if Resident #4 lost weight now that they were no longer using their feeding tube. Resident #111 Resident #111 was admitted to the facility with diagnoses of pneumonitis due to inhalation of food and vomit (also known as aspiration pneumonia, an acute lung inflammation caused by inhaling foreign material, typically food, vomit, or saliva into the airway), dysphagia (difficult swallowing), and encephalopathy (a broad term for brain dysfunction, damage, or disease, characterized by an altered mental state. The Minimum Data Set, dated [DATE], documented the resident was cognitively intact, understood others, and was usually understood by others, Resident #111's Comprehensive Care Plan for Self-Care and Mobility initiated 3/08/2026 documented the resident required assistance with self-care and mobility related to stroke with weakness to (1) side, traumatic brain injury, ventriculoperitoneal shunt placed. The goal was: resident's self-care and mobility status would improve through the review 06/05/2026 Interventions included: alternate solids and liquids with by mouth intake; encourage resident to get out of bed for all meals; resident to remain upright for 30 minutes after meals; ensure oxygen was greater than 92% during by mouth intake; monitor for changes in status, notify interdisciplinary team as needed. Resident #111's Comprehensive Care Plan for Activities of Daily Living initiated 3/08/2026, documented the resident was dependent on staff daily in meeting activities of daily living. Goal was resident would maintain current self-care and mobility status through the review06/05/2026 dat. Some interventions included: offer out of bed daily, eating: dependent assist of one (1), encourage resident to get out bed for meals due to dysphagia, monitor turn and reposition. During an interview on 3/06/2026 at 10:16 AM, Resident #111 stated they wanted to get out of bed. They stated they did not get out of bed often but did at times. During an observation on 3/06/2026 at 12:08 PM, Certified Nurse Aide #13 was observed assisting Resident #111 with their lunch meal. The resident remained in bed for the duration of the meal, the position of their bed was approximately 80 degrees, and the resident was slightly slouched. During an observation on 3/07/2026 at 5:06 PM, Resident #111 was observed in bed during dinner. There was no assistance nearby. The head of the bed was not at 90 degrees. During an interview on 3/06/2026 at 12:08 PM, Certified Nurse Aide #13 stated they did not know if Resident #111 usually got out of bed for lunch and that they were told to go feed the resident. They stated they were not aware of any reason that Resident #111 needed to be up and out of bed. Certified Nurse Aide #13 was not aware of any directives for feeding Resident #111 such as alternating liquids and solids or of their history of aspiration. During an interview on 3/06/2026 at 12:12 PM, Licensed Practical Nurse #11 stated Resident #111 did not get out of bed for meals anymore. They stated it had been a while since Resident #111 had gotten out of bed to eat. During an observation on 3/12/2026 at 12:14 PM, Resident #111 was observed in bed during a lunch meal and Certified Nurse Aide #15 was assisting them with eating their meal. During an interview on 3/12/2026 at 12:14 PM, Certified Nurse Aide #15 stated they did not know Resident #111's care plan or what it said, but knew the resident needed to be up. They stated they did not know details of the resident's care plan, such as alternating liquids and solids. During an interview on 3/13/2026 at 9:20 AM, Occupational Therapist #1 stated Resident #111 was on aspiration precautions. During an interview on 3/11/2026 at 2:18 PM, Registered Nurse #4 stated Certified Nurse Aides should know a resident's condition/history, including aspiration risk prior to assisting with feeding. They stated Certified Nurse Aide #13 should have been instructed on the Resident #111's care needs prior to assisting them with feeding. During an interview on 3/13/2026 at 12:36 PM, Director of Nursing #1 stated that residents with a history of pneumonitis related to inhaling food, such as Resident #111, should be monitored during meals to reduce the risk of aspiration, optimally out of bed. Resident #130 Resident #130 was admitted to the facility with diagnoses of fracture of right acetabulum (a break to the right-side socked portion of the pelvic bone that forms the hip joint), type 2 diabetes (an endocrine dysfunction causing unregulated blood glucose levels), and cerebral infarction (a medical condition where blood flow to the brain is interrupted, leading to brain tissue damage). The Minimum Data Set (an assessment tool) dated 3/03/2026, documented the resident was cognitively intact, usually understood others, and was usually understood by others. A complaint filed with the New York State Department of Health on 3/02/2026 at 9:13 AM, documented Resident #130 requested to use the bed pan and a Certified Nurse Aide told Resident #130 that they could not put the resident on the bed pan because they did not have time and stated they should poop in their pants. Resident #130's Baseline Care Plan, dated 2/25/2026, documented the resident required substantial/maximal assist for toileting hygiene. It further documented toilet transfer was no attempted due to medical condition or safety concerns. Resident #130's Comprehensive Care Plan for Activities of Daily Living initiated 3/08/2026 documented the resident was dependent on staff daily in meeting activities of daily living needs related to weakness and debility. Interventions included toileting hygiene: substantial/maximum assist of one (1) and toilet transfer: activity does not occur or partial moderate assist of one (1). Toilet transfer was updated to supervision or touching assist of one (1) on 3/12/2026. During an interview on 3/04/2026 at 8:22 PM, Resident #130 stated yesterday a Certified Nurse Aide told them to urinate in their pants. They stated they were told the same thing over the weekend. Resident #130 stated it made them feel like a little kid, because they knew when they needed to urinate and should not have to urinate in their pants. During an interview on 3/09/2026 at 12:06 PM, Family Member #1 stated Resident #130 was told again over the weekend to soil themselves by the same Certified Nurse Aide. Family Member #1 stated they talked with the Certified Nurse Aide #10 directly and told them that it was inappropriate and not to do that. They stated Certified Nurse Aide #10 has been more respectful since they spoke to them. During an interview on 3/12/2026 at 11:58 AM, Certified Nurse Aide #10 stated they have not heard staff tell residents to soil themselves and if they did, they would tell a nurse. They stated if a resident was told to soil themselves, it would probably make the resident feel pretty bad and degraded. When questioned about such statements being made to Resident #130, they stated they told the resident they would come back and change them once they were finished with what they were doing, rather than assisting the resident with care at that time. Certified Nurse Aide #10 stated they thought Resident #130 was a check and change, but they should have used a bed pan. When asked how they knew what a resident's care needs were, they stated they looked at the kiosk. They stated for Resident #130, for toileting it just said substantial assist. Certified Nurse Aide #10 stated they talked with Licensed Practical Nurse #7 after it happened. During an interview on 3/12/2026 at 12:14 PM, Licensed Practical Nurse #7 stated they had never witnessed a staff member tell a resident to soil themselves. If they witnessed that they would talk with the Certified Nurse Aide, check the resident's care card, offer assistance, then report it to the Director of Nursing When questioned about Certified Nurse Aide #10's interaction with Resident #130, they stated they thought Family Member #1 had called them to check on the resident because someone had told the resident to go in their pants. They stated they told Certified Nurse Aide #10 that that was unacceptable and made them apologize to the resident. Licensed Practical Nurse #7 stated Certified Nurse Aide #1 stated they had just helped Resident #130 use the urinal and lunch trays were out and that they would be right back, so if the resident went in their pants, they did not mind changing them when they returned. During an interview on 3/13/2026 at 12:24 PM, Director of Nursing #1 stated they had not observed or heard staff tell a resident to soil themselves, but they have received complaints about it and have educated staff. They stated it made the residents feel terrible and like they were not important when told to soil themselves. Director of Nursing #1 stated Family Member #1 called them and told them what had happened, but they could not locate the particular staff member. They stated as they were interviewing, they were educating. They stated they were not aware that Certified Nurse Aide #10 was involved. 10 New York Codes, Rules, and Regulations 415.12(a)(3)

Based on observation, record review, and interviews conducted during a survey, the facility did not ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being for two (2) (Resident #'s 68 and 92) of two (2) residents reviewed. Specifically, Resident #68 was not consistently offered or provided with activities that were meaningful to them and met their interests and preferences; and Resident #92 did not attend any activities, nor were one-to-one activities documented as provided. This is evidenced by: The policy titled Activities revised 1/2026, documented it was the policy of the facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility sponsored group, individual, and independent activities would be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities would encourage both independence and interaction within the community. It further documented that activities would be designed with the intent to: (a.) enhance the resident's sense of well-being, belonging, and usefulness; (b.) create opportunities for each resident to have a meaningful life; (c.) promote or enhance physical activity; (d.) promote or enhance cognition; (e.) promote or enhance emotional health, (f.) promote self-esteem, dignity, pleasure, comfort, education, creativity, success, and independence; (g.) reflect resident's interest and age; (h.) reflect cultural and religious interests of the residents; and (i.) reflect choices of the residents. Resident #68 Resident #68 was admitted to the facility with diagnoses of major depressive disorder (a mental health condition characterized by persistent sadness, loss of interest, and other symptoms that significantly impair daily life), type 2 diabetes (an endocrine dysfunction causing unregulated blood glucose levels), and mild cognitive impairment (a condition marked by memory or thinking problems that are more severe than normal aging but do not significantly disrupt daily life). The Minimum Data Set (an assessment tool) dated 12/05/2026, documented the resident was sometimes understood by others, sometimes understand others, and was severely cognitively impaired. Resident #68's Comprehensive Care Plan for Activities initiated 9/15/2025, documented the resident was able to make recreation and leisure preferences known. They enjoyed being around other people but stated they were shy and would not initiate conversations. The goal documented Resident #68 would attend programs of known interest such as bingo, coloring, arts and crafts, discussions during this review. Interventions included: assist resident in finding programs of interest, introduce resident to peers with similar interests, invite/escort/provide resident transportation to activities of choice/interest, and provide monthly calendar/daily schedule of events. A progress note dated 1/15/2026 at 9:30 AM, documented a one-to-one visit was provided to Resident #68. It further documented they shared some laughs and Resident #68 shared some of their past memories. There was no documented evidence that Resident #68 was provided with activities or attended activities after the progress note dated 1/15/2026 was written. During an observation on 3/04/20206 at 10:22 AM, Resident #68 was observed sitting with other residents at a table in the common area in between the [NAME] and Daffodil units. No activities were present. The television was on. During an observation on 3/12/2026 at 10:28 AM, five (5) residents were observed in the common area in between the [NAME] and Daffodil units. There were no activities present. There was music playing on the television. Resident #68 declined going to the activity offered in the main dining room and remained in the common area. During an observation on 3/13/2026 at 10:00 AM, Resident #68 was sitting at the table in the common area with other residents. There were no activities present. During an Interview on 03/11/2026 at 10:48 AM, Licensed Practical Nurse #9 stated activities were done in the main dining room, like coloring. They stated the residents would sometimes watch movies on the unit. During an interview on 3/11/2026 at 10:59 AM, Certified Nurse Aide #9 stated there were no activities offered on the unit, only in the main dining room. During an interview on 3/11/2026 at 11:14 AM, Registered Nurse #3 stated activities wereusually held in the main dining room. They stated that was where they had the fun activities. On the unit they had dolls, put on calming music, and some residents would look at magazines. Registered Nurse #3 stated activities were also provided in the resident rooms and the activity aides would go from room to room and try to engage with the residents. During an interview on 3/13/2026 at 8:55 AM, Activities Director #1 stated Resident #68 had minimal participation in activities. They stated Resident #68 did attend coffee hour, music, and their family would visit and take them outside when the weather was nice. Activities Director #1 stated they had 2 full-time activity aides and a per-diem aide. They did not have any volunteers. Activities Director #1 stated they would love to have one (1) activity aide per unit. Then they could have one (1) aide in the main dining room and the others on the units doing one-to-one visits. Activities Director #1 stated all residents were offered to attend activities in the main dining room, if appropriate. They offered some smaller group activities on the unit, such as reminiscing group for those that did not go to the main dining room. When asked to see Resident #68's activity record, they stated they were not sure what was going on with their documentation in the electronic medical record. When they tried to pull up Resident #68's documentation of activities attended/offered it documented no documentation selected for this criteria could be found. Resident #92 Resident #92 was admitted to the facility with a diagnoses of Cerebral Palsy (a group of permanent, non-progressive neurological disorders that affect movement, muscle tone, and posture due to abnormal brain development or damage); Developmental Disorder of Scholastic Skills (refers to persistent, significant learning difficulties in reading, writing, or mathematics that are not caused by low intelligence, sensory impairment, or inadequate schooling); and adult failure to thrive (a rapid decline in physical, mental, and functional health, often without a single, clear cause). The Minimum Data Set, dated [DATE], documented the resident had severe cognitive impairment. Resident #92 had no documented evidence of comprehensive care plan for Activities. During an observation on 3/04/2026 at 8:30 AM, Resident #92 was observed in a common area for over 45 minutes dozing off, slumped over in their wheelchair. There were no staff interactions with the resident. Resident #92 did not attend the activity that took place in the dining room. During an observation on 3/11/2026 at 1:45 PM, Resident #92 was observed lying in their room, in bed, lights off, awake and chewing on a toy. Staff were preparing for a group activity in the dining room. During an interview on 3/11/2026 at 1:45 PM, Certified Nurse Aide #12 stated Resident #92 did not go to group activities. There was no documented evidence that Resident #92 was offered or provided with activities. During an interview on 3/11/2026 at 1:55 PM, Activities Director #1 stated on Tuesdays, Wednesdays and Thursdays there were two activity aides plus the director. On Fridays and Mondays there was one (1) activity aide and the director. On Saturday and Sunday, there was only one (1) activity aide. They stated they would like to have an additional activity aide hired so that there was an activity aide assigned to each unit. There were no activities scheduled on weekends after 4:00PM. Activities Director #1 stated for those residents who were unable to attend group activities, they had one-to-one sensory programs. They stated there were two (2) Residents (#37 and #74) that did not attend group activity but made use of personal iPad. They stated Resident #92 had sensory visits two to three times a week. Activities Director #1 was asked to show documentation of Resident #92's log of sensory visits. They accessed Point Click Care (charting system for the facility) and the tracking activities for Resident #92 dated 2/24/26 - 3/11/26 were blank. Activities Director #1 stated there was no routine of sensory visits for Resident #92, they provided visits ad-lib. Resident #92 did not attend the group music activity the previous day and Activities Director #1 had no explanation as to why they did not. During an interview on 3/11/2026 at 2:15 PM, Activity Aide #1 and #2 stated they had not done any one-to-one sensory with Resident #92 and were not aware of who does. During an interview on 3/13/2026 at 12:24 PM, Director of Nursing #1 stated they thought the activities program faced some challenges. They stated they would like to see more activities on the unit for those that could not or did not go to the main dining room. They further stated they would like to have one (1) more activity aide, that way they would have one (1) activity aide for each unit. 10 New York Codes, Rules, and Regulations 415.5(f)(1)h

Based on observations, record review, and interviews conducted during a survey, the facility did not ensure that each resident received the necessary respiratory care and services that followed professional standards of practice, for one (1) (Resident #43) of one (1) resident reviewed for oxygen administration. Specifically, Resident #43 supplemental portable oxygen tank was noted to be in the red empty zone on 3/4/2026, 3/7/2026 and 3/8/2026.This is evidenced by:Resident #43 was admitted with a diagnoses of unspecified diastolic congestive heart failure (occurs when the heart's left ventricle (heart chamber) becomes stiff and fails to relax properly between beats, preventing it from filling fully with blood), chronic respiratory failure with hypoxia (a long-term condition where the lungs cannot adequately transfer oxygen into the blood), pleural effusion elsewhere classified (abnormal accumulation of fluid within the pleural space, the thin cavity between the layers surrounding the lungs). The Minimum Data Set (an assessment tool) dated 1/26/2026, documented the resident usually could be understood and was understand by others with intact cognition.The facility's Policy and Procedure titled Oxygen Administration revised 5/2025, documented check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated.During an observation on 03/04/2026 at 08:30 AM, Resident #43's portable oxygen tank was empty, and resident noted to have a non-productive cough.During an observation on 03/04/2026 at 12:37 PM, Resident #43 was in dining room, and their oxygen tank was in the red zone for empty.During an observation on 03/08/2026 at 1:15 PM, Resident #43's tank was empty. Resident was in common area sitting in their wheelchair. Surveyor asked Licensed Practical Nurse #10 to check the oxygen and oxygen tank was replaced.Resident #43 Medication Administration Record documented Supplemental oxygen at 4 liters per minute via nasal cannula continuously every shift -Start Date 01/26/2026. On 3/8/2026 a new order was entered onto the Medication Administration Record, documented Check oxygen tank level and replace tank if less than 25% full every 2 hours for oxygen dependence -Start Date 03/08/2026 1600. The Comprehensive Care Plan for Oxygen dated 1/26/2026 documented Resident #43 receives supplemental oxygen therapy related to chronic respiratory failure. Monitor for signs and symptoms of respiratory distress and report to Medical Doctor as needed: Respirations, Pulse oximetry, Increased heart rate, Restlessness, Diaphoresis (sweating), Headaches, Lethargy (weakness), Confusion, Hemoptysis (coughing up blood), Cough, Pleuritic (lung) pain, Accessory muscle usage, Skin color.During an interview on 03/04/2026 at 12:37 PM, Licensed Practical Nurse #1 stated they recently checked Resident #43's oxygen tank and they were about to replace it.During an interview on 3/12/2026 at 10:30 AM, Director of Nursing #1 stated nursing staff were responsible for checking oxygen tanks per order and replacing oxygen tanks as needed.During an interview on 3/8/2026 at 1:44 PM, Director of Nursing #1 stated the oxygen tanks should be checked every 4 hours. They stated that this was an ongoing issue and would add an order to every resident on oxygen to check the tanks.10 New York Code of Rules and Regulations 415.12(k)(6)

