Every finding on record at Eddy Village Green at Beverwyck

Based on observation, record review and interviews conducted during survey, the facility failed to ensure residents were free from neglect and abuse for two (2) (Resident#7 and Resident #26) of seven (7) residents reviewed for abuse and neglect. Specifically, (a) on 07/21/2025, Resident #7 Comprehensive Care Plan intervention to take resident to the bathroom immediately after dinner due to resident's high risk for fall was not implemented and Resident #7 sustained a fall with injury (an abrasion to the left lateral knee area and a bruise to their left inner thigh), and (b) on 05/11/2025, Resident #26's hipsters (pants with padded hips to help decrease the chances of injury) which were a care planned intervention to be placed on the resident daily, were not put on Resident #26 and Resident #26 fell from their wheelchair. Resident #26 sustained a change in status causing their weight bearing status to change from non-weightbearing on their right lower extremity (when the right foot/leg must not touch the floor or support any body weight) to full non-weight bearing status (when one cannot put weight on an injured limb and it must be fully supported at all times). This resulted in actual harm to Resident #7 and Resident #26 that was not Immediate Jeopardy. Findings include:Facility policy and procedure titled Abuse Prevention and Investigation Policy effective 03/25/2025, documented residents had the right to be free from verbal, sexual, physical, and mental abuse; neglect, and mistreatment. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also included the deprivation of goods or services that were necessary to attain or maintain (physical, mental, and psychosocial well-being. It included verbal abuse, sexual abuse, physical abuse, and mental abuse. Neglect was defined as failure to provide timely, consistent, safe, adequate and appropriate services, treatment, and care necessary to avoid physical harm, mental anguish, or mental illness, such as nutrition, medication, therapies, sanitary clothing and surroundings, and activities of daily living. Resident #7 Resident #7 was admitted to the facility with diagnoses of unspecified dementia, with psychotic disturbance (cognitive decline combined with hallucinations or delusions where the specific type of dementia is not defined), unspecified glaucoma (diagnosis in which glaucoma, a group of eye diseases that damage the optic nerve leading to irreversible vision loss if not treated, but the specific type has not been documented), and benign prostatic hyperplasia without lower urinary tract symptoms (noncancerous enlargement of the prostate gland due to aging and hormonal changes). The Minimum Data Set (a resident assessment tool) dated 03/27/2026, documented the resident rarely/never made themselves understood and rarely/never had the ability to understand others. The Comprehensive Care Plan with focus Alteration in elimination as evidenced by bowel incontinence, functional incontinence, urinary tract function sufficiently intact, but cannot remain continent due to external factors (mobility, cognition, diuretic), BPH (benign prostatic hyperplasia), initiated 12/30/2020, documented as interventions, toilet upon waking, 11:30 AM, even if family present please take resident in and by 3:30 PM and after dinner, before bed and check and change twice during the night initiated 04/10/2024, updated 02/02/2026 and take me to the bathroom as soon as I am finished with dinner as I am at high risk for falls as I will attempt to take myself to the bathroom as soon as I finish my dinner meal initiated 01/22/2024. The Comprehensive Care Plan with focus Resident may have potential for physical/psychological injury/victim of abuse related to aggressive behaviors of another resident initiated 12/29/2020 documented as an intervention assist me directly after meals as I will wheel myself right to my room for toileting or attempt to get into bed initiated 02/06/2024. The Comprehensive Care Plan with focus Safety awareness deficit related to decreased strength/endurance, history of falls, seizure initiated 12/30/2020 documented an intervention do not place stand lift outside of my door and take me to the bathroom as soon as I finish my dinner initiated 01/22/2024. Resident #7's Kardex (a quick reference tool used to summarize essential resident information and care plan ) followed by certified nurse aides documented under toileting section toilet upon waking, 11:30AM, even if family present please take them in and by 3:30 PM and after dinner, before bed and check and change twice during the night on 04/10/2023 and under the safety section do not place lift outside of my door and take me to the bathroom as soon as I finish my dinner initiated 01/22/2024. It also documented in this section assist me directly after meals as I will wheel myself right to my room for toileting or attempt to get into bed. The Facility Investigation dated 07/24/2025 documented on 07/21/2025 at 8:15 PM, Resident #7 was observed by certified nurse aides to be on the floor in their room. The resident had an abrasion to their left lateral knee area (left side of the knee) and a bruise to their left inner thigh. Upon house camera review and statements from staff, it was noted Resident #7's care plan was not followed, and the resident was not assisted to the bathroom after dinner per plan of care. The certified nurse aides responsible for care and oversight of the resident were terminated, Resident #7's family member was updated on findings, the incident was reported to the Department of Health, education was provided to all staff regarding following care plans, highest risk for falls individuals were reviewed in the house, and staff were instructed not to wash dishes in the evening until all residents have been taken to the bathroom and/or assisted to bed. During an observation on 04/28/2026 at 6:01 PM, Resident #7 was sitting in their wheelchair at a table in the dining area. They completed their dinner and had a cup of ginger ale in front of them. At 6:10 PM, Certified Nurse Aide #5 wheeled Resident #7 from the dining area to their room. Registered Nurse #5 approached Resident #7's room. Certified Nurse Aide #5 left the room, and Registered Nurse #5 administered medications to Resident #7 until 6:30 PM. At 6:30 PM, Registered Nurse #5 wheeled Resident #7 out of their room into the common living area with other residents who were watching television. Resident #7 was observed by Surveyor from 6:01 PM through 6:59 PM and was not observed to be taken to the bathroom after dinner. During an interview on 04/28/2026 at 6:51 PM, Certified Nurse Aide #5 stated after dinner, residents were toileted and assisted with getting ready for bed. The Kardex for each resident was hung in the closet and it let them know how to provide care for the residents. They checked the Kardex daily to see if there were any changes to it. They stated Resident #7 was dependent upon staff for assistance with toileting, and they were toileted every two (2) hours. They stated Resident #7 was supposed to be taken to the toilet after dinner, but they were not taken to the toilet once the resident finished dinner on this date. During an interview on 05/01/2026 at 1:25 PM, Director of Nursing #1 stated the Kardex's for residents were kept in their closet and they should be checked by the certified nurse aides at the beginning of each shift before they provide care for a resident. If a resident were to have a specific time they were to be toileted, it was expected to be done at that time. Resident #7 should be taken to the bathroom after meals. This resident was taken to use the bathroom after meals because when they were done eating, they began to propel themselves to the bathroom. There was a reportable incident of a fall for Resident #7 that previously occurred in which the care plan for the resident was not followed and they were not toileted after completion of dinner. Resident #26 Resident #26 was admitted with diagnoses of Alzheimer's disease (a progressive, irreversible neurodegenerative disorder that affects memory, thinking, and behavior), insomnia (inability to sleep), and age-related osteoporosis (a disease characterized by decreased bone mass and strength, leading to brittle bones that break easily, particularly in the hip, spine and wrist. The Minimum Data Set, dated [DATE], documented the resident was rarely/never understood, rarely/never understood others and was completely cognitively compromised. The Comprehensive Care Plan for Osteoporosis date initiated 05/01/2025 and last revised 02/26/2026, documented that Resident #26 had a history of pathological bone fracture related to osteoporosis and had a fall on 05/11/2025. The documented interventions included non-weight bearing right lower extremity. The Comprehensive Care Plan for Safety Awareness, date initiated 06/14/2023 and last revised 05/14/2025, documented the resident had safety awareness deficit related to confusion/decreased memory, dementia, history of falls, limited mobility. This care plan documented the resident had a slip/fall from recliner on 07/07/2024 and an intervention initiated on 07/08/24 documented to apply clean hipsters daily. Resident #26's Kardex as of 05/06/2025 documented under the section for safety to apply clean hipsters daily. A fall follow-up note dated 05/11/2025 at 2:41 PM documented that Resident #26 was left in their wheelchair after lunch sitting in the common area, Resident #26 did not have hipsters on as stated in care plan as all hipsters were in laundry, wheelchair was not in locked position. Order received for left hip x-ray and order to keep resident in bed until results of x-ray returned. Facility Situation, Background, Assessment, Recommendation (SBAR) Report dated 05/12/2025 documented on 05/11/2025, Resident #26 had a fall in the living room close to 2:00 PM. The resident's routine was to be taken to the bathroom after lunch and then sit in a recliner in the living room. On 05/11/2025 at 1:51 PM, Resident #26 was seen on camera standing up and tripping over the wheelchair footrests into another resident's wheelchair and onto the floor. An x-ray was ordered to the left hip and pelvis. Impression: moderate degenerative changes bilateral hips. Concern for fracture of right hip (identified on 04/29/2025 prior to the fall) with signs of impaction, varus angulation of right femur (a deformity where the femur bows outward). No evidence of left hip fracture. Recommend CT (computed tomography) of the pelvis for further investigation (Health status note documented previously completed x-ray to right hip and pelvis on 04/29/2025 indicated osteopenia [a condition characterized by lower than normal bone mineral density]. Cortical irregularity along the lateral aspect of the femoral neck concerning for a small subchondral nondisplaced fracture [a hairline crack in the bone directly beneath joint cartilage where the bone fragments remain aligned]. A health status note dated 05/11/2025 at 7:37 PM documented that Medical Provider #1 and Resident #26's family member felt that based on x-ray results, it was not pertinent to send resident to hospital at that time. Resident #26 was made non-weight bearing and a mechanical lift was to be used when getting the resident out of bed. An orthopedic consult dated 05/14/2025 documented Resident #26 was seen for follow up x-ray post fall 05/11/2025. Findings documented increased pain with right hip logroll (a physical examination technique used to evaluate hip pathologies) compared to last week (Resident #26 was seen by orthopedics on 05/01/2025 prior to the incident). Diagnosis documented suspected right hip fracture with increased pain. Recommendations included non-weight bearing status right lower extremity, there has been advancement of symptoms, choices were to go to hospital for advanced imaging (computed tomography, magnetic resonance imaging) or commit to long term non-weight bearing status. Family to discuss. A communication/family note dated 05/15/2025 at 2:39 PM documented that the facility spoke to family, and they had decided against pursuing further diagnostic testing and surgery. The family understood that the resident would be non-weight bearing with comfort as the goal. The family representative had spoken with other family members who were medically trained, and they requested certain medications be given for pain management. Resident #26 was using the (brand name) chair (a specialized, durable medical wheelchair designed for comfort, pressure redistribution, and positioning) for out of bed seating and reported that they were comfortable and had no evidence of pain noted while seated in the chair. Medical Director #1 and Physical Therapy notified of family wishes. The Facility Investigation report dated 05/15/2025 documented that Certified Nurse Aide #6 assigned to provide care to the resident on 05/11/2025, reported they did not place the hipsters on Resident #26 when they got the resident up because the hipsters were not in the room at the time and the certified nurse aide did not want to leave the resident in their room unattended. Certified Nurse Aide #6 stated that they knew there was a clean pair for the resident in the laundry room and planned to put them on the resident after lunch when they took Resident #26 to the bathroom. The house cameras were reviewed which showed Certified Nurse Aide #6 going in to provide care to the resident at 9:28 AM. Certified Nurse Aide #6 left the room twice during that time, once to retrieve the resident's wheelchair in the living room and once to throw away garbage and was seen on camera stopping to speak to a resident family member. The house camera also revealed an agency certified nurse aide going into the resident's room and sitting in the chair in the corner of the room as the door was open. At no time, did the caregiver ask the other certified nurse aide to go retrieve the hipsters located in the laundry room which is located on the same level and less than 60 feet from the resident's room. Documentation of the actions taken as a result of the incident were that hipsters would be on the treatment record for residents who wear them to ensure a nurse was checking for placement. Additional hip protectors have been ordered to ensure every resident had at least two (2) pairs so there was a pair in their room at all times. The certified nurse aide responsible for providing care to the resident on 05/11/2025 7:00 AM to 3:00 PM shift was terminated from employment. The nurse would confirm that the hipsters were being worn when the residents got up in the morning. During an interview on 05/01/2026 at 3:23 PM, Director of Nursing #1 stated regarding the incident on 05/11/2025, Certified Nurse Aide #6 had ample opportunity to get hipsters from the laundry. The laundry room was not far from the resident's room, maybe 20 feet. They could have asked another aide to get the hipsters for them, which would have been the expectation. During an interview on 05/01/2026 at 2:48 PM, Administrator #1 stated if a resident had needs that were care planned for, such as toileting the resident after dinner, the care plan should be followed, and the intervention should be done. 10 New York Codes, Rules, and Regulations 415.4