Based on observations, record review, and interviews conducted during a survey, the facility did not ensure residents were treated with respect and dignity in a manner and in an environment that promoted maintenance or enhancement of quality of life for two (2) (Resident #'s 92 and 130) of three (3) residents reviewed. Specifically, (a.) Resident #92 was observed slumped over in their wheelchair in a common area for over 45 minutes without any staff interaction; and (b.) Resident #120 was told by staff to soil themselves. Additionally, during a lunch observation in the main dining room, staff were observed talking amongst themselves and using their phones off to the side of the room, while residents were eating. This is evidenced by: The undated facility policy titled Resident Dignity, documented the facility shall care for its residents in a manner and in an environment that promoted maintenance or enhancement of each resident's quality of life. It was documented that each staff member would treat each resident as individual human beings. The residents shall have the right to participate in care planning, each resident's care plan shall be individualized to meet the resident's needs and preferences. Treating residents as individual human beings leads to increased dignity and trust; and 5.) all employees must remain aware that they have a responsibility to maintain each resident's dignity. Resident #92 Resident #92 was admitted to the facility with a diagnoses of Cerebral Palsy (a group of permanent, non-progressive neurological disorders that affect movement, muscle tone, and posture due to abnormal brain development or damage), Developmental Disorder of Scholastic Skills (refers to persistent, significant learning difficulties in reading, writing, or mathematics that are not caused by low intelligence, sensory impairment, or inadequate schooling); and adult failure to thrive (a rapid decline in physical, mental, and functional health, often without a single, clear cause). The Minimum Data Set, dated [DATE], documented the resident had severe cognitive impairment. During an observation on 3/04/2026 at 8:30 AM, Resident #92 was observed in a common area for over 45 minutes dozing off, slumped over in their wheelchair. There were no staff interactions with the resident. During an observation on 3/11/2026 at 1:45 PM, Resident #92 was observed lying in their room, in bed, lights off, awake and chewing on a toy. Resident #130 Resident #130 was admitted to the facility with diagnoses of fracture of right acetabulum (a break to the right-side socked portion of the pelvic bone that forms the hip joint), type 2 diabetes (an endocrine dysfunction causing unregulated blood glucose levels), and cerebral infarction (a medical condition where blood flow to the brain is interrupted, leading to brain tissue damage). The Minimum Data Set (an assessment tool) dated 3/03/2026, documented the resident was cognitively intact, usually understood others, and was usually understood by others. Resident #130's Baseline Care Plan, dated 2/25/2026, documented the resident required substantial/maximal assist for toileting hygiene. It further documented toilet transfer was not attempted due to medical condition or safety concerns. Resident #130's Comprehensive Care Plan for Activities of Daily Living initiated 3/08/2026, documented the resident was dependent on staff daily in meeting activities of daily living needs related to weakness and debility. Interventions included toileting hygiene: substantial/maximum assistance of one (1) and toilet transfer: supervision or touching assist of one (1). During an interview on 3/04/2026 at 8:22 AM, Resident #130 stated yesterday a Certified Nurse Aide told them to urinate in their pants. They stated they were told the same thing over the weekend. Resident #130 stated it made them feel like a little kid, because they knew when they needed to urinate and should not have to urinate in their pants. During an interview on 3/09/2026 at 12:06 PM, Family Member #1 stated Resident #130 was told again over the weekend to soil themselves by the same Certified Nurse Aide. Family Member #1 stated they talked with the Certified Nurse Aide #10 directly and told them that it was inappropriate and not to do that. They stated Certified Nurse Aide #10 has been more respectful since they spoke to them. During an interview on 3/12/2026 at 11:58 AM, Certified Nurse Aide #10 stated they have not heard staff tell residents to soil themselves and if they did, they would tell a nurse. They stated if a resident was told to soil themselves, it would probably make the resident feel pretty bad and degraded. When questioned about such statements being made to Resident #130, they stated they told the resident they would come back and change them once they were finished with what they were doing, rather than assisting the resident with care at that time. During an interview on 3/12/2026 at 12:14 PM, Licensed Practical Nurse #7 stated they have never witnessed a staff member tell a resident to soil themselves. If they did witness that they would talk with the Certified Nurse Aide, check the resident's care card, offer assistance, then report it to the Director of Nursing. They would consider this a dignity concern. When questioned about Certified Nurse Aide #10's interaction with Resident #130, they stated they thought Family Member #1 had called them to check on the resident because someone had told the resident to go in their pants. They stated they told Certified Nurse Aide #10 that it was unacceptable to tell a resident this and made them apologize to the resident. During an interview on 3/13/2026 at 12:24 PM, Director of Nursing Nursing#1 stated they have not observed or heard staff tell a resident to soil themselves, but they have received complaints about it and have educated staff. They stated it made the residents feel terrible and like they were not important when told to soil themselves. Director of Nursing #1 stated Family Member #1 called them and told them what had happened, but they could not locate the particular staff member. They stated they were not aware that Certified Nurse Aide #10 was involved. Facility: During a meal observation on 3/04/2026 at 12:29 PM, three (3) staff members were observed to the side of the main dining room away from the residents, talking amongst themselves while the residents were eating. One (1) staff member was observed sitting with the residents. During a meal observation on 3/05/2026 at 12:27 PM, three (3) staff members were observed sitting on the side of the main dining room talking with each other away from the residents and using their phones periodically. No staff were observed sitting with residents while they were eating. During a meal observation on 3/06/2026 at 12:21 PM, three (3) staff members were observed sitting away from the residents to the side of the main dining room, talking amongst themselves, and using their phones periodically. During an interview on 3/13/2026 at 8:55 AM, Activities Director #1 stated they thought the staff should be sitting and engaging with the residents during lunch. They stated they had spoken with their staff about being on their phones. They further stated they would consider it a dignity issue if the activity staff were sitting apart from the residents and engaging with themselves rather than with the residents during mealtime. During an interview on 3/13/2026 at 12:24 PM, Director of Nursing #1 stated it was not appropriate for staff to sit off to the side of the main dining room while the residents ate. They could not observe resident needs if they were sitting off to the side and using their phones. They further stated it was not respectful. 10 New York Codes, Rules, and Regulations 415.5(d)(1)(i)

Based on record review and interviews, the facility did not ensure that as needed psychoactive medications had an end date for one (1) (Resident #10) of five (5) residents reviewed for unnecessary medications. Specifically, for Resident #10, there was no end date to an order for an as needed narcotic medications. This is evidenced by: The policy and procedure titled Psychotropic Medications, reviewed 12/2025, stated as needed orders for psychotropic medications including anti-psychotic, anti-anxiety, anti-depressant, and hypnotic medications, are limited to 14 days. Resident #10 was admitted with the diagnoses of schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), chronic kidney disease (when the kidneys stop filtering waste from the blood), and iron deficiency anemia (when there isn't enough iron in the body). The Minimum Data Set (an assessment tool) dated 2/9/2026, documented the resident was understood, could understand others, and was cognitively intact. The physician's order dated 02/18/2026, documented tramadol HCl (a narcotic medication) oral tablet 25 milligrams give one tablet by mouth every 12 hours as needed for pain with no end date ordered. The physician's order dated 02/20/2026, documented morphine sulfate (a narcotic medication) solution 20 milligrams per milliliter give 0.25 milliliters sublingually every two hours as needed for pain with no end date ordered. During an interview on 03/06/2026 at 11:09 AM, Director of Nursing #1 stated the nurses should be aware that as needed psychotropic and narcotic medications required a 14-day end date. They stated that when a provider entered an order it went into pending order status that the nurses should check and correct with the provider if necessary. During an interview on 03/06/2026 at 12:53 PM, Medical Doctor #1 stated they depended on the nurses to cue them for any order changes that should be made. They stated they trusted their nurses to know about any required end dates for medications. They did not state they did not know about the regulation but that they had received so much education on regulations over the year. 10 New York Codes, Rules, and Regulations 415.12(l)(1)

Based on record review and interviews during a survey, the facility did not ensure that as needed psychoactive medications had an end date for one (1) (Resident #10) of five (5) residents reviewed for unnecessary medications. Specifically, for Resident #10, there was no end date to an order for lorazepam (a psychoactive medication). This is evidenced by: The policy and procedure titled Psychotropic Medications, reviewed 12/2025, stated as needed orders for psychotropic medications including anti-psychotic, anti-anxiety, anti-depressant, and hypnotic medications, are limited to 14 days. Resident #10 was admitted with the diagnoses of schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), chronic kidney disease (when the kidneys stop filtering waste from the blood), and iron deficiency anemia (when there is not enough iron in the body). The Minimum Data Set (an assessment tool) dated 2/9/2026, documented the resident was understood, could understand others, and was cognitively intact. The physician's order dated 02/20/2026, documented lorazepam (an anti-anxiety medication) 2 milligrams per milliliter give 0.5 milliliters by mouth every six hours as needed for anxiety with no end date ordered. During an interview on 03/06/2026 at 11:09 AM, Director of Nursing #1 stated the nurses should be aware that as needed psychotropic and narcotic medications required a 14-day end date. They stated that when a provider entered an order it went into pending order status that the nurses should check and correct with the provider if necessary. During an interview on 03/06/2026 at 12:53 PM, Medical Doctor #1 stated they depended on the nurses to cue them for any order changes that should be made. They stated they trusted their nurses to know about any required end dates for medications. They did not state they did not know about the regulation but that they had received so much education on regulations over the year. 10 New York Codes, Rules, and Regulations 415.4(a)(1)

Based on observation, record review, and interviews conducted during the survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for two (2) (Sunflower Unit Cart A and [NAME] unit cart B) of three (3) medication carts reviewed, and one (1) (Sunflower/Daffodil AD unit) of two (2) medication rooms reviewed. Specifically, three (3) bottles of eye drops; two (2) inhalers; one (1) Lantus insulin pen (1) one Lidocaine vial one; one (1) liraglutide insulin pen; one (1) NovoLog insulin kwik pen all had no open and, or expiration dates. One (1) outer lock of a narcotic lock box was left open; and one (1) narcotic lock box outer lock was broken leaving the door ajar. This is evidenced by: The facility's Policy and Procedure titled Medication Storage revised 9/2025 documented all injectable multi-dose vial preparations must be dated and initialed upon opening. When an open vial is found not dated it must be discarded. The facility's Policy and Procedure titled Medication Storage revised 09/2025, documented, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. Schedule II, III, IV and V controlled medications are stored separately from other medications in a double locked cabinet designated for that purpose. Regulation S483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. During an observation on [DATE] at 9:45 AM, the Sunflower Unit Medication Cart A contained one (1) bottle of Artificial Tears open; one (1) bottle of Brimonidine 1% eye drops; and one (1) Albuterol HFA (hydrofluoroalkane) inhaler all without open and, or expiration dates. During an observation on [DATE] at 10:00AM, the Sunflower/Daffodil AD unit Medication room had Side D outer lock of a narcotic lock box left open; and Side A narcotic lock box outer lock was broken leaving the door ajar. During an observation on [DATE] at 10:30AM, the [NAME] Unit Cart B contained one (1) Lantus insulin pen; one (1) Lidocaine open vial; one (1) Liraglutide insulin pen; and one (1) fluticasone inhaler all with no open and no expiration dates. During an interview on [DATE] at 10:05AM, Licensed Practical Nurse #7 stated they contacted maintenance previously about the broken lock on narcotic box for Side A. Maintenance was called again and arrived during observation to repair lock. During an interview on [DATE] at 10:10AM, Licensed Practical Nurse #10 stated they were in a rush to get on the floor and left the outer lock of the narcotic box open. They also stated it was their understanding that the medication room counted as one of the double locks required for narcotics. During an interview on [DATE] at 11:45 AM, Licensed Practical Nurse #2 was unaware of medication shortened expiration dates. Licensed Practical Nurse #2 also stated that insulin expired on the date printed on the bottle or pen. They stated they did not know that there was a list of medications that had shortened expiration dates. During an interview on [DATE] at 10:00 AM, Director of Nursing #1 stated insulin administration including insulin kwik pens were reviewed and demonstrated during nurse orientation. They stated shortened expiration dates were also covered during nurse orientation, and the list of these medications should be posted in the medication room. 10 New York Codes, Rules, and Regulations 415.18(d)

Based on observation, record review, and interviews during a recertification and abbreviated survey (Case #s NY00358820 and NY00359065), the facility did not ensure the provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, the facility's staffing minimum staffing levels were not met each day from 1/12/2025 through 1/17/2025 per facility assessment and New York State Nursing Home Minimum Staffing and Direct Resident Care. This is evidenced by: Upon entrance to the facility on [DATE] there were 118 residents residing on 3 units. Nursing Homes are required by New York State Public Health Law and Regulations to meet minimum staffing standards. These minimum standards required every nursing home to maintain daily staffing hours equal to 3.5 hours of care per resident per day by a certified nurse aide, licensed practical nurse, or registered nurse. Of the 3.5 hours required, at least 2.2 hours of care per resident per day must be provided by a certified nurse aide and at least 1.1 hours of care per resident per day must be provided by a licensed nurse. The facility assessment dated ,d+[DATE] documented that the staffing plan was based on the resident population and their needs for care and support. The staffing plan documented the following daily staffing needs: ** Shift, Category of Staff, Number of Staff, Total Hours Worked Days, Registered Nurse, 1-4, 7.5-30 Days, Licensed Practical Nurse, 3-6, 22.5-45 Days, Certified Nurse Aide, 6-14, 45-105 Evenings, Registered Nurse, 0-1, 0-7.5 Evenings, Licensed Practical Nurse, 3-6, 22.5-45 Evenings, Certified Nurse Aide, 6-12, 45-90 Nights, Registered Nurse, 0-1, 0-7.5 Nights, Licensed Practical Nurse, 2-3, 15-22.5 Nights, Certified Nurse Aide, 3-8, 22.5-60 [Note: Where Days = 7 AM to 3 PM, Evenings = 3 PM to 11 PM, Nights = 11 PM to 7 AM] ** A review of staffing sheets provided by the facility from 12/01/2024 through 1/11/2025 documented the following: Based on facility census, there were not the required number of Registered Nurses or Licensed Practical Nurses on 12/07/2024, 12/14/2024, 12/28/2024, 12/31/2024, and 1/05/2025. On 12/07/2024, the facility census was 118. There were 15 licensed nurses (Licensed Practical Nurses and Registered Nurses) scheduled to work on that day. The required hours of licensed care for the facility were 129.8 hours based on the census. The licensed staff scheduled accounted for 120 hours of care. On 12/14/2024, the facility census was 119. There were 16 licensed nurses scheduled to work on that day. The required hours of licensed care for the facility were 130.9 hours based on the census. The licensed staff scheduled accounted for 128 hours of care. A review of staffing sheets provided by the facility from 1/12/2024 through 1/17/2025 documented the following: Based on facility census, there were not the required number of Registered Nurses or Licensed Practical Nurses on 1/12/2025 and 1/17/2025. To fulfill the staffing requirement for licensed nursing care (Registered Nurses and Licensed Practical Nurses) per resident per day, a facility with a census of 118 would need to schedule at least 17 staff members with nursing licenses for the entire day. ** Date, Facility Census, Scheduled Staff, Actual Scheduled Hours, Required Staffing Hours 01/12/2025 ,118 ,10 ,80 ,129.8 01/13/2025 ,118 ,17 ,136 ,129.8 01/14/2025 ,118 ,18 ,144 ,129.8 01/15/2025 ,118 ,19 ,152 ,129.8 01/16/2025 ,118 ,19 ,152 ,129.8 01/17/2025 ,118 ,16 ,128 ,129.8 ** Based on facility census, there were not the required number of Certified Nurse Aides on any day between 1/12/2025 and 1/17/2025. To fulfill the staffing requirement for Certified Nurse Aide care per resident per day, a facility with a census of 118 would need to schedule at least 37 staff members with nurse aide certifications for the entire day. ** Date, Facility Census, Scheduled Staff, Actual Scheduled, Required Staffing Hours 1/12/2025, 118, 14, 112, 289.1 1/13/2025, 118, 26, 208, 289.1 1/14/2025, 118, 31, 248, 289.1 1/15/2025, 118, 30, 240, 289.1 1/16/2025, 118, 29, 232, 289.1 1/17/2024, 118, 23, 184, 289.1 ** A review of punch cards provided by the facility from 1/12/2024 through 1/17/2025 documented the following: To fulfill the staffing requirement for licensed nursing care (Registered Nurses and Licensed Practical Nurses) per resident per day, a facility with a census of 118 would have at least 17 staff members with nursing licenses registered as working the entire day. Per the punched timecards, and based on the facility census, there were not the required number of Registered Nurses or Licensed Practical Nurses on 1/12/2025 or 1/17/2025. ** Date, Facility Census, Staff Timecard Punches, Actual Scheduled Hours, Required Staffing Hours 1/12/2025, 118, 12, 96, 129.8 1/13/2025, 118, 19, 152, 129.8 1/14/2025, 118, 22, 176, 129.8 1/15/2025, 118, 25, 200, 129.8 1/16/2025, 118, 23, 184, 129.8 1/17/2025, 118, 14, 112, 129.8 ** To fulfill the staffing requirement for Certified Nurse Aide care per resident per day, a facility with a census of 118 would need to schedule at least 37 staff members with nurse aide certifications for the entire day. Per the punched timecards, and based on the facility census, there were not the required number of Certified Nurse Aides on any day between 1/12/2025 and 1/17/2025. Date, Facility Census, Staff Timecard Punches, Actual Scheduled Hours, Required Staffing Hours 1/12/2025, 118, 16, 128, 289.1 1/13/2025, 118, 23, 184, 289.1 1/14/2025, 118, 21, 168, 289.1 1/15/2025, 118, 26, 208, 289.1 1/16/2025, 118, 19, 152, 289.1 1/17/2025, 118, 13, 104, 289.1 During a Resident Council Meeting on 1/14/2025 at 11:07 AM observed by the New York State Department of Health survey team, five out of five residents expressed concerns related to staffing in the building. When asked if they got the help and care they needed without waiting a long time and if staff responded to their call light timely, residents stated they did not, and it could take a good hour for call lights to be answered. The residents noted that it took longer for the call lights to be answered at nighttime. The residents' stated staffing was a disaster on the weekends. During an interview on 1/14/2025 at 9:32 AM Family Member #3stated that they had concerns with staffing, particularly on the weekends. The Family Member #3 further stated that they provide personal care and ambulation assistance because staff were not providing the care. During an interview on 1/17/2025 at 11:23 AM, Staffing Coordinator #1 stated that they put their schedule in place months in advance and gave it to upper management for review. At the time of the interview, Staffing Coordinator #1 stated they had completed the staffing schedule through May 2025. Every Tuesday and Thursday, upper management and Staffing Coordinator meet to discuss any issues with the schedule as it was written. Additionally, the Staffing Coordinator #1 stated that the Director of Nursing should not be in an assignment, but it has happened. It most recently happened over the holidays. Staffing Coordinator #1 stated they used travel nurses or borrow from other corporate facilities. Borrowing from another corporate facility was a last resort. During an interview on 1/21/2025 at 2:02 PM Licensed Practical Nurse #1 stated that they worked alone the day before and there was not enough staff at the facility. Licensed Practical Nurse #1 stated that they struggled to complete all their work, but they loved the residents, so they stay even though the work was difficult. During an interview on 1/21/2025 at 2:16 PM Registered Nurse #1 stated that there was never enough staff to give everyone the ability to do their job effectively, but they had only been employed at the facility a little over a month and was still learning. During an interview on 1/23/2025 at 8:44 AM, Director of Nursing #1 stated that they had been the Director of Nursing for 3 months and employed at the facility for 9 months. Director of Nursing #1 stated that it was hard to recruit staff because the pay structure was not good, but the facility was working with the union to increase the amount that can be offered to staff. During an interview on 1/23/2025 at 11:03 AM Administrator #1 stated that they used to recruit for the whole building and beginning on 1/06/2025, corporate also started helping with staff recruitment. Administrator #1 stated they spend 2-3 hours a day trying to get staff hired or interviewed. 10 New York Code Rules and Regulations 415.13(a)(1)(i-iii)

FACILITY Sufficient and Competent Nurse Staffing 01/13/25 11:37 AM [NAME] O2 cannula not in nose. 2.5L NC on concentrator. Problems at nighttime getting help. + cough. Usually takes 10-15 minutes to get help. Only one person works at night. 01/17/25 11:23 AM Interview with Deprincess Golden Staffing coordinator Given numbers on PBJ that were less than 8h in the building. 7/4 7.5h - looked at punch sheets and stated that the RN was present for 7:05 to 3:04. Asked if took a lunch break would that be a 7.5h day. Couldn't confirm that was the situation for that day. 7/14 confirmed there was no RN on that day. 9/20 stated the DON was in the building at the time for full 8h and another RN was here 6.75 The staff are not allowed to clock in 7 minutes before shift start or 7 minutes before time to leave. Puts her schedule in place months in advance and gives it to upper management for review. Right now she has the schedule out to May so that the facility knows well in advance that there aren't 8h scheduled. Every T/Th she meets with the DON and Admin to discuss any staffing issues she has. Works with staff to swap hours to try and meet the 8h requirement. For example if a nurse is working a 12h shift 7-7 she will ask them to work 8-8 to meet the requirement. The DON shouldn't be in an assignment but it does happen. Recently it happened over the holidays. When speaking with Yonni the staffing coordinator will advocate for her staff and stated the admin and DON do listen. They work together to recruit more RNs. Will go to Centers corporate if they need staffing. Deprincess has called Corporate maybe once to advocate for them to send more staff. They use Travelers. Some are from local agencies. Some they are from agencies that are outside the state like Louisiana. Have pulled staff from other Centers. Stated she recruits staff from people she knows as a health care worker in the past. The staff already in house recruit and send people to her. Borrowing from a sister facility is a last resort. The LPNs that work w here are really good. There are local RNs that will come in if they need to to do things that LPNs can't do. There is an oncall RN list updated monthly. DePrincess does the CNA and LPN orientation. She does not do the RN orientation. If the staff are not newly graduate, orientation is usually around 4 days, never shorter. While they are on orientation, they cannot work by themselves. If the staff is a new graduate, the orientation is longer, no less than 6 months but probably about 2 weeks. She does not let anyone loose if the orienting staff state that the new person is ready. After the CNA packet is completed in orientation there is a skills assessment test. Licensed person above the new person does a competency test and signs off that the new staff are ready. DePrincess does not get involved with performance reviews but does talk to the staff and report upwards if she is hearing that someone isn't ready or isn't a good match for the facility. Stated home grown staff and contractors want to be here and ask to come back. 01/23/25 11:03 AM Yonni interview. Until 1/6 he was doing recruiting for the whole bldg. Constantly reaching out to corporate and uses PLOY which is a website that funnels online resumes and applications. Corporate took it over on 1/6 and now he spends 2-3 hours a day trying to get staff hired or interviewed. There is a sign on and referral bonus. They go to job fairs to try and recruit nursing students. Tries to set up clinical rotations to come to the bldg. Is talking to CDTA to get them to put a bus stop in front of the bldg to make the building more accessible.