Based on record review, observations, and interviews during the survey, the facility failed to ensure that food was stored, prepared, distributed, or served following professional standards for food service safety in the Main Kitchen and in the house kitchens for House 21 and House 31. Specifically, proper labeling/dating of open items was not followed, and expired food items were found stored ready for use in the refrigerators and freezers. Findings include:Policy titled, Production, Purchasing, Storage; subject Food and Supply Storage, revised 01/2026, documented all food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Foods past the use by, sell by, best by, or enjoy by date should be discarded. Cover, label, and date unused portions and open packages. Use the Medvantage/Freshdate labeling system or complete all sections of an orange label. Products are good through the close of business on the date noted on the label. Date and rotate items; first in, first out. Discard food past the use-by or expiration date. Food prepared in-house and then stored frozen should be kept no longer than three months. Commercially produced foods may be held frozen until the manufacturer's expiration date, or for 3 (three) months if no expiration date on the package. Once the packaging around the food has been opened, food must be used within 3 (three) months. Observations conducted on 04/20/2026 from 10:04 AM to 10:55 AM revealed the following: The following items were found to have been opened and without proper labeling and/or dating or past their use by date in the Main Kitchen refrigerator:A package of American cheese.A partially used package of a head of iceberg lettuce.1 (one) bag of spinach and 2 (two) unopened bags of spinach.1 (one) head of fennel, unwrapped with no use by date. It was unclear if the fennel was used.A package of strawberries.A bag of carrots.A bag of turnips .A bag of onions .2 (two) bags of cilantro.A box with 7 (seven) individually wrapped cucumbers were found with no use by date.The following items were found to have been opened and/or without proper labeling and/or dating or past their use by date in the Main Kitchen freezer:Four (4) bags of blue cheese crumbles.An opened bag of blueberries.An opened bag of sausage crumbles.An opened bag of beef/veal patties.An unidentifiable piece of meat wrapped in clear plastic wrap and labeled beef dated 4/20 (year not included) for today's date.A wrapped package of turkey meatloaf dated 08/11/2025 with a discard date of 10/10/2025.A plastic container labeled tofu marked 6/17/2025 with a use by date of 12/14/2025.A bag of opened peas.A bag of opened corn kernels.5 (five) turkey breasts wrapped in plastic wrap in a plastic bin. The box they came in was discarded. The items were not marked with a use by date.The following items were found opened without proper labeling and/or dating or past their use by date in the pantry in the main kitchen:A bag of tortilla chips marked open 4/18/2026 with a discard date of 4/22/2026.An open and a closed package of dry bread stuffing mix wrapped together in plastic wrap with an opened date of 2/11/2026 and a discard date of 2/14/2026.The following item was found without proper labeling and/or dating or past their use by date in the refrigerator in the kitchen in House #31:Sliced tomatoes in a plastic container covered with plastic wrap. There was no label that indicated a date the item was first used or when to discard the item by.The following items were found without proper labeling and/or dating or past their use by date in the freezer in the kitchen in House #31:An opened package of waffles, an opened package of sausage patties, an opened package of sausage links, an opened bag of pre-made ready to bake cookies, an opened container of chocolate marshmallow ice cream. All of these items were not labeled with the date the items were opened or the date to use the items by.The following item was found without proper labeling and/or dating or past their use by date in the pantry/storage area behind kitchen in House #31:A plastic container with dry cereal date opened 8/26/2025, discard date of 2/22/2026.The following item was found without proper labeling and/or dating or past their use by date in the refrigerator in the pantry/storage area behind the kitchen in House #31:An opened package of meat patties with no opened or use by date.An unopened container of whole milk with a best by date of April 23, 2026. The following item was found opened without proper labeling and/or dating or past their use by date in the freezer in the pantry/storage area behind the kitchen in House #31:An bag of premade meatballs with no opened or use by date.The following item was found opened without proper labeling and/or dating or past their use by date in the freezer in the pantry/storage area behind the kitchen in House #21An bag of ready to bake cookies with no opened or use by date.During a follow up inspection of the kitchen in House #21 on 4/30/2026 at 3:59 PM , the following items were found to be out of compliance with New York State food safety regulations:The following items were found without proper labeling and/or dating or past their use by date in the refrigerator in the pantry/storage area behind the kitchen in House #21:An unlabeled plastic container with a red liquid, possibly cranberry juice, with no opened or use by date.A plastic bag of mushrooms and a plastic bag of peeled garlic cloves. The bags for these items were tied in a knot. There was no opened or use by date on either bag.During an interview on 4/27/2026 at 10:55 AM, Assistant Director of Dining Services #1 stated the Main Kitchen prepared the dinner meal for the residents in the nursing home and everything in that kitchen had the potential to be served to residents in the nursing home. All open items should have had a visible expiration date on them. In order to label and date items, they used a data mark printer. When an item was opened, they would enter the product into the printer and it would automatically generate a label with the date the item was opened and the use by date for that item. They stated sometimes items were not dated because they were overlooked, and sometimes it was due to laziness. Not all items in the cooler were used every day, and some items had the date to use them by on their packaging but if an item was taken out of its packaging or original box, it needed to be labeled as staff needed to know when they expired. They stated they were going to throw away all the expired items and everything that was not labeled with a use by date because they did not know when the items were opened or when they needed to be used by.During an interview and observation on 04/30/2026 at 4:10 PM, Certified Nurse Aide # 7 stated items should be labeled and dated with dates the items were opened and when the items needed to be discarded by. They could not say when the mushrooms, garlic, and container of red liquid seen in House #21 on 04/30/2026 were placed in the refrigerator or when they should have been used by because there was no label on them with the date they were opened and the date they should be discarded. They stated they were going to throw those items away and they were observed discarding the items in the trash. 10 New York Codes, Rules, and Regulations 415.14(h)

Based on observation, interview, and record review conducted during a survey, the facility failed to report all alleged violations involving abuse, neglect, and injuries of unknown source immediately, but not later than two (2) hours after the allegation was made, to the administrator of the facility and to other officials (including to the State Agency) for two (2) (Resident #s 12 and 27) of five (5) residents reviewed. Specifically, (a) Resident # 12 reported an incident with alleged abuse on 01/05/2026 at 9:00 PM. This incident was reported to the Department of Health on 01/06/2026 at 9:59 AM. (b) Resident # 27 reported an incident with alleged abuse on 03/30/2025 at 10:09 AM, which was reported to the Department of Health on 03/30/2024 at 6:42 PM. Findings Include:The facility's Policy and Procedure dated 03/25/2025 titled Abuse Prevention & Investigation documented, the incident must be reported immediately upon witnessing or learning of a suspected allegation of abuse to a direct supervisor, charge nurse, administrator, Director of Nursing Services, or other appropriate designee without fear of retaliation and regardless of whether the reporting staff member feels the allegation is credible. As per state laws, rules, and regulations all staff have the obligation to report incidents of abuse to the Department of Health. A report to the Department of Health must be made immediately, but no later than two (2) hours after an allegation of abuse is made. Record review revealed a nursing progress note, dated 01/05/2026 at 9:19 PM, documented a bruise on Resident #12's left upper extremity. Record review revealed the allegation of abuse to Resident #12 was sent from the facility to the New York State Department of Health as a Facility Reported Incident on 01/06/2025 at 9:59 AM.Investigation of Abuse statement by Certified Nurse Assistant #2 dated 04/01/2025, documented while they were preforming routine morning care with Resident #27 on 03/30/2026 around 8:00 AM, they were told by the resident their arm was hurting because someone beat them up the night before.Record review revealed the allegation of abuse to Resident #27 was sent from the facility to the New York State Department of Health as a Facility Reported Incident on 03/30/2025 at 6:42 PM. The incident was documented as being initially reported to staff on 03/30/2025 at 8:00 AM.During an Interview on 05/01/2026 at 10:37 AM, Certified Nurse Assistant #3 stated that as soon as the resident was safe, they reported suspected abuse or statements about abuse to the supervisor and/or nurse. They stated abuse allegations needed to be reported to the Department of Health within two (2) hours. During an interview on 05/01/2026 at 12:08 PM, Registered Nurse #1 stated that any allegations of abuse should be reported immediately as well as reported to Department of Health within two (2) hours. The time to report to the Department of Health started with the first employee that was informed of the allegation. During an interview on 05/01/2026 at 1:26 PM, Director of Nursing #1 stated all abuse allegations must be reported to the Department of Health within two (2) hours.During an interview on 05/01/2026 at 2:48 PM, Administrator #1 stated if a resident reported abuse or a staff member suspected it, it should be reported to nurse immediately. The nurse would then report to the on-call person, which typically was themselves or an administrative nurse. If they were not the on-call person, the on-call nurse would then notify them. They further stated staff knew how to report to the Department of Health if they could not reach administration, and that the report to the Department of Health needed to be made within two (2) hours.10 New York Codes, Rules, and Regulations 415.4(b)(2)

Based on observation, interview, and record review conducted during a survey, the facility failed to ensure that each resident had a person-centered individualized care plan developed and implemented according to professional standards of practice for two (2) (Resident #'s 4 and 22) of 17 residents reviewed. Specifically, (a) for Resident #4, their medicated dandruff shampoo was not noted to be required in the resident's Comprehensive Care Plan; and (b) for Resident #22, the Comprehensive Care Plan did not address the resident's difficulty with speaking. Findings Include: The facility's policy and procedure dated 06/27/2023 titled Interdisciplinary Care Conference and Care Planning documented that at a minimum the baseline care plan will include healthcare information necessary to properly care for each resident immediately upon their admission and address resident-specific health and safety concerns. The plan will include initial goals, physician orders, medications, dietary orders, therapy orders, social services, and any applicable recommendations. The entire interdisciplinary team will participate in the development and implementation of each resident's care plan, working together contributing their knowledge and skill set in an effort to provide the greatest benefit to the resident. All resident care plans should reflect the resident's cultural preferences, values and practices. Resident #4 Resident #4 was admitted to the facility with the diagnoses of atherosclerotic heart disease (a condition where plaque built up inside the heart arteries causing them to harden and narrow), adjustment disorder with depressed mood (a short-term stress-related mental health condition characterized by an intense, emotional reaction to a significant life change or stressor), and need for assistance with personal care (need for someone to assist with activities of daily living). The Minimum Data Set (an assessment tool) dated 04/03/2026, documented Resident #4 was usually understood, usually understood others, and was minimally cognitively impaired. A physician order dated 3/30/2026 documented that the resident was to have Sebex Shampoo 2-2% (Salicylic Acid-Sulfur), apply to scalp topically in the morning every Monday, Friday for dry scalp - apply on shower days.The Kaiser Permanente Website (healthy.kasierpermanente.org) documented that Sebex 2-2% shampoo was used to treat dandruff and other scalp conditions (such as itching, scaling, flaking). The was no documented evidence that there was any care plan area addressing Resident #4's need for Sebex shampoo or related condition of having dandruff. During an observation on 04/27/2026 at 12:30 PM, Resident #4 was noted to have flaky dandruff appearing skin on their head. During an interview on 4/30/2026, Registered Nurse #1 stated they tried to make sure that care plans were correlated to the resident's medications as best they could. Registered Nurse #1 stated that Resident #4's need for dandruff shampoo should be in the care plan. Resident #22 Resident #22 was admitted to the facility with the diagnoses of hemiplegia and hemiparesis following cerebral infarction (mild weakness to near or total paralysis after having a stroke), dysarthria (a motor speech disorder caused by brain damage that makes it difficult to control the muscles used for speaking), and anarthria (a severe motor speech disorder characterized by the complete loss of the ability to produce articulate speech, resulting from brain injuries or neurological disorders that paralyze speech muscles). The Minimum Data Set, dated [DATE], documented Resident #22 was able to be understood, understood others, and was minimally cognitively impaired. During an interview on 04/27/2026 at 10 AM, Resident #22 was noted to be limited with verbal responses and made more hand gestures for answers instead of words. In response to some questions during the interview process, Resident #22 was noted to not answer at all and just stared at the surveyor. There was no documented evidence that Resident #22's difficulty in verbally responding to questions was included in the Comprehensive Care Plan. During an interview on 05/01/2026 at 1:25 PM, Director of Nursing #1 stated when a resident was admitted to the facility, they go through their diagnoses and problems and put that information into a care plan. All disciplines have a portion of the care plan they were responsible for, and care plans were updated if there was a new diagnosis, change in condition, or hospitalization. During an interview on 05/01/2026 at 2:48 PM, Administrator #1 stated if a resident had needs that were care planned for, the care plan should be followed, and the intervention should be done. The care plans should include areas to address issues the residents had and be updated based on changes with the resident. 10 New York Code of Rules and Regulations 483.21 (b) (1)