Based on observation, record review, and interviews during the recertification survey the facility did not provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections; and maintain an infection prevention and control practices designed to help prevent the development and transmission of communicable diseases and infection for all resident's and staff on 4 of 4 units. Specifically, (a.) during general observations staff were observed not putting on and taking off Personal Protective Equipment or practicing hand hygiene while entering and exiting residents' rooms with Transmission and Enhanced Barrier Precautions; (b.) for Resident #218, oxygen tubing was observed lying on the floor; (c.) Resident #17 was observed with urinary catheter bag lying on the floor; and (d.) catheter care for Resident #364 was not maintained as ordered to prevent urinary tract infection and urinary catheter bag was observed lying on the floor. 48413 This was evidenced by: Cross referenced to F882 Policy and Procedure titled, C-IC-1 Infection Prevention and Control, created 10/2015 and revised 5/30/2024 documented: Policies, procedures, and practices of Infection Prevention and Control in the facility were designed to: Prevent, identify, report, investigate, and control infections and communicable diseases in the facility through a system of surveillance; Identify and determine, when possible, incidents of communicable disease or infections should be stated; Maintain a safe, sanitary, and comfortable environment for residents, healthcare personnel, visitors, and others who may visit the facility. Based on the facility assessment: Establish guidelines for the adherence to Standard Precautions in the care of residents; Establish guidelines for adherence to Enhanced-Barrier Precautions in the care of residents, when applicable; Establish guidelines for implementing Transmission-Based Precautions, when necessary, based on the pathogen and circumstances of the illness/infection and to be the least restrictive possible for the resident under the circumstances; and Establish guidelines and practices for hand hygiene to be observed by healthcare personnel, residents and visitors. The Policy and Procedure titled, Catheter Guidelines; Urinary, revised 9/11/2023, Infection Prevention and Control documented do not position catheter drainage bag touching the floor. A minimum of standard precautions followed when handling or manipulating the drainage System: Additional precautions (e.g., enhanced barrier, contact, droplet) will be followed based on the resident's plan of care and/or individualized needs; Provide routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering). 48744 Resident #17 Resident #17 was admitted to the facility with diagnoses of anxiety disorder, paraplegia (inability to voluntarily move the lower parts of the body), and stage 4 pressure ulcer of buttock. The Minimum Data Set, dated dated dated [DATE] (an assessment tool), documented the resident was cognitively intact. The resident was able to make themselves understood and was able to understand others. During an observation on 1/13/2025 at 1:53 PM, Resident #17 was in bed and the resident's urinary catheter drainage bag was exposed, lying on the floor. Resident #218 Resident #218 was admitted to the facility with diagnoses of Chronic Obstructive Pulmonary Disease (an inflammatory disorder that causes muscle pain and stiffness); failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity); and dementia (loss of memory, language, problem-solving and other thinking abilities). The Minimum Data Set, dated dated dated ,d+[DATE], documented the resident had no impaired cognition, could be understood or understand others. During an observation on 1/13/2025 at 1:40 PM, Resident #218 was sitting in their room and there was no labeling on either oxygen tubing to their concentrator or portable oxygen bottle. Resident oxygen tubing from the concentrator was sitting on the floor of the resident's room. During an interview on 1/13/2025 at 1:41 PM, Resident #218 stated staff never changed the tubing and rarely labelled it either. 51131 Resident # 364 Resident #364 was admitted to the facility with diagnoses of unspecified fall, influenza virus A and other acidosis (a condition where the body has too much acid in body fluids). A Minimum Data Set, dated dated dated [DATE] documented Resident #364 was cognitively intact, could be understood, and understand others. During an observation on 1/13/2025 at 1:41 PM, Resident #364 had a urinary catheter in place connected to a bed bag. The urinary catheter bag was observed uncovered and lying on the floor. A care plan titled risk for Multiple Drug-Resistant Organisms (MDRO) colonization/ infection related to indwelling urinary catheter dated 1/08/2025 documented goal of Resident #364 would remain free of Multiple Drug -Resistant Organism infection/colonization. Interventions included: Educate Resident, family and visitors on Enhanced Barrier Precautions; Enhanced barrier precautions: wear personal protective equipment (gown, gloves) when providing high contact activities at bedside including dressing, bathing/showering, transferring, changing bed linens, providing hygiene, changing briefs/assisting with toileting, device care and/or use, or wound care. May additionally wear face protection (e.g., goggles, face shield, face mask) if there is a risk of splash or spray or circulating respiratory viruses in the community; and Remove Personal Protective Equipment , perform hand hygiene and reapply necessary Personal Protective Equipment before caring for another resident. During an interview on 1/14/2025 at 1:47 PM, Resident #364 stated they had never had a nurse check their catheter until 1/14/2025 when the nurse came in the room, did not put on Personal Protective Equipment, and looked at the catheter underneath their brief. Resident #364 stated staff left a package of cleansing wipes on the bedside stand and told them to clean the catheter three times a day. Resident #364 stated they were not given education on how to clean the catheter and they had not had a shower since leaving the hospital on 1/08/2024. Resident #364 stated the Certified Nurse Aides and the nurses who had taken care of them had never worn a gown or a mask until 1/14/2025; and they only recalled seeing staff wearing masks and gloves on 1/14/2025. During observations on 1/13/2025 at 11:00 AM, a Certified Nurse Aide did not perform hand hygiene, put on or take off personal protective equipment before entering or exiting Resident #83's room [ROOM NUMBER] times to retrieve supplies. Resident #83 was noted to be on enhanced barrier precautions, and the Certified Nurse Aide had provided personal care. During an observation on 1/13/2025 at 11:31 AM, a shared bathroom was noted to have personal care items not labeled or designated as belonging to which resident in the shared room, including, but not limited to a denture cup, and wash basin. During an observation on 1/13/2025 at 11:48 AM, a shared bathroom was noted to have personal care items not labeled or designated as belonging to which resident in the shared room, including, but not limited to 2 wash basins, and a bariatric bed pan. During an observation on 1/13/2025 at 12:07 PM, a shared bathroom was noted to have personal care items not labeled or designated as belonging to which resident in the shared room, including, but not limited to a bed pan. During an observation on 1/13/2025 at 12:07 PM, a Certified Nurse Aide did not perform hand hygiene, put on or take off personal protective equipment before entering a resident's room, who was on transmission-based precautions. Upon exiting the room, the Certified Nurse Aide was observed to not be wearing gloves, taking dirty towels and cups from the resident's room to the dirty utility room. During an observation on 1/13/2025 at 12:09 PM, a Certified Nurse Aide was observed leaving the dirty utility room without completing hand hygiene and directly entered another resident's room. During an observation on 1/13/2025 at 12:13 PM, a Certified Nurse Aide was observed entering a resident's room, who was on enhanced barrier precautions, and they did not complete hand hygiene or put on personal protective equipment. During an observation on 1/13/2025 at 1:05 PM, a Certified Nurse Aide was observed providing incontinence care to a resident on transmission-based precautions. The Certified Nurse Aide did not put on or take off personal protective equipment or perform hand hygiene both before and after providing personal care to the resident. During an observation on 1/22/2025 at 10:31 AM, Licensed Practical Nurse #6 on B Unit was observed wearing their N95 mask under their nose. During an interview on 1/15/2025 at 6:00 PM, Certified Nurse Aide #1 stated they needed to wear a gown, gloves and a mask when they entered a room with a Transmission Barrier Precaution or Enhanced Barrier Precaution sign. They stated that all Personal Protective Equipment was located on the resident's door. They stated they could go to the clean utility room and get more Personal Protective Equipment if it had been stocked. Certified Nurse Aide #1 stated that most aides only wore the Personal Protective Equipment when they were giving personal care to a resident, not if they were just answering the light or checking in on them. During an interview on 01/17/2025 at 12:05 PM, Director of Nursing #1 stated that handwashing must be completed when staff entered the patient's room, exited the room, before and after care was provided and between passing trays and during meals. Director of Nursing #1 stated that Enhanced Barrier Precautions required a mask, gloves and gown; and Transmission Based Precautions required N95 mask, gloves, gown and face shield. They stated staff were trained in Standard Precautions and Enhanced Barrier Precautions/ Transmission Barrier Precautions education, and this was provided at hire, yearly, and as needed. Director of Nursing #1 stated when they saw a staff member not wearing Personal Protective Equipment or applying Personal Protective Equipment incorrectly, they had stopped and re-educated them by asking them what they had done incorrectly and then walked them through the process of putting on and taking off step by step. Director of Nursing #1 stated they did not complete this as a formal education and had not asked staff to sign off that they were re-educated. They stated they depended on their unit managers from 7 AM to 4:30 PM Monday through Friday to monitor the standard precautions and Registered Nurse supervisors to monitor for noncompliance on weekends and evenings. Director of Nursing #1 stated if someone was noted to be noncompliant on more than one occasion, they were in serviced and retrained and auditing would be done by someone. Director of Nursing #1 stated supplies were located in the central supply room and maintenance, or housekeeping restocked the carts and door containers when they were low. Hand sanitizers were located on the wall in dispensers and there are individual bottles of sanitizer located in the central supply room. Director of Nursing #1 stated employees were expected to put on and take off Personal Protective Equipment in the resident's room; staff were expected to carry linens and soiled clothing in a garbage bag. 10 New York Code of Rules and Regulations 483.80 (b) (1)-(4) (c)

Based on record review and interview during the recertification survey, the facility did not ensure each resident was treated with respect and dignity and cared in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 4 (Resident #s 13, 17, 62, and 364) of 40 residents reviewed. Specifically, [a.] Resident #13 was unable to attend activities of their choice as their wheelchair was not able to fit through the interior doorways to the activities room, which caused the resident to feel excluded, [b.] Resident #17 expressed feeling like a burden and was uncomfortable asking for help because of staff ' s unprofessionalism, [c.] Resident #62, was observed on 1/13/2025 at 11:40 AM with matted, greasy hair, fully clothed, and was malodorous. , and [d] Resident #364 was observed on 1/13/2025 at 1:41 PM, with a urinary catheter drainage bag that was not covered with a privacy pouch. This is evidenced by: The Policy and Procedure titled, Quality of Life/Dignity, revised 5/28/2024, documented each resident would be cared for in a manner that promoted and enhanced quality of life, dignity, respect, and individuality. Policy implementation documented, residents would be treated with dignity and respect at all times. ' Treated with dignity ' was defined as the resident would be assisted in maintaining and enhancing his or her self-esteem and self-worth, residents would be assisted in attending the activities of their choice, including activities outside the facility, and residents would be assisted in transporting throughout the facility as needed. The policy documented staff would speak respectfully to residents. Demeaning practices and standards of care that compromise dignity were prohibited. Staff would promote dignity and assist residents as needed by promptly responding to the resident ' s request for toileting assistance and other needs. The Policy and Procedure titled, Catheter Guidelines; Urinary, revised 9/11/2023, documented urinary catheter use would adhere to the principles of dignity to include discreet use and privacy (e.g. covering urinary catheter drainage bags). Resident #13: Resident #13 was admitted to the facility with diagnoses of acute and chronic respiratory failure with hypoxia (low level of oxygen in the bloodstream), morbid (severe) obesity and type 2 diabetes mellitus without complications. The Minimum Data Set (an assessment tool) dated 11/12/2024 documented the resident was cognitively intact, could be understood, and understand others. The Care Plan for Resident #13 titled, does not express an interest in recreational activities, initiated 8/4/2023, documented a goal that the resident ' s wishes related to their recreational/leisure area would be respected and listed respect resident refusals as an intervention/task. During an interview on 1/13/2025 at 11:39 AM, Resident #13 stated their wheelchair did not fit through the activities entrance and they would like to go to more activities like bingo. During an observation on 1/16/2025 at 9:12 AM, Resident #13 ' s wheelchair was brought to the activities room. The wheelchair was not able to be pushed through the interior doorways that led into the activities room as it was wider than the doorways. During a subsequent interview on 1/16/2025 at 11:46 AM, Resident #13 stated, ' I feel kinda left out a little bit. I do like going to bingo. I ' m what you call a people person. I like talking to people. It ' s not that I don ' t want to go down there, but I can ' t fit through the doors. ' Resident #13 explained that for them to attend an activity in the activities room, they needed to have their wheelchair pushed through an exterior door on their unit that leads to an exterior door of the activities room, which was able to be opened to accommodate the width of their wheelchair. This meant they needed to go outside to have access to the activities room. Resident #13 stated they would do this during the good weather to be able to attend activities, but they rather do it year-round if they could. Resident #13 stated if their wheelchair fit through the interior doors to the activities room, they would attend activities more often. During an interview on 1/16/2025 at 9:12 AM, Certified Nurse Aide #2 stated Resident #13 ' s wheelchair did not fit through any of the interior doors. Stated that when the weather was nice, they would bring Resident#13 into the activities room from one of the outside doors, but the other residents would watch, and it made Resident #13 feel uncomfortable. Now resident #13 spends their time on the unit. During an interview on 1/17/2025 at 11:24 AM, Corporate Recreation Director #1 stated Resident #13 did say they wanted to go to activities. Corporate Recreation Director #1 stated they had Certified Nurse Aides show them the path they used to get Resident #13 into the activities room from the outside. They stated Resident #13 stated if the weather was nice, they did not mind being brought to activities like this, but if the weather was not nice, Resident #13 stated they did not want to go outside. Corporate Recreation Director #1 stated Certified Nurse Aides stated for the most part, the facility did a good job with maintaining the sidewalk used to bring Resident #13 to the activities room, but there was a ' rut ' (deep track) that could make it hard to push the wheelchair. They stated the aides would get by it and they got through it. Resident #17: Resident #17 was admitted to the facility with diagnoses of anxiety disorder, paraplegia (inability to voluntarily move the lower parts of the body), and stage 4 pressure ulcer of right buttock. The Minimum Data Set, dated dated dated [DATE], documented the resident was cognitively intact. The resident was able to make themselves understood and was able to understand others. The Certified Nurse Aide Task Report dated January 2025, documented the resident required assistance with catheter care/bowel incontinence and bowel movements every shift. During an interview on 1/16/2025 at 12:57 PM, Resident #17 stated staff need an in-service on professionalism. Stated staff made them feel like they were a burden when they asked for things. Resident #17 stated they needed help when they needed to have a bowel movement and staff ' s unprofessionalism made them feel uncomfortable to ask for help. Stated they knew there was a lot of residents that felt like that. Stated they heard staff talking about things that were not Resident #17 ' s business. Resident #17 stated staff would talk about their own, other staff ' s, and residents ' personal business. Resident #17 stated staff need an in-service on dignity. During an interview on 1/23/2025 at 4:22 PM, Registered Nurse #2 stated most staff working in the facility were agency staff. Stated there was not a lot of facility hired staff. Stated agency staff did receive orientation but did not know what it entailed. Their expectation was that all staff would be respectful to all residents. Stated they had not observed any staff being disrespectful but was not in the building during the evenings and nights. Stated a supervisor was in the building during those times. Resident #62: Resident # 62 was admitted to the facility with diagnoses of pubic ramus fracture (a fracture of the pubic bone), primary osteoarthritis (arthritis of the bones and joints), left shoulder, and muscle weakness. The Minimum Data Set, dated dated dated [DATE] documented the resident was cognitively intact, could be understood, and could understand others. During an observation on 1/13/2025 at 11:40 AM, Resident #62 was observed seated in a wheelchair in their room, with the door closed. Resident #62 had matted and greasy hair, was fully clothed, and was malodorous. The room was cluttered with personal belongings and their breakfast tray was still present on the bedside table. Resident #62 expressed their frustration that their breakfast tray had sat on the bedside table since 8:00 AM and staff had not come in to remove it. Stated that every day the meal tray would stay on the bedside table until the next meal, when it was replaced with the next tray. Resident #62 reported they shared a bathroom with another resident in an adjoining room. Stated the other resident would lock Resident #62 ' s side of the bathroom door when they used the bathroom and there was a time when the door stayed locked. Stated they put their call light on and waited by the bathroom door for two hours before staff answered the light. Resident #62 reported they were embarrassed because they had been incontinent of stool while they waited for staff to unlock the door,and felt this could have been prevented. Resident #62 could not remember the exact date of the incident but stated it happened on the 3:00 PM to 11:00 PM shift sometime around Christmas. Resident #62 stated the Certified Nurse Aides and Licensed Practical Nurses on evening and night shifts were ' very rude and unhelpful. ' During an interview on 1/15/2025 at 6:00 PM, Certified Nurse Aide #1 stated they normally work the 3:00 PM to 11:00 PM shift but were often floated to other units. Certified Nurse Aide #1 stated the residents could be demanding. Certified Nurse Aide #1 reported Resident #62 was a demanding resident. Certified Nurse Aide #1 stated they did not remember the bathroom being locked in Resident #62 ' s room. Certified Nurse Aide #1 reported staff tried to answer call bells a quickly as possible, but there had been busy times when it had taken 40 minutes or more. Certified Nurse Aide #1 stated ' These people should be grateful for the care we give them. If not for this place, where would they be? They should treat the aides with respect if they want to get respect ' . During an interview on 1/21/2025 at 1:17 PM, Licensed Practical Nurse # ' s 3 and 4 stated Resident #62 had a shared bathroom. They stated other residents often lock both doors for privacy. This happens frequently in all shared rooms. Licensed Practical Nurse #3 stated that no call light should go unanswered for more than 5 minutes. They stated they were unaware Resident #62 had been locked out of the bathroom and waited 2 hours for someone to answer the call light, causing incontinence. Licensed Practical Nurse #3 stated this should not have happened and it was considered poor care. During an interview on 1/22/2025 at 2:04 PM, Social Worker #1 stated they were not aware of the locked bathroom door, but they were aware of concerns about care, voiced by Resident #62 ' s family member. Social Worker #1 reported they checked in on Resident #62 often and they did not think the resident was unhappy. Social Worker #1 stated the resident ' s biggest concern had been about the size of their bed. Resident #364: Resident #364 was admitted to the facility with diagnoses of unspecified fall, influenza virus A, and other acidosis (a condition where the body has too much acid in its fluids). A Minimum Data Set, dated dated dated [DATE], documented the resident was cognitively intact. The resident was able to make themselves understood and was able to understand others. The Care Plan for Indwelling Urinary Catheter related to urinary retention, dated 1/8/2025, documented goals that the resident would show no signs or symptoms of urinary infection, and the resident would remain free from catheter-related trauma. Interventions documented change catheter as ordered; ensure tubing was anchored to prevent pulling; and maintain urine collection bag below the level of the bladder. During an observation on 1/13/2025 at 1:41 PM, Resident #364 ' s urinary catheter drainage bag was lying flat on the floor. The drainage bag did not have a cloth privacy cover. Resident #364 reported they were admitted to the facility with the catheter in place from their hospital stay. Resident #364 reported the catheter drainage bag had always been uncovered and lying on the floor or on the bed. During an interview on 1/14/2025 at 11:00 AM, Resident #364 asked the surveyor about the privacy bag which was covering the catheter drainage bag, ' Why are we suddenly covering this now? ' During an interview on 1/21/2025 at 1:17 PM, Licensed Practical Nurse #3 stated all urinary catheters with exposed drainage bags were required to have a privacy bag and were to be hung below the level of the bladder. Licensed Practical Nurse #3 stated they did not know why Resident #364 did not have a privacy bag to cover their exposed catheter bag on 1/13/2025. 10 New York Code of Rules and Regulations 415.5(a) 51131 51317