Based on record review and interviews conducted during a survey, the facility failed to ensure that it maintained acceptable parameters of nutritional status, provided nutrition care and services to each resident consistent with the resident's comprehensive assessment, recognized, evaluated, and addressed the needs of every resident for three (3) (Resident #s 12, 20, and 22) of three (3) residents reviewed for nutrition/hydration status maintenance. Specifically, Residents #s 12, 20, and 22 had significant weight changes that were not assessed timely.Findings include:Facility policy titled, Clinical Nutrition Services, dated 05/1995 and last revised 01/2024, documented that the registered dietitian or designee would complete a nutrition evaluation within 72 hours of admission. The dietitian would complete a comprehensive nutrition assessment according to the admission date and Minimum Data Set schedule. The dietitian would monitor regularly to ensure residents maintained acceptable parameters of nutritional status. Residents were offered a therapeutic diet when it had been determined that there was a benefit. The procedure documented was the dietitian or designee would complete the comprehensive nutritional assessments within seven (7) days or per community schedule. Documentation must be completed in a timely and accurate manner. All documentation must include a signature, including electronic signage of the respective clinical team member. The quarterly assessment would be completed per the Minimum Data Set schedule. Interval evaluations would be completed for the following, but were not limited to: Resident with a confirmed significant change in weight would be evaluated as soon as possible but no longer than (five) 5 days after notification, a care plan would be updated per review of resident's nutritional status and monitoring frequency determined based on significance, etiology, response to interventions and clinical judgement. Residents with insidious weight loss (gradual unintended progressive weight loss over an extended time). Monitor and document as part of monthly weight review process.Residents identified as at risk per the validated malnutrition screening tool, a progress note would be written, and as needed thereafter. Resident #12:Resident #12 was admitted to the facility with diagnoses of Parkinson's Disease without dyskinesia (a disorder of the central nervous system that affects movement, often including tremors, but did not experience involuntary, erratic movements), dysphagia (difficulty swallowing, often caused by nerve damage, muscular issues, or blockages), and stage three (3) chronic kidney disease (moderate kidney damage). The Minimum Data Set (an assessment tool) dated 03/20/2026, documented the resident had intact cognition, made themselves understood, and understood others.A review of Section K (Swallowing/Nutrition Status) of the Minimum Data Set, dated [DATE] documented Resident #12 had a significant weight loss (of either) five (5) percent or more in the last month, or of 10 percent or more in the last six (6) months). It further documented that Resident #12 was not on a physician-prescribed weight-loss regimen.The Comprehensive Care Plan, initiated 09/17/2025, documented the resident was at nutritional risk and goal, initiated 12/10/2025, included resident would maintain a plus or minus three (3) percent current body weight for 90 days. Interventions included weighing the resident monthly and providing ice cream once (1) daily with dinner as a supplement.Review of the electronic health record revealed significant weight loss for Resident #12 when weighed on 01/02/2026, 02/01/2026, 03/01/2026, and 04/02/2026. There were generated warnings related to significant weight loss.There was no documented evidence that Resident #12's weight loss was assessed when known on 01/02/2026, 02/01/2026, 03/01/2026, until 03/13/2026 when a routine Mini Nutritional Assessment and Nutrition Quarterly Review was completed.Nutrition Quarterly Review dated 03/13/2026 documented a three point seven (3.7) percent loss over the last 30 days, an eight point five (8.5) percent loss over the last 90 days, and a 13 percent loss over the last 180 days. Weight loss continues. (Supplement) plus previously ordered but discontinued due to loose stools and Resident #12 was not interested in taking any supplements. (Supplement) Clear daily now ordered, (Supplement) ice cream provided daily. No changes to plan of care at this time and will continue to monitor. Resident #20 Resident #20 was admitted to the facility with the diagnoses of Alzheimer's disease with late onset (a progressive degenerative neurological disease affecting memory), paroxysmal atrial fibrillation (a type of irregular heart rhythm where the upper chambers of the heart beat chaotically and out of sync with the lower chambers), and pharyngeal phase of dysphagia (a swallowing disorder where food or liquid was difficult to move from the throat to the esophagus). The Minimum Data Set, dated [DATE], documented Resident #20 was sometimes able to understand others, was usually understood, and was completely cognitively compromised. A review of Section K (Swallowing/Nutrition Status) of the Minimum Data Set, dated [DATE] documented Resident #20 had no or unknown weight loss (of either) five (5) percent or more in the last month or loss of 10 percent or more in the last six (6) months). The Comprehensive Care Plan, initiated 02/22/2024, documented the resident was at nutritional risk and goal, revised 03/06/2024, included the resident would maintain a plus or minus three (3) percent current body weight for 90 days. Interventions included weighing the resident monthly, initiated 02/22/2024, and to provide a daily supplement on 10/15/2025.Review of Weights and Vitals Summary in Resident #20's electronic health record revealed the following:On 11/01/2025, Resident #20 experienced a four point seven (4.7) percent weight loss. On 11/02/2025, a reweight of the resident confirmed this weight loss.There was no documented evidence that the medical practitioners assessed Resident #20 until a Nutrition Assessment, Mini Nutritional Assessment, and Medical Director/ Nurse Practitioner Weight Alert completed on 01/02/2026.Document titled Nutrition assessment dated [DATE] noted a weight loss trend for the last six (6) months. The resident was receiving a supplement once (1) a day. No changes to plan of care at the time and the resident would continue to be monitored. Review of Weights and Vitals Summary in Resident #20's electronic health record revealed the following:On 04/03/2026, the resident demonstrated a seven point five (7.5) percent weight loss from their weight on 01/02/2026. A warning was generated.On 04/04/2026, a reweight was obtained