Based on observations, record reviews, and interviews during a recertification survey, the facility did not ensure residents were assessed by an interdisciplinary team to determine their ability to safely self-administer medication when clinically appropriate for 2 (Residents #s 13 and 22) of 2 residents reviewed for self-administration of medication. Specifically, (a.) Resident #13 was observed with their prescribed Albuterol inhaler and Trelegy inhalers on their overbed table and; (b.) Resident #22 was noted to have an Albuterol sulfate hydrofluoroalkane (HFA) inhaler on their overbed table. There was no documented evidence that Resident #s 13 and 22 were assessed to determine their ability to safely self-administer medications, and there was no physician order for self-administration of medications. This is evidenced by: Facility policy titled Medication-Self Administration created 03/2018, last revised 07/2019 stated criteria must be met to determine if a resident is both mentally and physically capable of self-administering medication and to keep accurate documentation of these actions. Procedure included, staff and practitioner would assess each resident's mental and physical abilities to determine whether self-administering medications was clinically appropriate for the residents upon request. In addition to general evaluation of decision-making capability, the nurse would perform a more specific skill assessment, this could be accomplished on paper or through Electronic Health Record system. If the team determines from this assessment, that a resident cannot fully safely self-administer medications, the nursing staff may determine that the resident could self-administer medications with assistance from the nurse, by storing the medication in the med-cart and having the resident being observed self-administered at the prescribed time Procedure also included, The Electronic Medication Administration Record/Medication Administration Record must identify medications that are self-administered and the medication nurse would need to follow-up with resident as to documentation and storage of medication during each med pass. Facility policy titled Medication-Storage created 02/2014 revised 01/2019 stated this center would have Medications stored in a manner that maintained the integrity of the product, ensures the safety of the residents, and is in accordance with Department of Health Guidelines. With the exception of Emergency Drug Kits, all medications would be stored in a locked cabinet, cart, or medication cart that is accessible to only authorized personnel, as defined by facility policy. Resident #13 Resident #13 was admitted to the facility with diagnoses of acute and chronic respiratory failure with hypoxia (a medical condition where the body is unable to effectively exchange oxygen and carbon dioxide in the lungs leading to persistently low levels of oxygen in the blood), type 2 diabetes mellitus without complications (a chronic condition that happens when a person has persistently high blood sugar levels) , and chronic obstructive pulmonary disease with (acute) exacerbation (narrowing of airways in the lungs making it difficult to breathe). The Minimum Data Set (an assessment tool) dated 11/12/2024 documented the resident was cognitively intact, had the ability to make themselves understood and had the ability to understand others. During an observation on 01/13/2025 at 11:56 AM, an Albuterol inhaler (a prescription medication used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by lung diseases such as asthma and chronic obstructive pulmonary disease) was noted to be present on the overbed table of Resident #13. During an observation on 01/15/2025 at 10:25 AM, an Albuterol inhaler (as described above) and a Trelegy inhaler (a prescription inhaler used to treat asthma and chronic obstructive pulmonary disease) was noted to be present on the overbed table of Resident #13. A review of Resident #13's medical record did not include documented evidence that the resident was assessed for their ability to self-administer their medications. A review of Resident #13's care plan did not include documented evidence that the resident could self-administer their medications. A review of the physician orders for Resident #13 dated 03/04/2024 documented Proventil HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT Solution 0.5-2.5 (3) MG/3 ML (Albuterol) to be inhaled orally every four hours every day for shortness of breath to be administered by clinician. A review of the physician orders for Resident #13 dated 02/20/2024 documented Trelegy-Elliptia Inhalation Aerosol Powder Breath Activated to be inhaled orally one time a day for chronic obstructive pulmonary disease to be administered by clinician. During an interview on 01/15/2025 at 10:25 AM, Resident #13 stated the inhalers were there to help their breathing, The Trelegy was used once a day, and the Albuterol was used four times a day. The nurses were there when it was used. They stated the nurses handed the medication to them and watched them use it. They stated medications were left on the overbed table throughout the day, and at the end of the day after the last time it was used, the nurses kept it on their medication cart. Resident #13 stated they never went through an assessment for administering their own medications and stated, They trust me. They know I'm not going to overdose. During an interview on 01/15/2025 at 11:26 AM, Licensed Practical Nurse #1 stated there were no residents that were able to self-administer medications on the unit and they would never leave medications at the bedside. If they found medications at the bedside, they would go to a nurse manager. Licensed Practical Nurse #1 stated there was a protocol for residents to be allowed to self-administer medications, but they were not sure of the protocol because medications were not left at the bedside. During an interview on 01/15/2025 at 10:58 AM, Registered Nurse #1 stated there needed to be an order for a resident to be able to self-administer medications. The resident needed to be trained and demonstrate they could use the medication appropriately. Registered Nurse #1 stated they did not have any residents on the unit that they were aware of who could administer their own medications. During a follow up interview on 01/21/2025 at 9:31 AM, Registered Nurse #1 stated there were no orders for Resident #13 to have any medications at the bedside. During an interview on 01/21/2025 at 10:12 AM, Director of Nursing #1 stated there were no residents in the building that administered their own medications. They stated if a resident was not capable to administer their own medications independently but could do so with supervision, residents should not have access to the medications until it was provided by Nursing and medications were to be kept locked up on the medication cart. Resident #22 Resident #22 was admitted to the facility with diagnosis of diabetes mellitus, chronic obstructive pulmonary disease (inflammation inside the airways), and anxiety disorder (a type of mental health condition. Those affected may respond to certain things and situations with fear and dread). The Minimum Data Set, dated dated dated [DATE], documented resident was cognitively intact, could be understood, and understand others. During an observation on 1/13/2025 at 11:58 AM, Resident #22 was noted to have an Albuterol sulfate hydrofluoroalkane (HFA) inhaler on their overbed table. The Medication Administration Record dated 12/30/2024, documented give Ventolin hydrofluoroalkane (HFA) Aerosol solution 108 (90 base) micrograms (albuterol sulfate) 2 puffs inhale orally every 4 hours as needed for wheezing or shortness of breath. During an interview on 1/13/2025 at 11:58 AM, Resident #22 stated the nurse gave them the inhaler out of the medication cart because they know when to use it. Resident #22 stated they used the inhaler when they felt they needed it. During an interview on 1/15/2025 at 10:29 AM, Licensed Practical Nurse #7 stated to their knowledge no resident at the facility self-administered their medication. If a resident was able to self-administer, there would be an order in the medication administration record. During an interview on 01/21/25 at 01:13 PM, Director of Nursing #1 stated there were no residents at the facility who self-administered their medication. If a resident wished to self-medicate, there would be an assessment completed; a doctor's order would be placed in the medication administration record and the care plan would be updated. 10 New York Codes, Rules, and Regulations: 415.3(f)(1)(vi) 51317

Based on record review and interviews during the recertification survey, the facility did not ensure that each resident was screened for a mental disorder or intellectual disability prior to admission for 7 (Resident #s 6, 17, 22, 24, 40, 60, and 92) of 40 residents reviewed. Specifically, the Preadmission Screening and Resident Review (PASARR, New York State Department of Health form 695) was incomplete for Residents #s 6, 17, 22, 24, 40, 60, and 92). This is evidenced by: The Policy and Procedure titled, Preadmission Screening and Resident Review (PASARR)/Screens, revised 12/2019, documented the Admissions department would obtain a completed Level 1 Screen for all admissions prior to being accepted to and arriving at the facility. The Admissions department would ensure that if the Level 1 Screen required a Level II Preadmission Screening and Resident Review (PASARR) evaluation, the Level II Preadmission Screening and Resident Review (PASARR) evaluation was completed and obtained for those individuals prior to admission to the facility. Upon admission, the social worker would be responsible to ensure the completed Level 1 Screen (and Level II Preadmission Screening and Resident Review (PASARR) if required) was in the medical record. To identify if a Level II Preadmission Screening and Resident Review (PASARR) evaluation was required for a resident who had a newly diagnosed mental illness or intellectual disability, a Level 1 Screen would be completed by a qualified screener. A new Screen and a Level II Preadmission Screening and Resident Review (PASARR) evaluation (if required) would be completed within the required timeframe according to state regulations. The Director of Social Work would conduct regular audits to ensure compliance of the Screen/ Preadmission Screening and Resident Review (PASRR) process. Resident #17: Resident #17 was admitted to the facility with diagnoses of major depressive disorder (recurrent), Post-Traumatic Stress Disorder (a mental health condition caused by an extremely terrifying event, with symptoms that may include flashbacks, nightmares, severe anxiety, and uncontrollable thoughts about the event), and anxiety disorder. The Minimum Data Set, dated dated dated [DATE], documented the resident was cognitively intact. The resident was able to make themselves understood and was able to understand others. The Telepsychology Note dated 10/23/2024 at 1:10 PM, Notes documented Post-Traumatic Stress Disorder, generalized anxiety disorder, major depressive disorder; recurrent, unspecified, and anxiety disorder. The provider met with the resident, who refused to engage with the provider. The resident's behavior documented anxious, pleasant, resistant, and paranoid. The Preadmission Screening and Resident Review for Resident #17 dated 8/31/2022, Level I Review for Possible Mental Illness (MI) (question 23 - does this person have a serious mental illness?) documented no, when the resident had a diagnosis of major depressive disorder (recurrent, moderate). Level II Referrals (questions 33 and 34) were unanswered. There was no documented evidence of a Level II Referral for Resident #17. Resident #40: Resident #40 was admitted to the facility with diagnoses of seizure disorder (brain condition that causes episodes of abnormal electrical activity in the brain), morbid obesity (severe form of obesity that's characterized by a high body mass index), and bipolar disorder; current episode depressed, moderate (mental illness that causes extreme mood swings). The Minimum Data Set, dated dated dated [DATE], documented the resident was minimally cognitively impaired, could be understood, and understand others and needed significant help with activities of daily living. The Preadmission Screening and Resident Review for Resident #40 dated 11/20/2020, Dementia Diagnosis (question 22), Level I Review for Possible Mental Illness (MI) (question 23), Level I Review for Possible Mental Retardation/Developmental Disability (MR/DD) (questions 24, 25, 26), and Level II Referrals (questions 33 and 34), were unanswered. Resident #60: Resident #60 was admitted to the facility with diagnoses of bipolar disorder, schizophrenia (a serious mental health condition that affects how people, think, feel, and behave), and unspecified dementia without behavioral disturbance. The Minimum Data Set, dated dated dated [DATE], documented the resident had moderate cognitive impairment. The resident usually made themselves understood and usually understand others. The Preadmission Screening and Resident Review for Resident #60 dated 10/4/2022, Level I Review for Possible Mental Illness (MI) (question 23 - does this person have a serious mental illness?) documented no, when the resident had diagnoses of schizophrenia and bipolar disorder. Level II Referrals (questions 33 and 34) were unanswered. There was no documented evidence of a Level II Referral for Resident #60. During an interview on 1/16/2025 at 9:45 AM, Director of Social Work #1 stated the Preadmission Screening and Resident Review Level II form was not required for Resident #60 because they needed to qualify for all requirements on page 30-32 of the Instruction Manual for Screen form that they used. The Surveyor reviewed the document and pointed out that Resident #60 could potentially qualify for all the requirements based on their diagnoses of bipolar disorder and schizophrenia with dementia. Director of Social Worker #1 responded, That doesn't apply because they were admitted for rehab. The Director of Social Work #1 stated, I checked with my Corporate Social Worker, and they said we do not have to do it. During an interview on 1/22/2025 at 10:41 AM, Minimum Data Set Coordinator #1 stated the Social Worker was responsible for reviewing the Preadmission Screening and Resident Review. They stated there should be a Level II evaluation whenever there was a qualifying mental illness diagnosis. During an interview on 1/23/2025 at 9:41 AM, Corporate Registered Nurse #1 was asked to provide Level II evaluations on Resident #s 6, 17, 60, and 92. They stated the residents did not have a qualifying stay for mental illness and according to Corporate, the facility did not have to do a Level II. 10 New York Code of Rules and Regulations 415.11(e) 48615 48744

Based on observation and staff interviews during a recertification survey, the facility did not ensure a safe, comfortable home-like environment and effective housekeeping and maintenance services were maintained for 5 (Units A, B, C, D, and G) of 5 resident units. Specifically, for all units, the handrails throughout the unit were scuffed, nicked, and scraped, exposing the untreated wood; for Unit A, there was not sufficient hot water to the resident's rooms; for Units B, C, D, and G, the bathrooms were not fully cleaned, tidy, and lights in residents bathroom not working. This is evidenced by: The undated Policy &Procedure, titled Maintenance/Housekeeping Work Order Policy, documented that it was the facility's policy to ensure all areas maintained a clean, comfortable, and well-functioning environment. When problems were identified, employees were required to complete a Maintenance/Housekeeping Work Order. Observations: Observations on Unit A were as follows; -On 1/13/2025 at 12:14 PM, room [ROOM NUMBER] lighting in the bathroom was not fully lit only dimly working and the water was not hot and took approximately 3 minutes to get to a comfortable temperature. The door handle on the inside of room [ROOM NUMBER] sticks and unable to open the door. -On 1/13/2025 at 12:59 PM, Handrails throughout the unit were scuffed, nicked, and scraped, exposing the untreated wood. -On 1/13/2025 at 3:32 PM, in room [ROOM NUMBER], the toilet was stained with a reddish color and had not been cleaned Observations on Unit B were as follows; -On 1/13/2025 at 11:49 AM, the handrails throughout the unit were scuffed, nicked, and scraped, exposing the untreated wood. -On 1/13/2025 at 12:22 PM, the resident stated that it was hard to regulate the heat in the room which gets very warm sometimes too warm. Observations on Unit C were as follows: -On 1/13/2025 at 12:41 PM, the handrails throughout the unit were scuffed, nicked, and scraped, exposing the untreated wood. -On 1/13/2025 at 11:49 AM, multiple shared bathrooms were not cleaned and had buildup around toilets and in corners of bathrooms. Observations on Unit D were as follows; - On 1/13/2025 at 12:07 PM, the handrails throughout the unit were scuffed, nicked, and scraped, exposing the untreated wood. - On 1/13/2025 at 11:13 AM, Room A-10 was very dirty. The room was cluttered with equipment, a wheelchair, and a walker. The areas around the bathroom door and entry door in the hinged corner crusted with dirt and dust. The floor and bedside tray were sticky with spilled food. - On 1/13/2025 at 4:50 PM, Resident room A-10 still had cluttered equipment in the room as well as uncleaned areas. The resident's floor still had areas that were not cleaned from the previous observation. Observations on Unit G were as follows: - On 1/13/2025 at 10:58 AM, room [ROOM NUMBER] had valance coming off the holder above the window, and exposed radiator tubing under the radiator. - On 1/13/2025 at 11:46 AM, the bathroom for room [ROOM NUMBER] had no light working. - On 1/13/2025 at 12:41 PM, the handrails throughout the unit were scuffed, nicked, and scraped, exposing the untreated wood. During an interview on 1/14/2025 at 2:21 PM, Family Representative #2 reported there was always a smell on the unit from bags when they change people. They stated staff left the bags in the hallway and then removed them to the soiled linen room at a later time. They stated that housekeeping was less to be desired, and they did not do the proper cleaning of areas as they felt the floors were not properly cleaned. During an interview on 1/21/2025 at 11:04 AM, Director of Housekeeping #1 stated that resident rooms were cleaned daily. They stated they did a 4/10 daily cleaning of the rooms in which they clean the high-touch areas, made sure there was no dust in the rooms, cleaned the bathroom, sweep and mopped the floors. They stated that they did a 10/10 deep clean of the room when a resident was discharged , or a resident changed room. They stated they did evaluations and inspections on rooms occasionally and kept records of what was cleaned. They stated they may have to increase the consistency of spot inspections for their staff. Currently, they stated they did not have any complaints or grievances when it came to the cleanliness of resident rooms. During an interview on 1/23/2025 at 9:45 AM, Director of Maintenance #1 stated the unit damage to the walls, doors, and handrails happened from residents' grabbing and scratching the rails as well as their wheelchairs or stretchers hitting it. If any damage to the walls occurs or other issues the staff need to inform maintenance so they could fix it. Director of Maintenance #1 stated they had not received any work orders related to any issues within the units. Work orders were created by staff when an issue occurred and were placed in a work order book. Maintenance would then review the books several times a day and fix any immediate issues they find. They stated that if a part needs to be ordered then the work order did not get completed. Director of Maintenance #1 stated that they did not notify residents that the order could not be completed due to a part being ordered. They stated that they were aware of the handrails but have not done anything yet to correct them. e Director of Maintenance #1 stated that the building was old. They stated that the facility was working with an outside contractor to replace all of the current lights in the building with higher-efficiency LED lighting. They stated that they had completed the main areas and hallways and were now transitioning to resident rooms which they believed would start very soon. They stated that they were aware that hot water took some time to get from the boiler to the resident's room on the far side of the building. They have instructed staff to let water run to get the hot water circulating through the system to the resident' rooms and showers in those locations. Director of Maintenance #1 stated that they were transitioning heating and air-conditioning units in the resident's rooms to newer units. If an issue regarding the units was reported, then the maintenance department would correct it by replacing the unit in the resident room. In mentioning room [ROOM NUMBER], Director of Maintenance #1 viewed the exposure of the hoses under the radiator system. They stated that the unit was smaller, and they would need to do something regarding the exposed hoses. In mentioning the exposed old radiator piping they stated that they would need to do something about that as well since these were a smaller unit. 10 New York Codes of Rules and Regulations 415.5(h)(2) 48744

Based on observations, interviews, and record review conducted during a recertification survey, the facility did not ensure residents had the right to voice grievances without discrimination or reprisal and without fear of discrimination or reprisal. Specifically, residents were not provided information on how to file a grievance or complaint anonymously. This is evidenced by: The facility Policy titled, Grievances, created 3/2016 with a current revision date of 7/02/2024, documented policy implementation included upon admission, the resident and/or resident representative are provided with information on how to file a grievance. Grievances may be submitted orally, in writing, and anonymously. Written grievances should be signed by the resident and/or representative whenever possible. The Director of Social Work is the facility's Grievance Officer and is responsible for facilitating the grievance process. During a general observation on 1/23/2025 at 1:48 PM, there was no location for a resident or representative to put a completed grievance form if they wanted to file a grievance anonymously. There was no secured box or drop area noted in an easily accessible location for residents or representatives, such as in the front lobby of the facility, or on any of the three units throughout the facility, for anonymously completed grievance forms. During Resident Council meeting on 1/14/2025 at 11:07 AM, that was attended by five residents, it was stated if residents wanted to file a grievance, they would go to the office and ask to speak with the administrator. Most residents at the meeting stated they had never filed an official grievance. They stated people may be afraid to speak frankly due to retaliation. They also stated it may be hard to file an anonymous complaint because it could be obvious which resident the concern was related to, and that confidentiality could be broken. The resident council president shared that some residents take their concerns to the president, and they share it with the Director of Social Work or another staff member. During an interview on 1/21/2025 at 2:29 PM, Licensed Practical Nurse #1 was asked if there was a place, such as a box, in which a resident could submit an anonymous grievance. Licensed Practical Nurse #1 stated they did not know of a place where an anonymous grievance could be deposited. When asked what they would do if a resident came to them with a grievance, they stated they did not know what they would do and they would find the unit manager or the Director of Nursing to let them know. They stated they assumed there was some paperwork they would need to fill out. During an interview on 1/21/2025 at 2:31 PM, Registered Nurse #1 was asked to describe the grievance process. They stated there was a form to take down the information and they would bring it to their supervisor who was the Director of Nursing. They stated they would start to think of immediate steps that should be taken for the resident or family member. Registered Nurse #1 stated there was no box on the unit for an anonymous grievance to be deposited. During an interview on 1/21/2025 at 2:11 PM, Director of Social Work #1 stated they were the Grievance Officer and there was a binder on each unit labeled 'grievances' with blank grievance forms. Staff could fill out the grievance form. They stated when they received the completed form, they went to the appropriate team member to discuss the grievance and come up with a resolution as a team, followed up with the resident and implemented the resolution. The grievance process procedure was outlined in the new admission paperwork provided to the residents when they were admitted to the facility. They stated there was no way to file a grievance anonymously. During an interview on 1/22/2025 at 1:59 PM, Administrator #1 stated there were binders on each unit for filling out blank grievance reports. When asked how the residents would know about this binder, they replied there was an ad hoc meeting in December in the dining room and this was discussed. When asked about how a resident could file an anonymous grievance, Administrator #1 stated residents usually do not want their grievances to be anonymous because the Administrator would not be able to rectify it. Residents came to them with the details of their grievance, and they investigated it. Administrator #1 stated they had not been in a situation where the resident reporting the grievance wanted to be completely anonymous. When asked how a resident could file an anonymous grievance, Administrator #1 stated residents could put the completed form in their box outside their office door or could give it to someone the resident trusted and have that person slip it under the administrator's door or put it in the social worker's mailbox. 10 New York Codes, Rules, and Regulations: 415.3(d)(1)(i)

Based on observations, record review, and staff interviews during the recertification survey, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, 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 (Resident #40) of 40 residents reviewed for abuse, neglect, exploitation, or mistreatment. Specifically for Resident #40 the facility did not report a violation of Comprehensive Care Plan requiring two care givers to provide personal care which resulted in a fall with injury. This is evidenced by: The facility policy titled, Abuse Policy, created 9/2012, last updated 12/2022, documented that the facility prohibited the mistreatment, neglect, and abuse of residents/patients and misappropriation of the resident/patient property by anyone including but not limited to staff, family, friends and residents of the facility. The policy further documented that neglect was defined as failure of the facility, its employees or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish or distress. Under Abuse - Protocol, it was documented that the Administrator and Director of Nursing were responsible for investigating and reporting. Under Abuse - Prevention, it was documented that to identify, correct, and intervene in situations where abuse, neglect, and or mistreatment were more likely to occur included, but was not limited to, identification/analysis of sufficient staffing on each shift to meet the needs of the residents/patients, assigned staff demonstrating knowledge of individual resident/patient needs, and sufficient and appropriate supervisory staff to identify inappropriate behaviors. Resident #40 Resident #40 was admitted to the facility with the diagnoses of seizure disorder (brain condition that causes episodes of abnormal electrical activity in the brain), morbid obesity (severe form of obesity that's characterized by a high body mass index), and bipolar disorder (mental illness that causes extreme mood swings). The Minimum Data Set (an assessment tool) dated 10/16/2024, documented that the resident was able to understand others, be understood, was minimally cognitively impaired, and needed significant help with activities of daily living. Review of the Comprehensive Care Plan for Activities of Daily Living, created 12/04/2023 and last updated 10/09/2024, documented the goal of Resident's activities of daily living status will improve through the review date. The documented interventions included that Resident #40 was dependent on 2 or more staff members and did not use their own strength to complete the following tasks: - Shower/Bathe - Roll Left and Right: Dependent x 2 or more staff - Lying to Sitting on Side of Bed - Personal Hygiene - Toileting Hygiene Review of the Comprehensive Care Plan for mobility, created 12/01/2023?and updated 10/09/2024, documented the resident would remain free of complications related to immobility, including contractures ( permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff), thrombus formation (the formation of a blood clot inside a blood vessel), skin-breakdown, and falls related injury. The documented interventions included but were not limited to, wheeling in wheelchair (resident was dependent on at least one person to physically assist them to complete the task). The resident did not use own strength for any part of the activity. A facility incident report, dated 10/01/2024 at 6:31 PM, documented that the resident had fallen out of bed while being cared for by Certified Nurse Aide #5. Resident #40 stated per the report, that the staff member was assisting them to roll over, the resident rolled too close to the edge of the bed and fell off it. Registered Nurse #6 was called to assess Resident #40, and the decision was made to send the resident to the hospital because the resident was complaining of pain to their leg, had struck their head, was on Eliquis (a blood thinner), and they had a laceration on their toe which was bleeding. A hospital orthopedic (a doctor that specialized in bones and tendons) consultation note dated 10/02/2024 at 2:54 AM documented that Resident #40 had sustained a right distal femur fracture (a break in the lower part of the right thigh bone, just above the knee joint). Resident #40 did not require surgical intervention for the fracture. There was no documented evidence that the incident was reported to the Department of Health. During an interview on 1/13/2025 at 11:58 AM, Resident #40 stated that in October they were getting cleaned up and a Certified Nurse Aide rolled them over too far and Resident #40 fell out of bed and broke their leg. Resident #40 stated that the Certified Nurse Aide #5 had been fired after the fall. Resident #40 stated that they did not like getting out of bed because it required a Hoyer lift and that they couldn't stand on their own because of their leg. During an interview on 1/21/2025 at 1:17 PM, Licensed Practical Nurse #4 stated that the Director of Nursing keeps all incident reports and investigations in their office. Licensed Practical Nurse #4 stated documentation of resident incidents and complaints were never documented in the medical chart. The information was included on the incident report by the Director of Nursing or the Administrator, and they were the only authorized staff to report incidents to the Department of Health.? During an interview on 1/21/2025 at 2:02 PM, Licensed Practical Nurse #1 stated they were educated on abuse and neglect yearly. If a resident sustained a fall during care, which resulted in a broken bone, it would require reporting and possibly a call 911. During an interview on 1/21/2025 at 2:16 PM, Registered Nurse Manager #1 stated that for falls with injuries, the Unit Manager and the Director of Nursing should have been notified immediately. Registered Nurse Manager #1 stated that only the Director of Nursing or the Administrator reported to Department of Health, but if the Registered Nurse Manager #1 thought an incident needed to be reported and they thought that no one had reported it, the Registered Nurse Manager #1 would call themselves. During an interview on 1/22/2025 at 12:40 PM, Director of Nursing #1 stated they had to pull up the policy for abuse and reporting to refer to it when asked about the reporting process for allegations of abuse, neglect, and misappropriation. Director of Nursing #1 stated they were responsible for investigating allegations, interviewing all staff and residents involved, and bringing the information to the Administrator. They stated the Administrator could speak to the reporting within two (2) hours requirement.? During an interview on 1/22/2025 at 1:00 PM, Administrator #1 stated they would report all allegations of abuse within two (2) hours if they were found to be substantiated. Administrator #1 also stated the regulation for reporting abuse stated that all abuse needs to be reported within two (2) hours, and they would attempt to unsubstantiate the abuse allegations within two (2) hours. Administrator #1 stated that if there were multiple witnesses to the incident, if a staff member was not working, or if there was no evidence of abuse, they would consider the allegation unsubstantiated and not report it. During a follow up interview on 1/23/2025 at 8:44 AM, Director of Nursing #1 stated if a resident fell because of a care plan violation, the Department of Health had to be called within 2 hours. The employee involved would be sent home, and an investigation would begin. If the staff did not know how the resident got injured, that would be a reportable incident. 10 New York Code of Rules and Regulations 415.4(b)(2) 51131

Based on interview and record review, the facility did not ensure each resident had an appropriate and safe discharge for 1(Resident #362) of 3 residents reviewed for discharge. Specifically, Resident #392 did not feel they were discharged appropriately, did not have a discharge planning meeting with Social Work and did not receive adequate discharge education or written notice of their rights to appeal the decision. This is evidenced by: Resident # 362 was admitted to the facility with diagnoses of fracture of one femur, repaired (broken hip repaired surgically), polysubstance abuse (drug and alcohol abuse) and unspecified osteoarthritis (arthritis of the bones and joints). The Minimum Data Set (an assessment tool) dated 1/14/2025 documented resident was cognitively intact, could be understood by and could understand others. Policy and procedure titled, Discharge - Transfer/Discharge Process, created 11/2017 and revised 10/10/2024, documented if a resident was being discharged to the community, the Social Worker or designee in conjunction with the interdisciplinary team and healthcare provider would coordinate the necessary medical, physical, mental, and psychosocial services for the resident's safe transition to the community. The resident and/or their representative would receive written notice of the facility's intent for transfer/discharge and their appeal rights prior to the time of discharge from the facility. A Physical Therapy Initial assessment dated [DATE], documented Resident #362 presented below baseline and would benefit from skilled Physical Therapy to increase strength, balance, endurance coordination, and safety to decrease pain and improve functional mobility. The assessment further documented Resident #362 needed to be able to climb stairs to safely return to their home in the community. A Physical Therapy Evaluation dated 1/13/2025, documented remaining impairments were decreased and skilled Physical Therapy was required due to decreased self efficacy, impairments in multiple areas of the body and to multiple systems, need for multiple therapies, pain severity level and time since onset or acuity of the resident's injury. Physical Therapy assessment dated [DATE] documented Resident #362 demonstrated little to no physical impairments as a result of skilled rehab and that the resident reached their maximum potential. Record Review of Social Work discharge planning update note for Resident #362 dated 1/17/2025, documented the following: - Social Worker #1 met with Resident #362 to discuss discharge planning. - A 2-wheeled walker was provided. -Referral to be made for Physical Therapy and Occupational Therapy through a Certified Home Health Agency. - Resident would be transported to their home by a family member. - Social Work would fax a discharge notice to Primary Care Provider. - Resident signed their discharge notification. There was no documented evidence that education was provided to Resident #362 or if Notification of Appeal Process had been reviewed. During an interview on 1/14/2025 at 11:13 AM, Resident # 362 stated they were admitted on [DATE]. They stated that on 1/09/2025, they were very distressed by the care they had received and requested to leave the facility for another facility. They were told by the 3 PM - 11 PM nurse that they were not allowed to leave because they had signed for admission for 20 days. Resident #362 stated they were told if they left, they would be signing out Against Medical Advice and the insurance would not pay for their stay. The 3 PM - 11 PM nurse told them that they would call an ambulance and send Resident #362 wherever they wanted to go. Resident #362 Stated they became confused when Social Worker #1 came to them on 1/13/2025 and told them they were ready to leave. Social Worker #1 told Resident #362 they needed to sign a paper for the insurance stating they agreed with leaving. Resident #362 stated no other documentation was provided. Social Worker #1 told Resident #362 if they did not want to be discharged and chose to stay after 1/17/2025, they would be responsible for private pay. Resident #362 stated they did not feel ready to leave because they needed more Physical Therapy, and they thought they were deemed independent after they had complained about their care. During an interview on 1/23/2025 at 1:50 PM, Director of Rehabilitation #1 stated Resident #362 was very ready to go home as far as they could ascertain from the therapy documentation, but they would need to consult with the actual therapists for more details. During an interview on 1/23/2024 at 2:04 PM Social Work Director #1 stated they had received a Notice of Discontinuation of payment from Resident #362's insurance and this was the reason for discharge prior to 20 days. During an interview 1/23/2025 at 2:04PM, Social Work Director #1 stated Resident #362 was discharged because their insurance was cut. They stated the original plan had been approved for 20 days, but they were notified the insurance would stop paying on 1/17/2025. Social Work Director #1 did not report that an appeal had been offered to Resident #362 and appeal information was not documented. During an interview on 1/23/2025 at 2:04 PM Social Worker #1 stated they had delivered the Notice of Discharge to Resident #362 on 1/13/2025. Social Worker #1 stated Resident #362 was determined by the facility to be well enough to go home with [NAME] Home Care in place. Social Worker #1 stated they had not yet set up Home Care but planned to send a referral. They stated Resident #362 signed the discharge notice on 1/17/2025. Social Worker #1 did not report that an appeal had been offered to Resident #362 and appeal information was not documented. During an interview on 1/21/2025 at 2:20 PM, surveyor stated that resident was discharged on [DATE]; Administrator #1 stated, 'were they?' 10 New York Code of Rules and Regulations 483.15 (c)(5)

Based on observation and staff interview, during the recertification survey, the facility failed to store and serve potentially hazardous food under sanitary conditions. Specifically, the facility failed to recognize that the walk-in cooler and milk cooler were not operating properly, that food items were warm, and to notify appropriate staff to facilitate repairs. Ham was found to be 58 degrees Fahrenheit (F) after being held in the walk-in refrigerator for 3 days, pureed vegetables were found to be 58 F after being held in the walk-in refrigerator for 1 day, and cartons of milk were found to be 57 F, after being held in the milk refrigerator for an indeterminate period. Additionally, after identifying warm temperatures in the walk-in cooler, the kitchen staff did not institute emergency procedures to ensure food was held at 41 degrees F or less. Accepted safe food handling practice dictates that food be cold-stored at 41 F or less and requires that facilities provide refrigeration sufficient in number and capacity to cold-hold food at 41 F or less. This had the potential to effect 107 of 107 residents. This resulted in no actual harm but had the potential for more than serious harm that is Immediate Jeopardy to the health and safety of the residents. This is evidenced by the following: Cross References: F465 - Essential Equipment = L F490 - Effective Administration / Resident Well-Being = L During the initial tour of the main kitchen on 04/17/2017 at 8:00 am, ham was found to be 58 F, pureed vegetables were found to be 58 F, and cartons of milk were found to be 57 F. The temperature log for the walk-in refrigerator was reviewed on 04/17/2017. The log documented refrigerator temperatures of between 45-50 degrees Fahrenheit from 04/10/2017 through 04/17/2017 (acceptable temperature is 41 degrees Fahrenheit or below). The Maintenance Department work orders were reviewed on 04/17/2017. The work orders dated 04/12/2017 and 03/27/2017 stated that the walk-in freezer is running at a high temperature. The work order dated 04/10/2017 states that the cooler at Dietary 141 Rock is running at 60 F. The work order dated 03/06/2017, asks that the refrigerator coils and air curtains be cleaned. During an interview conducted on 04/17/2017 at 8:00 am, the Food Service Director stated that over the last several weeks the walk-in refrigerator temperatures were fluctuating and on 04/10/2017 the walk-in refrigerator coils were icing up requiring maintenance. Over the past weekend, experienced staff were in charge when the walk-in refrigerator temperatures spiked. The persons in charge should have notified the Food Service Director, the Administrator, and the Maintenance Department via a work order to repair the walk-in refrigerator. The Director of Plant Operations stated in an interview conducted on 04/17/2017 at 9:00 am, that when called on 03/29/2017, he believed the walk-in refrigerator wasn't maintaining temperatures from staff not closing the door; he thought a work order dated 04/10/2017, was for another building on the campus; and he was not aware of any temperature problems with the walk-in refrigerator from the previous weekend. The Administrator stated in an interview conducted on 04/17/2017 at 9:27 am, that she was not aware of issues with the walk-in refrigerator, maintenance staff are always on call regardless of any particular day, and that the proper procedure would have been for the kitchen staff to submit a work order with the Maintenance Department. Maintenance Employee #1 stated in an interview conducted on 04/17/2017 at 9:27 am, that he was on duty during the past weekend and was not made aware of any problems with the walk-in refrigerator. The Immediate Jeopardy was removed on 04/18/2017, prior to the survey exit. The facility discarded all food from the walk-in refrigerator, milk refrigerator, and unit nourishment refrigerators. The facility in-serviced staff on food cold-holding temperatures, monitoring of food temperatures and refrigeration temperatures, and internal reporting procedures for faulty equipment. The facility contracted repairs of the compressor servicing the walk-in refrigerator and returned the walk-in refrigerator to operation with 100% fresh food stock. 10NYCRR415.14(h)