and confirmed this weight loss. There was no documented evidence that the medical practitioners assessed Resident #20 for the one (1) month significant weight loss on 04/03/2026 through 4/29/2026.On 04/30/2026, it was documented in the Resident's electronic health record the resident's weight loss continued and the resident lost eight point two (8.2) pounds from 03/01/2026 to 04/03/2026. The resident continued on a supplement once (1) a day. Would recommend increasing the supplement t twice daily for weight maintenance. Resident #22: Resident #22 was admitted to the facility with diagnoses of cerebral infarction (the death of brain tissue caused by an interruption of blood flow to the brain), dysphagia (difficulty swallowing, often caused by nerve damage, muscular issues, or blockages), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest). The Minimum Data Set, dated [DATE] documented the resident made themselves understood and understood others. A review of Section K (Swallowing/Nutrition Status) of the Minimum Data Set, dated [DATE] documented Resident #22 had no or unknown loss of five (5) percent or more in the last month or loss of 10 percent or more in the last six (6) months. The Comprehensive Care Plan, initiated 10/15/2025, documented the resident was at nutritional risk.Review of Weights and Vitals Summary revealed Resident #22 exhibited a one (1) month significant weight loss of eight-point four (8.4) percent.Nutrition Quarterly Review dated 04/03/2026 documented the resident was at risk for unintended weight loss due to pain. And that there were no nutrition concerns. There was no documented evidence that the facility assessed Resident #22's significant weight loss until the routine Nutrition Quarterly Review on 04/03/2026. During an interview on 05/01/2026 at 11:07 AM, Certified Nurse Aide #4 stated they would immediately reweigh a resident if they noted that there was a five (5) pound weight change and then speak to the Registered Nurse on duty. During an interview on 5/01/2026 at 12:08 PM, Registered Nurse #1 stated that the facility policy was to obtain monthly weights for the residents that had an order for it, and if there was more than a five (5) pound weight change, the staff would obtain a reweight. They met with the Registered Dietitian on a weekly basis and asked if they wanted more frequent weights ordered. Registered Nurse #1 stated that reweights were sometimes hard to get. During an interview on 04/30/2026 at 11:32 AM, Registered Dietitian #1 stated that if there was a one (1) month significant weight change, the Registered Dietitian or the staff member who was adding the weight into the resident's chart would request a re-weight verbally or in an email. They were unable to provide a specific timeframe for when the re-weight would be needed. They further stated that if there was a one (1) or six (6) month significant weight change, the Registered Dietitian would fill out the Weight Alert in the electronic health record. They further stated that the Nurse Manager and Nurse Practitioner or Medical Doctor would sign off that they were aware of the significant weight change. The significant weight change would be documented in a quarterly or annual assessment. If the significant weight change occurred outside of the quarterly or annual timeframe, the Registered Dietitian would complete a progress note for one (1) and six (6) month significant weight changes. If new interventions were added, the Registered Dietitian would update them in the resident's care plan. If a resident continued to lose weight after a significant weight loss, the interdisciplinary team would hold a care conference with the family and discuss findings.During an interview on 05/01/2026 at 1:30 PM, Director of Nursing #1 stated the Physician was at the facility every Tuesday and would discuss significant weight changes. The Registered Dietitian was to complete the nutrition assessments on admission, quarterly, and with significant changes. During an interview on 05/01/2026 at 1:35 PM, Medical Director #1 stated that it was their expectation that the staff would notify them of residents who had significant weight changes. They further stated if a resident had multiple significant weight change alerts, they would be alerted electronically. 10 New York Code of Rules and Regulations 415.12(i)(1)

Based on observation, interview, and record review conducted during the recertification survey from [DATE] to [DATE], the facility did not ensure drugs and biologicals were stored in accordance with professional standards of practice. This was evident for 2 (House #s 21 and 31) of 2 Houses reviewed. Specifically, 1) the medication carts in House 31 contained an expired stock medication, 2) the medication carts in House #31 contained 3 insulin pens not labeled with the dates opened and the expiration dates after opening, 3) the medication carts in House #'s 21 and 31 contained 2 bottles of eye drops and 2 bottles of nasal sprays not labeled with the dates they were opened and the expiration dates after opening, and 4) the medication cart in House #31 contained an inhaler not labeled with the date opened, and the expiration date after opening. This was evidenced by: Documentation provided by the facility's Nursing Chief Executive Office on [DATE] at 9:32 AM included their pharmacy's policy regarding the storage and handling of medications. Section 4.8 of the pharmacy policy, regarding the procedure for appropriate labeling of medications, documented medications that are in multiple dose vials (i.e.: insulin) or containers (i.e., bulk liquids) must have a label indicating the date the container was first opened and the date of expiration. It documented multidose vials of injectable medications expire 28 days after the date opened, unless otherwise specified by the manufacturer, and medications with expiration dates of month and year only would expire on the last day of the month. The facility Medication Administration Policy stated the nurse was to carefully check the name, dose, amount of administration and expiration date. When preparing medications for administration, the nurse was to check the medication order three times before administering the medication, as follows: 1. Read the electronic medical record thoroughly 2. Read the label on the medication packet. 3. Compare label on medication packet to the electronic medical record. There was no documented evidence that the facility in-serviced staff on insulin vial and/or insulin pen, eye drop or inhaler expiration dates. During an observation on [DATE] at 1:50 PM, the House #31 medication cart contained a stock medication for Melatonin (sleep aid) labeled with an expiration date of [DATE]; and two Novolog Insulin Flex Pens and an Levemir Flex Pen all opened, unlabeled, with no open or expiry date. During an interview on [DATE] at 1:51 PM, Registered Nurse #1 - when asked to identify the expiration date of the insulin - stated the insulin would expire ,d+[DATE] days after it was opened. Registered Nurse #1 stated they should have written the date the insulin pen when it was opened. During an observation on [DATE] at 2:10 PM, the House #21 medication cart contained the following opened items that were unlabeled, without open dates and without expiry dates: - two bottles of brimonidine eye drops (to lower pressure inside the eye that is caused by open-angle glaucoma or eye hypertension), - two bottles of Timolol eye drops (used to treat glaucoma and high pressure inside the eye), - a Flovent Diskus Inhaler (helps keep lung inflammation low and the airways open), - an Advair HFA (treats asthma and chronic obstructive pulmonary disease), - a Fluticasone Nasal Spray (used to treat sneezing, itchy or runny nose, or other symptoms caused by hay fever, used to treat chronic rhinosinusitis with nasal polyps), and - one bottle of deep-sea nasal drops. During an interview on [DATE] at 2:10 PM, Registered Nurse #1 was asked to identify the expiration date of the Timolol and brimonidine eye drops, and the Flovent and Advair inhalers. They stated that they did not label the eye drops and the inhaler when they opened them. During an interview on [DATE] at 9:30 AM, the Director of Nursing stated that they were in the process of re-educating staff on keeping carts stocked and up to date; and that it was the overnight nurse's the responsibility to check medication expiration dates on the carts. During an interview on [DATE] at 9:50 AM, Registered Nurse #2 was asked how they calculate insulin flex pen expiration dates after opening and they stated the expiration date was already printed on the side of the insulin pen. Registered Nurse #2 stated they were not aware of pharmacy policy on storage and handling medications. 