Based on observation, interview and record review during the recertification survey, the facility failed to ensure that essential equipment was maintained in safe operating condition to prevent potential harm to residents from food borne illness. Specifically, the facility's malfunctioning walk-in refrigerator was not effectively repaired in a timely manner to ensure that potentially hazardous foods (PHF) or temperature control for safety (TCS) foods were stored at 41 degrees Fahrenheit (F) or less, in accordance with professional standards for food service safety, to prevent the potential for development of food borne illness. For a period of 5 days, from 04/13/2017 to 04/17/2017, the walk-in refrigerator temperatures ranged between 44 F to 50 F. Multiple food items were stored during that time period and available for use, including ham found to be 58 F and pureed vegetables found to be 58 F. This resulted in immediate jeopardy potentially affecting all 107 residents of the facility. This is evidenced by: The findings are: Cross References: F371 - Food Procurement, Storage, Preparation and Serving Food = L F490 - Effective Administration / Resident Well-Being = L During the initial tour of the main kitchen on 04/17/2017 at 8:00 am, ham was found to be 58 F, pureed vegetables were found to be 58 F, and cartons of milk were found to be 57 F. The temperature log for the walk-in refrigerator was reviewed on 04/17/2017. The log documented refrigerator temperatures of between 45-50 degrees Fahrenheit from 04/10/2017 through 04/17/2017 (acceptable temperature is 41 degrees Fahrenheit or below). The Maintenance Department work orders were reviewed on 04/17/2017. The work orders dated 04/12/2017 and 03/27/2017, documented that the walk-in freezer is running at a high temperature. The work order dated 04/10/2017 states that the cooler at Dietary 141 Rock is running at 60 F. The work order dated 03/06/2017, asks that the refrigerator coils and air curtains be cleaned. During an interview conducted on 04/17/2017 at 8:00 am, the Food Service Director stated that over the last several weeks the walk-in cooler temperatures were fluctuating above the 30's and on 04/10/2017, the walk-in refrigerator coils were icing up requiring maintenance. Beginning last Monday, April 10, 2017, temperatures in the walk-in refrigerator were increasing above the 30's. Over the past weekend experienced staff were in charge when the walk-in refrigerator temperatures spiked. The persons in charge should have notified the Food Service Director, the Administrator, and the Maintenance Department via a work order to repair the walk-in cooler. The Director of Plant Operations stated in an interview conducted on 04/17/2017 at 9:00 am, that when called on 03/29/2017, he believed the walk-in refrigerator wasn't maintaining temperatures from staff not closing the door; he thought a work order dated 04/10/2017, was for another building on the campus; and he was not aware of any temperature problems with the walk-in refrigerator from the previous weekend. The Administrator stated in an interview conducted on 04/17/2017 at 9:27 am, that the proper procedure is for the kitchen staff to submit a work order with the Maintenance Department when refrigeration problems arise. Maintenance Employee #1 stated in an interview conducted on 04/17/2017 at 9:27 am, that he was on duty during the past weekend and was not made aware of any problems with the walk-in refrigerator. 10NYCRR415.5(e)(1)(2)

Based on record review and interview conducted during the recertification survey, the facility failed to provide operative oversight to ensure that an effective system was in place to communicate malfunction of equipment essential to maintain health, safety and the highest practicable well-being of residents. Food service and maintenance staff did not report to the administrator that the kitchen walk-in refrigerator was malfunctioning and was not effectively repaired in a timely manner to ensure that potentially hazardous foods (PHF) and temperature control for safety (TCS) foods were stored at 41 degrees Fahrenheit (F) or less, in accordance with professional standards for food service safety, to prevent the potential for development of food borne illness. This resulted in immediate jeopardy potentially affecting all the residents of the facility. This is evidenced by: The findings are: Cross References: F371 - Food Procurement, Storage, Preparation and Serving Food = L F465 - Essential Equipment = L During the initial tour of the main kitchen on 07/18/2017 at 8:00 am, ham was found to be 58 F, pureed vegetables were found to be 58 F, and cartons of milk were found to be 57 F. The temperature log for the walk-in refrigerator was reviewed on 04/17/2017. The log documented refrigerator temperatures of between 45-50 degrees Fahrenheit from 04/10/2017 through 04/17/2017 (acceptable temperature is 41 degrees Fahrenheit or below). The Maintenance Department work orders were reviewed on 04/17/2017. The work orders dated 04/12/2017 and 03/27/2017. stated that the walk-in freezer is running at a high temperature. The work order dated 04/10/2017, documents that the cooler at Dietary 141 Rock is running at 60 F. The work order dated 03/06/2017, asks that the refrigerator coils and air curtains be cleaned. During an interview conducted on 04/17/2017 at 8:00 am, the Food Service Director stated that over the last several weeks the walk-in refrigerator temperatures were fluctuating and on 04/10/2017 the walk-in refrigerator coils were icing up requiring maintenance. Over the past weekend, experienced staff were in charge when the walk-in refrigerator temperatures spiked. The persons in charge should have notified the Food Service Director, the Administrator, and the Maintenance Department via a work order to repair the walk-in refrigerator. The Director of Plant Operations stated in an interview conducted on 04/17/2017 at 9:00 am, that when called on 03/29/2017, he believed the walk-in refrigerator wasn't maintaining temperatures from staff not closing the door; he thought a work order dated 04/10/2017, was for another building on the campus; and he was not aware of any temperature problems with the walk-in refrigerator from the previous weekend. The Administrator stated in an interview conducted on 04/17/2017 at 9:27 am, that she was not aware of issues with the walk-in refrigerator, maintenance staff are always on call regardless of any particular day, and that the proper procedure would have been for the kitchen staff to submit a work order with the Maintenance Department. Maintenance Employee #1 stated in an interview conducted on 04/17/2017 at 9:27 am, that he was on duty during the past weekend and was not made aware of any problems with the walk-in refrigerator. 10NYCRR415.26

Based on record review and staff interview during an abbreviated survey (Case # NY 348) the facility did not ensure that a resident with pressure sores received the necessary treatment and services to promote healing, prevent infection and prevent new pressure sores from developing for one (Resident #21) of three residents reviewed. Specifically, the facility did not ensure Resident #21's open area on the sacrum, documented as shearing (an applied force or pressure exerted against the surface and layers of the skin resulting in tissue injury) on the date of admission 7/23/15, did not worsen into an avoidable Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle ). Also, the facility did not ensure that it accurately and consistently assessed the open area on the resident's sacrum upon admission or thereafter until 8/11/15, did not implement or revise interventions as appropriate, did not provide care and treatment to the existing wound to minimize infection and to promote healing, did not notify the physician of changes in the wound, and did not implement preventative interventions in accordance with the resident's needs and current standards of practice from 7/23/15 through 8/11/15. This was evidenced by: The facility's Policy and Procedure (P&P) entitled Pressure Ulcer Prevention, Assessment and Treatment revised 7/2013, documented that the Registered Nurse's (RN's) responsibilities were to assess and document the resident's skin conditions and treatments, establish and update the care plan, implement and update as changes in care treatment occur, assess area weekly on wound rounds or as needed, initiate the Weekly Pressure Ulcer Flow Sheet, and complete the Pressure Ulcer Notification Form and forward to applicable departments including the Director of Nursing (DON), Dietary, Therapy, Unit Manager, Wound Care Nurse. It was also documented on the P&P that upon discovery of a new pressure ulcer, the RN on duty would be responsible for initiating the Physician Notification form. The P&P also documented that if the Braden scale score (a scoring system used to evaluate a patients risk of developing a pressure ulcer with the highest score of 23 indicating no risk and lowest score of 6 indicating severe risk) was less than 18, in addition to the prevention modalities being instituted on an individual basis, the resident will be evaluated for an individualized turning and positioning schedule. Resident #21 Note: All pressure ulcer locations referred to as coccyx, sacral or buttocks are referring to the same pressure ulcer. The resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 11 out of 15, indicating moderate cognitive impairment. Additionally, the hospital Discharge Summary dated 7/23/15, documented the resident received 10 doses of [MEDICAL CONDITION] treatment to his lower back. The [MEDICAL CONDITION] Treatment Summary dated 7/17/15, documented the resident recently completed a course of [MEDICAL CONDITION] therapy for metastatic disease involving L4 (fourth lumbar vertebra), with treatment dates from 7/3/15 to 7/15/15. The hospital Clinical Notes report dated 7/22/15 at 2:02 am, documented a Stage II (partial thickness loss of dermis (skin) as a shallow open ulcer with a red pink wound bed without slough) on the (resident's) buttocks. The Comments section of the facility's Integumentary System (Admission) (skin assessment) form and a Nursing Progress Note dated 7/23/15, documented shearing on coccyx area by the Registered Nurse (RN). There was no documented evidence of a description or an assessment of the shearing on coccyx area. The facility's Predicting Pressure Ulcer Risk form dated 7/23/15, documented a Braden Scale score of 16 (at risk). A physician's orders [REDACTED]. A Comprehensive Care Plan (CCP) entitled Impairment of Skin Integrity dated 7/23/15, documented that the resident was admitted with excoriation (a scratch or abrasion of the skin) to coccyx and barrier cream was initiated. There was no documented evidence on the CCP of the treatment for [REDACTED]. A pressure reducing mattress and a low air loss mattress were indicated as an action/approach on the Impairment of Skin Integrity CCP dated 7/23/15. These interventions were not included on the resident's Care Cards dated 7/23/15 and 8/19/15. Further record review revealed that a low air mattress was not ordered by the physician until 8/12/15. The Impairment of Skin Integrity CCP dated 7/23/15, did not include documented evidence of an intervention for repositioning this resident who was assessed as at risk for pressure ulcers, non ambulatory, and as requiring the assistance of two people for bed mobility. The Impairment of Skin Integrity CCP dated 7/23/15, included an action/approach to monitor and report status of impairment and provide updates as needed. There was no documented evidence on the CCP from 7/24/15 to 8/24/15 indicating the pressure ulcer on the resident's sacral area was being monitored. A resident Care Card (instructions for resident care) dated 7/23/15, documented the resident was non ambulatory, required a Hoyer lift with two Certified Nursing Assistant's (CNAs) for transfer, and a two person assist for bed mobility. The Care Card under Bed Positioning included areas to check for the use of pressure relief mattress and low air loss mattress. There was no documented evidence of a check on the Care Card indicating these interventions were in use. The Treatment Administration Record (TAR) documented a treatment beginning 7/24/15 through 8/10/15 to cleanse the coccyx area with normal saline and apply [MEDICATION NAME] every 3 days and prn. The Initial Nutrition assessment dated [DATE], documented the resident's skin was intact. A Weekly Bath and Skin Report dated 7/29/15, included documentation by a nurse, that the resident had no skin issues. A Weekly Bath and Skin Report dated 8/5/15, documented coccyx under open areas, along with an X. Instructions on the back of the form instruct the LPN to place a check mark under any skin condition that applied, even if it has been identified in the past. In addition, the LPN was to record abnormal skin conditions on an anatomical picture. There was a circled area on the coccyx of the anatomical picture along with the documentation of open area. Under Action Taken, cont was written. There was no documented evidence in the Nursing Notes regarding the findings of the weekly skin check and the facility could not provide any wound tracking documentation regarding the open area on the resident's coccyx. This finding was not documented on the CCP. There is also no documented evidence that the MD and the family were notified. A CCP dated 8/5/15, entitled At Risk for Skin Impairment, documented; resident at risk for skin breakdown secondary to debility, weakness. The CCP documented pressure reducing devices in place. There were no further updates on this CCP. A Nursing Note dated 8/11/15 at 10:00 pm, documented there was a large amount of foul drainage coming from the sacral wound with increased [DIAGNOSES REDACTED] (redness), the MD evaluated the resident, changed the treatment of [REDACTED]. No new updates or interventions related to the changes in the sacral wound were documented on the CCP. A Physician's note dated 8/11/15, documented sacral decubitus needs debridement (the removal of devitalized/necrotic tissue and foreign matter from a wound to improve the healing process), start Keflex (antibiotic). A physician's orders [REDACTED]. A Treatment Record for August 2015, documented a new treatment on 8/11/15, to cleanse the coccyx with normal saline and apply Santyl daily and prn. A Weekly Pressure Ulcer Flow Sheet dated 8/12/15, documented the MD was notified on 8/12/15 of a Stage II pressure ulcer on the resident's coccyx that measured 7.5 cm (centimeter) x 7.0 cm x 0.1 cm, moderate amount of serosanguinous (discharge of blood and serum drainage), no odor, 25% slough (devitalized tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist and sometimes stringy), 50% eschar, 25% pink wound bed, and no tunneling (passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound), undermined edges (edges with erosion underneath, resulting in a larger wound with a small opening), and no pain. However, the Stage Definitions printed on the back of the flow sheet documented that for a Stage II pressure ulcer, the ulcer is superficial, and slough is not present. Dietary supplements documented included vitamin therapy, high protein supplement, and Prostat (a high protein liquid supplement). An air mattress was documented under Preventive equipment. The facility was unable to provide wound tracking documentation for the shearing/open area on the resident's sacrum from 7/23/15 to 8/11/15. A Nursing Note dated 8/12/15 at 8:00 am, documented an assessment of the wound during wound rounds, noted that the writer was notified of the wound today by the Licensed Practical Nurse (LPN), documented to continue to monitor, and noted that the resident was on antibiotics. A Nursing Note dated 8/12/15 (time not legible) entered by the LPN, noted a late entry for 8/8/15, documented that a wound was noted with a dark purple center approximately 3 cm x 4 cm, and noted that the Supervisor was notified for evaluation of decline. Review of the 24-Hour Report dated 8/8/15, revealed no documentation of the changes to the resident's wound. A statement from the Registered Nurse (RN) Supervisor dated 10/10/15, documented that she did not recall the LPN telling her about the wound. There was no documented evidence that the MD was notified. A Weekly Bath and Skin Report dated 8/12/15, documented X under Open Areas and documented see below under Action Taken. Towards the bottom of the form, there was a circled area on the coccyx of the anatomical picture, along with the documentation of open area. There was no documentation in a Nursing Note regarding the findings during the weekly skin check and the findings were not documented on the CCP. A Physician order [REDACTED].>A Dietary Progress Note dated 8/12/15, documented added Prostat AWC (a high protein supplement for advanced wound care) 1 oz (ounce), TID (three times a day) for 6 weeks due to a worsening Stage II wound. A Physician order [REDACTED]. A Treatment Record dated August 2015, documented a new treatment beginning on 8/13/15 to cleanse coccyx with normal saline, apply Santyl nickel thick, and cover with Calcium Alginate daily and prn. It was documented as being done from 8/13/15 to 8/23/15. A Nursing Note dated 8/15/15 at 11:25 am, documented a new Stage II over spinous process on lower back, and documented will continue with turn & reposition every 2 hours while awake. This intervention was not documented on the CCP, nor was it documented on the Care Card. There was no other documentation about turning and positioning the resident until the Nursing Note on 8/21/15 at 9:38 pm, that documented turning and repositioning every 2 hours was encouraged. A Wound Notification Form submitted by the RN dated 8/15/15, documented a Stage II pressure ulcer over the spine and indicated that the original form was sent to the RN Wound Care Nurse, and copies were sent to Nursing Management and Administration, Dietician, Rehab Department, and the MDS Coordinator. The facility was unable to provide a Wound Notification form dated for the Stage II pressure ulcer located on the resident's sacrum on 8/11/15. A Weekly Pressure Ulcer Flow Sheet dated 8/15/15, documented the discovery of a new Stage II pressure ulcer on the resident's spine on the middle of the resident's back. There were no measurements documented on the flow sheet, and the depth was documented as sup. There was no documented evidence of an update on the CCP, after an assessment was done of the Stage II pressure ulcer located on the mid-back over the spine. A Physician order [REDACTED]. A Treatment Record dated August 2015, documented a new treatment beginning on 8/15/15 to cleanse the Stage II on the lower back over the spine with normal saline, and apply [MEDICATION NAME] dressing every 3 days and prn. A Dietary Progress Note dated 8/18/15, documented a Stage II now over the spine, will continue to follow. On 8/18/15, an assessment of the coccyx wound on the Weekly Pressure Ulcer Flow Sheet documented that the wound was a Stage II and measured 0.7 cm x 0.7 cm x 0.1, a large amount of green serosanguinous drainage, 50% slough, no eschar, 50% pink wound bed, and that the wound was improving. The Stage Definitions printed on the back of the flow sheet documented that for a Stage II pressure ulcer, the ulcer is superficial, and slough is not present. On 8/18/15, an assessment of the mid-back over the spine wound on the Weekly Pressure Ulcer Flow Sheet documented that the wound was a Stage II and measured 1.0 x 0.5 x 0.1 cm. On the Weekly Bath and Skin Report dated 8/19/15, there was no documention regarding the condition of the resident's skin. The Impairment of Skin Integrity CCP update dated 8/19/15, documented Keflex (antibiotic) was in place per Medical Doctor (MD) order and continue to follow by wound nurse. The location of the pressure ulcer was not documented. A resident Care Card dated 8/19/15, documented the resident required a Hoyer lift with two CNAs for transfer, was non ambulatory, and that the resident required a 2 person assist for bed mobility. The Care Card under Bed Positioning included areas to check for the use of apressure relief mattress and low air loss mattress. There was no documented evidence on the Care Card indicating these interventions were in use. On 8/24/15, an assessment of the coccyx wound on the Weekly Pressure Ulcer Flow Sheet documented the wound was now a Stage III pressure ulcer (full thickness tissue loss) and measured 7.6 cm x 6.0 cm x 0.8 cm, large amount of green drainage, odor noted, 35% slough, 15% eschar, 50% pink wound bed, 1.0 cm tunneling, and that the wound was deteriorating. A SBAR (Situation Background Assessment Recommendation) Communication Form (used to facilitate, prompt and appropriate communication) dated 8/24/15, documented the change in condition as wound odor and deterioration. A Physician order [REDACTED]. A Nursing Progress Note dated 8/24/15 at 11:50 am, documented that per MD, send resident to the ED for wound evaluation and treatment. A Nursing Note dated 8/24/15 at 12:00 pm, documented the resident had a low grade fever of 100.8. The hospital History Physical Exam dated 8/24/15, documented a Stage IV ( full thickness tissue loss with exposed bone, tendon, or muscle. It was noted that slough or eschar (thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue that may be loose or firmly adhered to the wound) may be present on some parts of the wound bed, often includes tunneling and undermining, and a decubitus ulcer and [MEDICAL CONDITION] in the resident's sacrum. It also documented, presents with fever likely secondary to [MEDICAL CONDITION] around the sacral decubitus ulcer. During an interview on 10/7/15 at 11:00 am with the RN Nurse Manager (RN-NM), she stated that she did not recall what the resident's skin issues were when the resident came into the facility, she thought that they were just using barrier cream. She stated that she knew he had an air mattress. After reviewing the CCP for Impairment of Skin Integrity, the RN-NM stated that she initiated the CCP, but could not identify where the Stage II pressure ulcers were located and could not determine how they were progressing. She stated that the changes to the wounds should have been updated on the CCP, but she had not been able to update the CCP because of the staffing changes in the facility. During an interview on 10/7/15 at 11:25 am with the DON, she stated that when an area is identified on the resident's skin at the time of admission, an assessment and a wound tracking sheet should be initiated. The DON stated that the RN who was doing the wound tracking no longer worked at the facility. The DON stated that she was not hired until September 2015. The DON stated that she would consider shearing to be a Stage II and would treat it accordingly. A statement from the RN Supervisor dated 10/10/15, documented that she did not recall the LPN telling her about an open area on the resident on 8/8/15. She stated that if she was alerted to an area that needed to be assessed, she would assess the wound, take measurements, write a note, call the MD for an order, complete the wound/skin care paperwork per facility protocol, and would alert the team; Dietary, Rehab, DON, Unit Manager, and Wound Care Nurse. She stated that after getting an order from the MD, she would initiate a treatment for [REDACTED]. During an interview on 10/19/15 at 12:55 pm, the LPN stated that the resident had an area on his bottom that they were treating since the time of admission. When asked what type of wound was being treated, the LPN stated that although she could not assess the wound, the resident's skin was not intact. She stated that the RN Supervisor who assessed the resident's skin assessed it as shearing and stated that the RN no longer worked at the facility. The LPN stated that there was a change in the area on the resident's coccyx on 8/8/15 and stated that she told the RN Supervisor, who was engaged in something at the time. The LPN stated that she did not write a note about it until 8/12/15, when it occurred to her that she had not written a note. When asked why the changes to the wound were not indicated on the 24 Hour Report, the LPN stated that the Supervisor would have written it on the report. She stated that she had the MD look at the resident while he was in the facility on 8/11/15 because it was markedly worse than it was. The LPN stated that because the resident came into the facility with the wound, she assumed that it was being followed on wound rounds. During an interview on 10/28/15 at 2:40 pm, the MD stated that he did not recall what the resident's sacral area looked like when he was first admitted to the facility. He stated that he usually looked at the wound and then would look at the documentation by the admitting nurse before he ordered a treatment. The MD stated that the resident was very weak and was not ambulatory. He stated that he suspected, given the resident's condition, that the resident needed a lot of perineal care (personal hygiene). He stated that in just the daily care alone, there were so many opportunities to see that the wound was getting worse. The MD stated that he did not recall being called about the open area to the resident's coccyx area on 8/5/15, the changes on 8/8/15, nor does he recall being notified about the Stage II on the resident's mid-back, on the spine on 8/15/15. The MD stated that he would expect the nurses to assess and monitor wounds and at the very least there should be some sort of chronicling about the wound. He stated that usually new wounds were brought to his attention and he looked at them. 10 NYCRR 415.12(c)(1)

Based on medical record review and interviews during a partial extended abbreviated survey (Case #NY 620) it was determined that the Administration failed to ensure that the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, for one (Resident #1) of two reviewed the Administration failed to ensure that allegations of abuse were fully investigated; that residents were protected from abuse while investigations were being conducted; an injury (fracture) of unknown origin was reported to the appropriate agency and failed to implement timely interventions to ensure that residents received appropriate treatment. This has the potential to affect all residents in the facility. This resulted in no actual harm but had the potential for more than serious harm that is Immediate Jeopardy. Refer to F225- Abuse- scope and severity-L During an interview on 9/20/13 the Director of Nurses (DON) stated that she had been informed on 9/4/13 that Resident # 1 had complained of leg/foot pain on the evening shift on 9/3/13 and the doctor had been notified and ordered an x-ray which had not yet been done. The resident had reported to staff that she had fallen in the bathroom earlier on 9/3/13 and three staff members had picked her up off the floor and she had leg pain after that. The registered nurse supervisor (RNS) working evenings on 9/3/13 had started to collect statements from the staff on duty regarding the resident's allegation and no one on staff had admitted to picking the resident up after a fall. The DON did not believe that any staff member would have picked the resident up off the floor and not reported it. The DON stated she did not report the resident's fracture of unknown origin to the New YorkState Department of Health (NYSDOH) because it had not been caused by abuse or mistreatment. The DON admitted she did not know how the fracture had occurred. The DON stated that she did not have statements from every staff member that worked the day and evening shift on 9/3/13 and had not interviewed staff on duty on 9/3/13 but had read some of their statements. She had not written a conclusion to her investigation of the incident because she only wrote up conclusions if she determined it was a reportable incident and she did not believe this situation was reportable. The DON went on to explain that in the afternoon on 9/19/13 she had been visited by a detective from the local police department and informed that an allegation of abuse had been made against an evening nursing supervisor (RNS) and an evening shift certified nursing assistant (CNA#2) as they provided care for Resident # 1. The police detective reported that a complainant had reported that as two staff members were preparing Resident # 1 for transport to the hospital for treatment of [REDACTED]. The DON stated that the detective used the term "abuse" in describing the way the resident had been handled. The DON stated that she had explained to the detective that Resident #1 was mean, very difficult to deal with and frequently combative with staff. She further explained to the detective that the staff members were probably trying to wash the resident up before sending her out to the ED (emergency department) because if the resident arrived at the hospital soiled, hospital personnel would report the facility to the NYSDOH. The DON stated that she had not started an abuse investigation after hearing of the allegation from the detective because the resident was probably kicking and hitting staff because she is combative especially during personal care. The DON stated that on 9/19/13 right after the detective left the building, both the RNS and CNA #2 had come in to work the evening shift, but she had not interviewed them concerning the allegations of abuse, nor had she taken statements from them at that time. The DON recalled that later in the afternoon on 9/19/13, at approximately 5:15pm, she first informed the facility administrator (FA) during a phone conversation, that the detective had been in and advised her of an allegation of abuse regarding the two employees. The DON stated she did not receive any instruction from the FA at that time and was not instructed to start an abuse investigation. During an interview on 10/22/13 at approximately 1:00pm, the facility Administrator (FA) stated that she had been informed that Resident # 1 had complained of leg pain in the evening on 9/3/13 and an x-ray had been ordered. The FA recalled speaking with the resident that morning (9/4/13) but could not recall what she and the resident discussed. The FA agreed that Resident # 1 could be a target for abuse because she could be difficult and combative at times. The FA recalled that statements had been obtained from staff members regarding the residents fracture after it was diagnosed but she could not recall reading the statements or that the statements only addressed whether or not the individual writing the statement had picked the resident up off of the floor on 9/3/13. The FA stated that she was unaware that after a local police officer had reported to the DON on 9/19/13 that an accusation of resident abuse had been made against the RNS and an evening shift CNA, that the accused staff was not interviewed and that there were no statements taken from staff members. The FA stated that perhaps the DON did not take staff statements or conduct interviews because the police officer did not determine during his visit, that abuse had occurred. The FA stated that there should have been a facility investigation into the allegation of abuse and the DON should have taken statements and conducted interviews and should have reported the residents fracture to the NYSDOH. 10NYCRR 415.26

Based on staff interviews and medical records review during a partial extended abbreviated survey (Case # NY 620), it was determined the facility failed to have evidence that all allegations of abuse were thoroughly investigated, failed to ensure that all alleged violations involving mistreatment, neglect, or abuse were reported immediately to the administrator of the facility and to other officials in accordance with State law for one (Resident #1) of two residents reviewed for investigations. Specifically, after Resident #1 was found to have a fracture of unknown origin, a complete investigation was not conducted; and did not report alleged abuse to officials in accordance with State law. After a report of possible resident abuse was brought to the attention of the Director of Nursing (DON) by the local police department, the facility administrator was not immediately notified; an investigation was not initiated and the accused employees were not removed from resident care pending the outcome of an investigation. This has the potential to effect all the residents in the facility. This resulted in no actual harm with the potential for more than serious harm that is Immediate Jeopardy to the health and safety of the residents and Substandard Quality of Care. This is evidenced by the following: Resident # 1 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS)dated 7/9/13 assessed the resident was cognitively intact. The facility's policy and procedure for Resident Abuse, Neglect, or Mistreatment dated as revised 1/26/13 documented under " Reasonable Cause", the presence of a physical condition at variance with the history or course of treatment of [REDACTED]. At the conclusion of the interview the employee will be notified that they will be suspended from their duties until the investigation is complete. Failure to follow a care plan must be reported if one or both of the following have occurred: There are repeated failures by staff to follow a care plan and resident harm has occurred. The policy documented that alleged abuse will be investigated fully. The procedure documented that the investigation should include interviewing all staff members directly related to the incident who are assigned to that unit. The investigation should beginby interviewing employees/visitors/persons having knowledge/contact 24 hours prior and eight hours after the incident. There was no documented evidence that a thorough investigation was done and that the employee involved were removed from direct resident care. During an interview on 9/23/13 at approximately 2:00 pm, a certified nursing assistant (CNA#1) stated that on 9/3/13, she gave Resident # 1 a shower in the shower-room in the hallway at approximately 10:00am. CNA #1 described Resident #1 as being cooperative at the beginning of the shower but toward the end became combative and was pushing her foot (at the ball of her foot) against the wall of the shower room. After the shower, CNA #1 returned the resident to her room and transferred her to a chair and the resident made no complaints of pain at that time. CNA # 1 reported to the licensed practical nurse (LPN#1) that the resident had been combative during the shower and was pushing her foot against the wall in the shower room. Sometime after lunch, CNA#1 placed the resident back to bed and again, the resident made no complaints of pain at that time. CNA # 1 stated that it was not unusual for the resident to be combative but she did not usually complain of pain. There was no documented evidence this incident occurred. A physicians order sheet dated 9/3/13 at 6:30 pm revealed an order to X-ray the resident's right ankle. The X-ray showed the ankle was fractured with [MEDICAL CONDITION]. During an interview on 9/20/13 at approximately 10:00 am, a registered nurse unit manager (RNUM) stated that she had been made aware at the beginning of her shift on 9/4/13, that Resident # 1 had started complaining of leg or ankle pain during the evening on 9/3/13 and that an x-ray of the resident's leg had been ordered. The RNUM stated that during the evening on 9/3/13, the evening supervisor documented on the supervisor's report that she had gotten written statements from some of the staff on-duty after Resident #1 reported that her leg pain was caused when she had fallen in the bathroom and three staff members had picked her up. After hearing that the RNS had obtained statements from the 9/3/13 evening staff, the RNUM continued to collect statements from the 9/3/13 day staff. The RNUM could not recall who she had taken statements from but thought it was from most of the staff that had worked days on 9/3/13. She did not interview any of the staff after taking their statements but thought the DON might have done some interviews during her investigation. During an interview on 9/20/13 the DON stated that she had been informed during morning report on 9/4/13 that Resident # 1 had complained of leg/foot pain on the evening shift on 9/3/13 and the doctor had been notified and ordered an x-ray which had not yet been done. The resident had reported to staff that she had fallen in the bathroom earlier on 9/3/13 and three staff members had picked her up off the floor and she had leg pain after that. The registered nurse supervisor (RNS) working evenings on 9/3/13 had started to collect statements from the staff on duty regarding the resident's allegation. The DON stated that no one on staff had admitted to picking the resident up after a fall and she did not believe that any staff member would have picked the resident up and not report it to someone. The DON added that, she did not report the resident's fracture of unknown origin to the New York State Department of Health (NYSDOH) because it had not been caused by abuse or mistreatment, even though she did not know how it occurred. The DON stated that she did not have statements from every staff member that worked the day and evening shift on 9/3/13 and had not interviewed staff on duty on 9/3/13 but had read some of their statements. She had not written a conclusion to her investigation of the incident because she only wrote up conclusions if she determined it was a reportable incident and she did not believe this situation was reportable. The DON went on to explain that in the early afternoon on 9/19/13 she had been visited by a detective from the local police department and informed that an allegation of abuse had been made against an evening nursing supervisor (RNS) and an evening shift certified nursing assistant (CNA#2) as they provided care for Resident # 1. The police detective reported that a complainant had reported that as two staff members were preparing Resident # 1 for transport to the hospital for treatment of [REDACTED]. The DON stated that the detective used the term "abuse" in describing the way the resident had been handled. The DON stated that she had explained to the detective that Resident #1 was mean, very difficult to deal with and frequently combative with staff. She further explained to the detective that the staff members were probably trying to wash the resident up before sending her out to the ED (emergency department) because if the resident arrived at the hospital soiled, hospital personnel would report the facility to the NYSDOH. The DON stated that she had not started an abuse investigation after hearing of the allegation from the detective, because the resident was probably kicking and hitting staff because she is combative, especially during personal care. The DON stated that on 9/19/13, right after the detective left the building, both the RNS and CNA #2 had come in to work the evening shift, but she had not interviewed them concerning the allegations of abuse nor had she taken statements from them at that time. The DON recalled that later in the afternoon on 9/19/13, at approximately 5:15pm, she first informed the facility Administrator (FA) during a phone conversation, that the detective had been in and advised her of an allegation of abuse regarding the two employees. The DON stated she did not receive any instruction from the FA at that time and was not instructed to start an abuse investigation. There was no documented evidence of an investigation after an allegation of abuse was reported by the local police department detective. During an interview on 9/20/13 at approximately 4:30pm, the registered nurse supervisor (RNS) stated that on 9/3/13 she was called to the resident dining room and asked to look at Resident # 1 who was complaining of pain in her foot/ankle. The RNS stated that on assessment, the resident's leg was not bruised and there was good range of motion but the leg was slightly swollen and it was sensitive to touch. When questioned, Resident #1 told the RNS that the pain started after she had fallen in the bathroom. The RNS called the on-call physician (MD#1), who instructed the RNS to get an x-ray of the resident's ankle. The RNS stated that she could not recall if she discussed with MD#1 if the x-ray should be done that evening or the next day and she did not recall if she told the x-ray people to come that evening or the next day. The RNS stated that she was told the next evening (9/4/13) sometime after arriving at work, that Resident #1 had a fracture. The RNS then called an ambulance who arrived soon after, to transport the resident to the local ED. The RNS recalled that when the emergency medical technicians (EMT's ) arrived she was assisting a certified nursing assistant (CNA#2) who was preparing Resident#1 for transport, after the resident had been incontinent of bowel. The RNS stated the EMT's instantly got an attitude because they were asked to wait until the resident was cleaned up. The RNS stated that as they were cleaning the resident, she was screaming and yelling and calling them names and trying to grab at them (the RNS and CNA#2). The RNS explained that she and CNA#2 were rolling the resident side to side and handling the resident only by her hips and not touching her legs and the resident was "screaming bloody murder and verbalizing, 'Leave me alone you [***] ." The RNS stated that the male EMT was definitely "having an attitude" then said to the RNS and CNA#2, "you're being awfully rough with her, and she's got a broken leg. She's in pain" The RNS asked the EMT's if they wanted to take the resident the way she was and one of them said they would. The RNS told CNA#2 to leave the resident the way she was and the RNS and CNA#2 then stepped back and let the EMT's take over. The RNS stated the EMT's wrapped a pillow around the resident's lower leg to use as a splint and then the male EMT took the resident's leg and was raising it up and down in the air and moving it around and causing the resident pain. The RNS stated she did not know why the EMT was moving the residents leg that way. The RNS stated that after seeing this, she then said to the male EMT, "You talk about being rough. Maybe I should make a phone call to someone, about you." The EMT's then took the resident by stretcher, to the ambulance. The RNS stated that she did not report the EMT's actions to anyone or write anything down about the EMT's actions. The RNS stated that she and CNA#2 were trying to do a "good job" preparing the resident for transport to the ED and that perhaps she had upset the EMT. During an interview on 9/20/13 at approximately 5:15 pm, a certified nursing assistant (CNA#2) stated that on 9/3/13 at approximately 2:50 pm, she was just arriving on the unit at the start of her shift and saw that Resident # 1's call-light was ringing. As she entered the bathroom, the resident requested assistance to get off the toilet. CNA #2 along with a second CNA who had also come to answer the call-light, assisted the resident to a standing position, pulled up her pants and helped her to sit in the wheelchair. Throughout the transfer, the resident never complained of any ankle or leg pain. CNA#2 was sure of the time this transfer took place, because recalled that she still wearing her jacket and carrying her bag from home. Later in the shift at around 5:15 pm, CNA#2 was approached by a visitor who reported that Resident #1 was in the dining room, crying with pain in her foot and saying that her foot was broken. When CNA #2 arrived in the dining room, she found the resident crying and complaining of pain and stating that her foot was broken. The resident had removed her own sock and as CNA #2 looked at the resident's foot, she did not think it looked swollen but recalled that the resident was in so much pain that she was unable to eat dinner and had repeated several times that she thought her foot was broken. CNA #2 thought the resident must have had a lot of pain at the time because the resident did not normally complain of pain and a second CNA was sent to get the nurse. CNA #2 continued helping other resident's with dinner while the nurses tended to Resident #1. Resident #1 was in so much pain that when it was time for her to go back to bed, CNA#2 asked for help with the transfer, so that the resident did not have to put any weight on her foot. Resident#1 stayed in bed for the rest of the evening and appeared to be sleeping when CNA #2 checked on her later in the shift. CNA # 2 further recalled that the next day, 9/4/13, when she arrived at work Resident # 1 had already had an x-ray done and around dinner time she was told that the resident was going out to the hospital with a broken leg and needed to be cleaned up prior to transport. CNA # 2 said she checked on the resident and saw that she had been incontinent of a large amount of urine and had pulled off her "brief." CNA #2 was sure the resident had been incontinent only of urine and not incontinent of bowel. As CNA #2 stated that as she started to clean the resident up, the evening registered nurse supervisor (RNS) came to assist. CNA # 2 stated that she washed the resident off and while trying to put a clean brief on the resident, rolling her from side to side, the resident was crying out and flailing her arms and yelling. At some point, two EMT's (emergency medical technicians) entered Resident #1's room and one of the EMT's seemed upset with CNA#2 and the RNS for rolling the resident side to side and said to them, you people are rolling her (Resident #1) around and her leg is broken. Do you know that? CNA #2 stated that she understood how the EMT, who was not familiar with the resident and how the resident frequently hits and yells and calls out like she is in pain, would have found it upsetting to have heard the resident yelling out. CNA # 2 added that she and the RNS were not trying to hurt the resident, just trying to get her cleaned up and ready to go to the hospital. CNA#2 added that it was not unusual for the resident to yell out or hit at the staff. CNA # 2 recalled that after the EMT's remark, she and the RNS did not attempt to move the resident again and did not attempt to place the clean brief on the resident but backed away from the bed. The EMT's then prepared to move the resident, using the sheet underneath her, as they always do but CNA#2 did not actually see the resident moved to the stretcher. CNA #2 stated that the EMT's did not splint the resident's leg or move her leg while she and the RNS were in the resident's room and that she and the RNS both left the resident's room together. CNA # 2 stated that she had been on duty the evening before (9/19/13) and had not been interviewed by anyone at the facility regarding preparing Resident #1 for transfer to the ED and was not aware of an allegation of abuse made against her or the RNS until informed by the DOH staff. CNA #2 stated that the DOH investigator was the first person to question her regarding getting Resident # 1 ready for transfer to the hospital ED. During an interview on 9/23/13 at approximately 3:00pm, LPN#1 stated that she worked a double shift on 9/3/13 from 7:00am to 11:00pm and recalled doing a skin check after Resident #1 had been given a shower and not finding any marks or bruises to the skin. LPN#1 recalled being told that the resident was combative during her shower but did not recall being told that she was hitting her foot against the shower room wall. LPN# 1 stated that later in the day, around dinner time, she was asked to look at Resident #1, who she found in the dining room and the resident was crying and complaining of pain in her foot. In a follow up interview on 10/15/13 at approximately 11:00 am, the RNUM stated that after realizing on 9/20/13 that she had not collected statements from all of the staff members on duty on 9/3/13, she had not attempted to collect the additional statements from those that were missing when the statements were reviewed on 9/20/13 by the DOH investigator. There were three missing statements from the 7:00 am-3:00 pm shift. During an interview on 10/22/13 at approximately 1:00pm the FA stated that had she been informed that Resident # 1 had complained of leg pain in the evening on 9/3/13 and an x-ray had been ordered. The FA recalled speaking with Resident #1 that morning (9/4/13) but could not recall what she and the resident discussed. The FA agreed that Resident # 1 could be a target for abuse because she could be difficult and combative at times. The FA recalled that statements had been obtained from staff members regarding the resident's fracture after it was diagnosed but she could not recall reading the statements or that the statements only addressed whether or not the individual writing the statement, had picked the resident up off of the floor on 9/3/13. The FA stated that she was unaware that after a local police officer had reported to the DON on 9/19/13 that an accusation of resident abuse had been made against the RNS and an evening shift CNA, that the accused staff was not interviewed and that there were no statements taken from staff members. The FA stated that perhaps the DON did not take staff statements or conduct interviews because the police officer did not determine during his visit that abuse had occurred. The FA stated that there should have been a facility investigation into the allegation of abuse and the DON should have taken statements and conducted interviews and should have reported the resident's fracture to the NYSDOH. During an interview on 10/22/13 at approximately 2:00pm, Resident # 1 stated that the cast on her leg was for a broken leg that occurred after she had fallen in a bathroom "quite a while ago" and was not able to get up off of the floor by herself. Resident # 1 stated that the bathroom was dark and it was not the bathroom in her room but was "out there somewhere," (The resident pointed toward the corridor as she said that.). Resident # 1 stated that while on the floor she called out for help and three people came into the bathroom to help her up and she had pain in her leg after that and knew her leg must be broken. Resident # 1 did not know who the three people were but knew they "worked in the dining room where they serve the food." The resident did not recall how she had gone to the hospital to have the cast placed but did recall that she had been at a doctors office the day before (10/21/13) and the doctor had not looked at her leg at all but just asked a lot of questions. (A review of Resident # 1's medical record revealed that she was at an appointment with a cardiologist on 10/21/13). 10NYCRR 415.4(b)(l)(ii)