10 NYCRR 415.18(d)

Based on observation, staff interviews, and record review during the recertification survey from [DATE] to [DATE], the facility did not ensure food was stored in accordance with professional standards for food service safety for two (2) of 2 resident central kitchens. Specifically, bulk food items and outside items were (A) not labeled for their contents, (B) not date-labeled after open or labeled with an expiry date, (C) and were not discarded by the best use date to discard food items. This was evidenced by: House # 31 During observations on [DATE] from 10:35 AM to 11:26 AM, the following was noted within the main kitchen area for House # 31: A) Eleven (11) items did not have labels describing what they were: Container of grated cheese located within a refrigerator Bag of carved meat located within a refrigerator Package of butter located within a refrigerator Frozen waffles located within a freezer Frozen scones located within a freezer Frozen cookies located within a freezer Frozen hamburger buns located within a freezer Frozen croissants located within a freezer Package of croissants located in storage room Bulk brown sugar located in storage room Bag of uncooked noodles located in storage room B) Eight (8) items lacked a label or writing of when they were opened: Container of mustard One container of beef and vegetable bases, respectively Six half gallons of Breyers ice cream (chocolate, vanilla, and strawberry, two each) Bag of Ruffles chips Package of cookies Italian breadcrumbs Package of Jell-O instant pudding Bag of [NAME] sugar C) Eleven (11) items were not adequately discarded by the end of the best-use date: Two meals brought in by family with discard date of [DATE]. Yellow shredded cheese with discard date of [DATE]. Shredded mozzarella cheese with discard date of [DATE]. Cooked bacon with discard date of [DATE]. Chocolate syrup with discard date of [DATE]. Package frozen cookies with discard date of [DATE]. Package of ice cream sandwiches with discard date of ,d+[DATE]. Package frozen scones with discard date of [DATE]. Package of frozen beans with discard date of [DATE]. Package of frozen chicken breasts with discard date of [DATE]. During observations on [DATE] from 10:35 AM to 11:26 AM, the main kitchen area for House # 31 did not have items properly labeled for residents. A store-bought [NAME] cheese package had residents' names and no date when brought in. House # 21 During observations on [DATE] from 11:50 AM to 12:15 PM, the following was noted within the main kitchen area for House # 21: A) Five (5) items did not have labels describing what they were: Container of bulk brown sugar. Package of frozen waffles. Bag of frozen sausage patties. Package of frozen scones. Resident's bottle of iced tea located in the main refrigerator. B) Four (4) lacked a label or writing of when they were opened: Container of instant oatmeal. Six half gallons of Breyers ice cream (chocolate, vanilla, and strawberry, two each). Bag of 3 uncut tomatoes. Container of Italian breadcrumbs. C) Four (4) items were not adequately discarded by the end of the best-use date: Container of cranberry sauce with discard date of [DATE]. Bag of romaine lettuce with discard date of [DATE]. Two (2) opened and partially used loaves of bread with discard date of [DATE]. One (1) unopened loaf of bread with discard date of [DATE]. During observations on [DATE] from 10:35 AM to 11:26 AM, the main kitchen area for House # 21 did not have items properly labeled for residents. A container of turkey soup for a resident brought in by a family member was labeled [NAME] for a best-use-by date. Record Review: An undated policy titled Food Safety Labeling Procedure documented that all food or beverage items that were either stored, opened, prepared, or leftover in our kitchens/storage areas and/or delivered to areas such as Nursing Stations or pantries would be clearly identified as to the item name/product, the production or opened date, and the use by date. A policy titled Use and Storage of Food Brought to Residents from the Outside, dated [DATE], documented that food brought in by family or other visitors was permitted, provided care was taken to ensure food was handled properly for safe and sanitary storage and consumption. If food was brought in by the family and was not consumed immediately by the resident, the food was to be stored in a container with a tight-fitting lid, clearly labeled with the resident name and room number, the date the food was brought to the resident, and the use-by date. Foods were to be consumed within seventy-two hours or per food and supply storage policy. A document titled Important Foodservice and Sanitation Guidelines described that any prepared food that was opened or stored must be labeled and dated for discard within three days. Any beverage or dairy product must be labeled on the date it was opened. Items must be discarded within seven days of being opened or by the manufacturer's use-by date, whichever came first. Any condiment-type item that must be refrigerated after opening must be labeled with the opened date, and items must be discarded within 30 days of being opened. Interviews: During an interview on [DATE] at 10:44 AM, Certified Nursing Assistant #3 stated that staff should have properly labeled as well as discarded the expired item. When an item is opened, staff should place a label on the item and then date it for best use by date according to their standards. They stated labels are found on the counters in each kitchen area, and if an item was not labeled correctly, they should have brought it to the attention of one of a director, facility administrator, or Food Service Directors. During an interview on [DATE] at 10:49 AM, Certified Nursing Assistant #4 stated all Certified Nursing Assistants were responsible for looking at items and determining if they need to be discarded by the date, and they all needed to be more diligent in labeling the items brought in by family members and when opening items. During an interview on [DATE] at 10:57 AM, Distribution Manager #1 stated they usually checked and labeled items, but it was the responsibility of all staff to maintain food standards and check labels for compliance. They stated they needed to be more diligent in labeling items brought from distribution to the kitchens. During an interview on [DATE] at 11:08 AM, the Food Service Director stated food and kitchen activities were ultimately their responsibility, but