Based on medical record review and staff interviews during a partial extended abbreviated survey (NY 620), the facility did not provide the necessary care and services to attain or maintain the highest practicable physical and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, when Resident # 1 was found in the facility dining room on 9/3/13 at approximately 5:15pm, crying in pain and stating that her ankle was broken, an x-ray of the resident's ankle was not done until the following day ( 9/4/13) at approximately 12:30pm. X-ray results were not obtained until approximately 4:00pm on 9/4/13 and the resident was not sent out to the emergency room for treatment until approximately 5:00pm on 9/4/13. This resulted in actual harm for the resident. This is evidenced by the following: Resident # 1 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessed the resident to be cognitively intact. Nurse's notes dated 9/3/13 and 9/4/13 chronicle the resident's complaints of right ankle pain: at 6:25 pm on 9/3/13 it was documented that Resident #1 complained of right ankle pain stating she fell and three staff members picked her up. The physician (MD) was notified and ordered an x-ray. The resident's right ankle was sensitive to touch and slightly [MEDICAL CONDITION] (swollen). A note written on 9/3/13 at 10:30pm, documented the resident received Tylenol for right ankle pain at 5:50pm. In a note written on 9/4/13 at 7:00am, it was documented that the resident's right ankle remained swollen and tender to the touch. In a note written on 9/4/13 at 12:05pm, the facility administrator (FA) documented the resident's x-ray was being taken at that time. On 9/4/13 at 3:00pm it was documented that the resident complained of ankle pain and was medicated and a purple ecchymotic area, 1.5 X 1.0cm was noted on the right knee. A note written at 5:00pm on 9/4/13 documented that the resident became upset on 9/3/13 while receiving a shower and was kicking and hitting at staff. The resident complained of right ankle pain and x-ray results were obtained documenting that the resident had an acute [MEDICAL CONDITION] fibula (lower leg/ankle). The MD was made aware and ordered to send Resident #1 to the Emergency Department (ED). In an untimed note written on 9/4/13, it noted wrote that the ambulance was called and report was given to the ED staff. A physicians order sheet dated 9/3/13 at 6:30pm revealed an order to X-ray Resident #1's right ankle. An x-ray report dated 9/4/13, not timed, documented that an x-ray of the Resident 1's right ankle done on 9/4/13, showed [MEDICAL CONDITION] and an acute [MEDICAL CONDITION] fibula. During an interview on 10/8/13 at approximately 11:00am, a representative of the mobile imaging company stated that their records revealed that a phone request for an x-ray of Resident # 1's right ankle was received on 9/3/13 at 6:45pm and the x-ray was ordered as "routine," meaning it was not urgent and it could be done sometime within the next 24 hours. The x-ray was completed on 9/4/13 at approximately 1:00pm and results of the x-ray were called to the RNUM on 9/4/13 at 2:15pm. During an interview on 9/19/13 at approximately 3:00pm, an emergency medical technician stated that a call was received at approximately 5:00pm on 9/4/13, to pick up and transport Resident #1 to a local emergency department. During an interview on 9/20/13 at approximately 5:15pm,a certified nursing assistant (CNA#2) stated that on 9/3/13 at approximately 5:15pm, she was approached by a visitor who reported that Resident #1 was in the dining room, crying with pain in her foot and saying her foot was broken. CNA #2 noted that the resident does not usually complain of pain and when CNA#2 arrived in the dining room, she found Resident #1 crying and complaining of ankle/leg pain and stating her foot was broken. The resident had removed her own sock and as CNA #2 looked at the resident's foot, she did not think it looked very swollen but added that the resident was in so much pain that she was unable to eat dinner and the resident repeated again that she thought it was broken. A second CNA was sent to notify the nurse. CNA #2 stated that she continued helping other resident's while the nurses tended to Resident #1 and when it was time to put Resident #1 back to bed, she was in so much pain that even though the resident was a one assist for transfers, CNA #2 asked a second CNA for help with the transfer so the resident did not have to put any weight on her foot. CNA #2 recalled that the resident stayed in bed for the rest of the evening and appeared to be sleeping when she was checked. CNA # 2 recalled that the next day, 9/4/13, when she arrived at work at 3:00pm, Resident #1's x-ray had been completed and she was sent out to the ER around 5:00pm. During an interview on 9/20/13 at approximately 2:30pm, the registered nurse unit manager (RNUM) stated that she did not know why Resident #1's ankle x-ray was not done on the day it was ordered (9/3/13). The RNUM added that the resident's leg was swollen and painful and she would not have waited until the next day but would have requested it to be done "stat." If the x-ray was ordered as a "stat" x-ray, it would have been done within four hours of the time it was ordered. The RNUM stated that she did not receive a call from the x-ray company with results at 2:15pm on 9/4/13. She stated that on 9/4/13 around 4:00pm, she called the x-ray company to inquire if the results of the resident's x-ray were available because no one had called her with the x-ray results. The RNUM recalled that after she spoke to the x-ray people and received a fax with the x-ray results at around 4:00pm, she contacted the physician and requested an order to send the resident to the ED. During an interview on 9/20/13 at approximately 4:30pm, the registered nurse evening supervisor (RNS) stated that on 9/3/13 she was called to the unit around 5:00 or 6:00pm and asked to look at Resident #1's ankle. The RNS stated the resident's ankle was swollen and very sensitive to the touch. The resident said she had fallen in the bathroom and three staff members had picked her up of the floor. The RNS called the MD and asked for an order to x-ray the ankle. The RNS stated she could not recall if she told the x-ray people to come that night or to come the next day and she could not remember if she discussed with the doctor, when the x-ray should be done. During an interview on 10/22/13 at approximately 2:00pm, Resident # 1's MD stated that he recalled receiving a phone call from a nurse informing him that Resident # 1 was having significant pain and some swelling in her ankle or foot. MD #1 was unsure of the date but stated that he gave the nurse an order for [REDACTED]. During an interview on 9/20/13 at 5:15pm, the facility Director of Nursing (DON) stated that she was concerned but not surprised that an order for [REDACTED]. If the x-ray was ordered as routine, it would be done within twenty-four hours. If the x-ray company could not accommodate this schedule, the option was to send the resident to the emergency department (ED). 10 NYCRR 415.12

Based on observation, staff interview, and medical record review the facility did not ensure that the residents' environment remained as free of accidents as is possible, and that each resident received adequate supervision to prevent accidents for one ( 114) of four residents' reviewed during a the standard recertification survey and a complaint investigation (Case #NY 686). Specifically, the resident was not reassessed for elopement risk timely or accurately after numerous verbalizations and attempts to leave the building, therefore no interventions were put into place to prevent unsafe wandering. On 5/21/11 a family member not being able to locate the resident during a visit resulted in the staff conducting a unit search. The resident was found on the grounds outside of the facility at the foot of a hill area leading to a parking lot. During the search it was discovered that the alarm on an exit door leading outside to a parking lot had been deactivated and was left unattended. Resident #114 required an emergency room visit for a laceration to the elbow that required sutures,this was actual harm that is not immediate jeopardy. This is evidenced by the following: Resident # 114 A family member was not able to locate the resident during a visit which resulted in the staff conducting a unit search. The resident was found on the grounds outside the facility at the foot of a hill area leading to a parking lot. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident with long and short term memory loss, able to understand, and able to be understood. The MDS further documented the residents' locomotion on and off the unit as requiring supervision with the primary mode of transportation as a wheel chair (w/c). The Comprehensive Care Plan ( CCP) titled Falls, dated 2/3/11, documented the resident had a history of [REDACTED]. There was no documentation found to indicate when the 15 minute checks were initiated. The CCP titled Wandering/Elopement, dated 5/21/11 at the time of the elopement, documented the problem as "actual". Documented under the approach column was to "place a wanderguard" with a handwritten notation in parenthesis "in place". Documented on the back of the CCP under evaluation, dated 5/22/11, included a handwritten note "resident went outside unattended, fell out of w/c and injured right elbow. Continues on 15 minute checks". The Certified Nursing Assistance (CNA) Accountability sheets (directs the care the CNA provides) dated 3/11 and 4/11 did not include an entry instructing the CNA to complete 15 minute checks. An undated CNA Accountability sheet did not include an entry for 15 minute checks or that a wanderguard was issued on 5/21/11. On 5/25/11 at 8:30 am and at 3:40 pm, the Director of Nurses (DON) was asked for a policy for Elopement/Dangerous Wandering Risk Assessments. The facility was not able to produce a written policy/procedure for Elopement/Dangerous Wandering Risk Assessments. The facility form titled Elopement/Dangerous Wandering Risk Assessment included the following directions: completion of the form to be done within 5 days of admission, quarterly, and with any incident of attempted elopement, elopement or dangerous wandering. The form consist of eight questions which include a score number assigned after each question. The total score ranges from 0-15. A score of "3" or below = minimal risk, score of "4" or "5" = moderate risk for elopement or dangerous wandering : Implement Care Plan, and a score of "6" or greater = High risk for elopement or dangerous wandering : Apply Wanderguard and implement "Potential for Elopement/Dangerous Wandering" Care Plan. Resident # 114 risk assessment for Elopement/Dangerous Wandering, dated 2/3/11, assessed the resident to have had the ability to move about the facility independently in a w/c, a [DIAGNOSES REDACTED]. The total risk score was equal to "4". There was no evidence that a Comprehensive Care Plan ( CCP) was initiated as directed on the Elopement/Dangerous Wandering Risk Assessment. The resident was reassessed on 2/16/11 with a score of "1" / minimal risk for elopement. The Nurse's Notes (N/N), dated 4/5/11 documented the resident exhibited exit seeking behavior. The staff reported the resident attempted to go outside through the back door. There was no documentation that an elopement attempt form or reassessment for elopement risk was completed or filled out as directed on the Elopement/Dangerous Wandering Risk Assessment. The N/N dated 4/10/11 documented the resident was very angry and was wandering the halls looking for a family member whom did not live locally. The N/N further documented that the "resident ate dinner well and again began to make several attempts to leave the building". There was no documentation that an elopement attempt form or reassessment for elopement risk was completed or filled out. The N/N dated 4/11/11 documented a family member felt the resident was having increased confusion. The N/N dated 4/14/11 documented the resident was climbing out of bed and stated " he was going home". The N/N dated 5/3/11 at 11:00 pm, documented the resident with confusion and was " looking for the family member whom did not live locally". An Elopement/ Dangerous wandering risk assessment dated [DATE], assessed the residents' risk score to be "2". The N/N dated 5/21/11, documented that on 5/21/11 at approximately 7:00 pm a family member came to visit an was unable to locate the resident. A unit search was conducted and the resident was found on the grounds outside of the building at the foot of a hill area leading to the parking lot. The N/N documented that the alarm to the exit door was not sounding, but a call for help from the resident and the sound of a chair alarm was heard by the staff during the search. The note included that the alarm to the exit door was "turned " off by the maintenance worker. The resident was assessed by the Registered Nurse Supervisor (RNS) and was noted to have a laceration to the right elbow. The resident was evaluated in the emergency room and received six sutures to the laceration on the right elbow. The resident was reassessed for risk of elopement/wandering on 5/22/11 and was scored at a 12/ high risk for elopement. The facility Accident and Incident Report, dated 5/21/11 at 7:10 pm , documented the residents' daughter came into visit and was not able to locate the resident. The staff started a search on the unit and it was discovered that "the resident had gone outside through an exit door located in the PT room. The report documented that the resident went down the hill to the parking lot and was found lying on his right side near a parked car and his wheel chair was 3/4 of the way down the hill". The report included documentation that the resident stated he wanted to go home and wanted to use the car at the foot of the hill. The resident further stated that he went "too fast and tipped over ". The physician's orders [REDACTED]. During an interview on 5/25/11 at 2:05 pm, CNA #1 stated that she last saw the resident in the unit hallway at approximately 6:00 pm. She stated that the resident asked her "how do I get out of here?". When the CNA was questioned about the residents statement of "wanting to know how to get out of here", she stated that it was not an unusual behavior and that the staff redirects him when he is "looking to go home or get out ". The CNA stated she redirected the resident to his room and had not seen him again before his being discovered outside. During an interview on 5/25/11 at 2:15 pm, CNA #2 stated she last saw the resident a " few minutes " past 6:00 pm, and brought him to the television area as he was asking her how to get out. The CNA stated that this was usual for the resident to ask "how to get out" and that the staff usual try to redirect him either to his room or the sitting area. A joint observation of the outside area where the resident was found was made on 5/25/11 at 2:15 pm with CNA #2 who assisted in the search and discovery of the resident. The location of the Physical Therapy ( PT) room is a short distance from the room in which the resident resides. A solid wooden door with a locking handle, leads from the unit hallway into the PT room. An exit door, equipped with a sound activating alarm, is located in the back right hand corner of the room. This door leads to an outside parking area. Outside of the door is a cement walkway approximately 3 foot wide which runs along side the building. Immediately outside the door, at the edge of the pavement, the grass area begins to slope downward ( a small hill), approximately 7-8 feet before meeting the edge of the blacktop pavement. During an interview on 5/27/11 at 9:50 am, CNA # 3, who was assigned to the residents' care on 5/21/11, stated that the resident was on 15 minute checks. When questioned as to the reason for these checks, the CNA replied " so I know where the resident is and what he is doing". The CNA stated that at approximately 3: 00 pm the resident asked her "where is the exit, I want to get out". The CNA stated the nurse was aware and was in the hallway when the resident was asking "how the hell do you get out of here". The CNA stated she monitored the resident frequently but the resident moved very fast in the w/c. The CNA stated that sometime between 6:30 pm and 7:00 pm she offered the resident to go to bed. The resident declined so she brought him to his room and gave him a snack. The CNA then stated she proceeded to care for another resident and around 7:00 pm she was informed by the other staff that the resident could not be found. She stated that she and other staff searched for approximately 10 minutes before the resident was found outside on the ground. When asked if the 15 minute checks were completed on 5/21/11, the CNA replied " I try to keep up with them, but I can't say it is exactly every 15 minutes. Sometimes it is 10 minutes and sometimes maybe 20 minutes." During an interview on 5/26/11 at 4:30 pm, the maintenance worker stated that on 5/21/11 he was assigned to wax the floors in the PT room, which is located on the same floor as the residents room. He stated that he was granted permission by the Maintenance Director to deactivate ( to turn off) the alarm system on the exit door leading out of the building. He stated that at approximately 6:30 pm he left the area for a dinner break. He stated that he did not turn the alarm to the exit door back on. He further stated that he had closed the door that leads from the hallway into the PT room before he left the unit, but he did not lock it. He stated that he had placed wet floor signs all around the area and he did not think any resident would go by them. During an interview on 5/25/11 at 3:25 pm, the Registered Nurse Manager (RNM), stated that the resident was always stating he wanted to go home but had never made any attempts to do so. During the same interview the RNM stated that on or about 5/17/11 a nurse was summoned to the front lobby due to the resident being at the front door and wanting to get out. She stated upon her arrival the resident was in front of the exit doors in his w/c and was stating "he needed to go home and just wanted to get out on the street and take a left hand turn to go home". The surveyor pointed out to the RNM that various N/N, dated between 4/10/11-5/3/11, documented the resident as having exiting seeking behaviors that included several attempts to leave the building. When asked if exit seeking behaviors would place a resident at a high risk for elopement, she stated "no, not necessarily, all nursing home residents want to go home". During an interview on 5/27/11 at 11:30 am, the RN Supervisor (RNS) # 1 who was on duty the evening of 5/21/11, stated that she was not aware of the incident until she was notified by the unit nurse that the resident was on the ground in the back parking lot. She stated she arrived to find the resident on the ground half on the grass and half on the pavement. She stated the resident stated " if that car wasn't there I would have rolled away". She stated that after a complete assessment she notified the physician and transferred the resident to the emergency room for treatment of [REDACTED]. She stated the resident returned to the facility with approximately 6 sutures in the elbow. During an interview on 5/27/11 at 1:30 pm, the Licensed Practical Nurse (LPN) stated that the resident had been issued a wanderguard on 5/22/11 at approximately 11:30. When asked why the wanderguard was issued on 5/22/11 she stated, "because he got out the back door the evening before". 10 NYCRR 415.12(h)(1)