that all staff in the kitchen area should have checked the items regularly for resident safety. They further stated that they would periodically meet with the food service division to review the items found. During an interview on [DATE] at 12:05 PM, Certified Nursing Assistant #1 stated all staff needed to be more diligent in labeling and tracking item dates and labeled when identified. During an interview on [DATE] at 12:07 PM, Certified Nursing Assistant #5 stated they were to label items with best used-by dates when food items were opened, and that they would contact food service or administrators for guidance if an item was unlabeled. During an interview on [DATE] at 12:11 PM, Certified Nursing Assistant #6 stated that all staff in the unit should have been more diligent in checking dates and labeling the items when opened, and that staff were to label outside food with a best use-by date and an appropriate label. During an interview on [DATE] at 12:25 PM, the Director of Nursing stated that the Food Service Director oversaw the food at the facility, although it is a joint staff effort to check the food and food items daily for potential expiration dates. They further stated that the distribution manager and Certified Nursing Assistants in the facility were to check the items regularly, with items opened then labeled per policy. 10 NYCRR 415.14(h)

Based on record review and interviews during the recertification survey from 11/28/2023 to 12/01/2023, the facility did not ensure they were in compliance with all regulatory requirements when they chose to ask residents or their representatives to enter into an agreement for binding arbitration for 3 (Resident #'s 1, 3, and 5) of 4 residents reviewed for binding arbitration. Specifically, the facility binding arbitration agreement (A) for Resident #1 did not explicitly grant the resident or their representative the right to rescind the agreement within 30 calendar days of signing it; (B) for Resident #3 did not explicitly state that neither the resident nor their representative were required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at the facility, and; (C) for Resident # 5 did not provide for the selection of an arbitration venue that was convenient to both parties. This was evidenced by: A) Resident #1 was admitted to the facility with diagnoses of dementia, depression, and hypertension. The Minimum Data Set (a resident assessment tool) dated 11/20/2023 documented the resident was able to make themselves understood, usually able to understand others, and was moderately cognitively impaired. The facility binding arbitration agreement, dated 12/28/2021, was reviewed; it did not include documentation it explicitly granted the resident or their representative the right to rescind the agreement within 30 calendar days of signing it. During an interview on 12/01/2023 at 01:22 PM, Social Worker #1 stated they reviewed the facility's binding arbitration agreements with residents or resident representatives following admission as part of the facility admission agreement process. The content in the facility binding arbitration agreement was reviewed with them verbatim as written in the binding arbitration agreement. During an interview on 12/01/2023 at 01:22 PM, the Administrator stated the facility's binding arbitration agreement did not include documentation that it was the right for the resident or their representative to rescind the agreement within 30 calendar days of signing the agreement. B) Resident #3 was admitted to the facility with diagnoses of dementia, depression, and hypertension. The Minimum Data Set, dated dated dated [DATE] documented the resident was able to make themselves understood, usually able to understand others, and was moderately cognitively impaired. The facility binding arbitration agreement, dated 6/06/2023, was reviewed; it did not include documentation that neither the resident nor their representative were required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at the facility. During an interview on 12/01/2023 at 01:22 PM, Social Worker #1 stated the facility's binding arbitration agreement was optional but did not include specific documentation that neither the resident nor their representative were required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at the facility. C) Resident #5 was admitted to the facility with diagnoses of hypothyroidism, osteoarthritis, and iron deficiency anemia. The Minimum Dat Set dated 10/04/2023 documented the resident was able to make themselves understood, able to understand others, and was cognitively intact. The facility binding arbitration agreement, dated 9/27/2023, was reviewed; it did not include documentation that provided for selection of an arbitration venue that was convenient for both parties. During an interview on 12/01/2023 at 01:22 PM, the Administrator stated the facility's binding arbitration agreement did not include documentation that provided for selection of an arbitration venue that was mutually convenient for both parties. During an interview on 12/01/2023 at 01:49 PM, the Administrator stated they were not aware of any issues related to the language in the facility's binding arbitration agreement. 10 NYCRR 415.30

Based on observation, record review, and staff interviews during the recertification survey from 11/28/2023 to 12/01/2023, the facility did not ensure hand hygiene procedures were followed by staff involved in direct resident contact for 2 (House #'s 21 and 31) of 2 houses reviewed for infection control. Specifically, for House #21, the facility did not ensure facility staff performed hand hygiene between doffing (removing) and donning (putting on) gloves while preparing dessert in the kitchen on 11/29/2023. For House #31, the facility did not ensure gloves were doffed and hand hygiene was performed by staff exiting the kitchen on 11/28/2023, and gloves were doffed, and hand hygiene performed by a staff member after touching 5 resident drink glasses, a resident, and prior to entering/exiting the kitchen on three occasions while passing drinks to residents in the dining room on 11/30/2023. This was evidenced by: The policy and procedure titled Hand Hygiene/Artificial Fingernails and dated 04/12/2022 documented handwashing was to be done before and after touching a resident, before and after wearing gloves, and before and after touching the residents' surroundings. House #21 During an observation on 11/29/2023 at 02:11 PM, Resident Care Companion #6 was in the kitchen preparing dessert, they then removed their gloves, assisted another staff member retrieve an item from the storage area, and placed on new gloves, and continued to prepare dessert. Hand hygiene/washing was not observed. During an interview on 12/01/2023 at 12:05 PM, Registered Nurse #1 stated hand hygiene needed to be performed before and after entering rooms, and after touching residents' personal items. Gloves needed to be removed prior to entering the kitchen. Hand hygiene needed to be performed after removing gloves, but they were not sure if it was policy to perform hand hygiene prior to putting on gloves. During an interview on 12/01/2023 at 11:58 AM, the Director of Nursing stated hand hygiene should be done whenever changing gloves, going in and out of the kitchen, and when preparing food. House #31 During an observation on 11/28/2023 at 12:16 PM, Resident Care Companion #3 was in the kitchen with gloves on. They removed their gloves prior to exiting the kitchen area and did not perform hand hygiene. They walked straight to a resident's room and entered without performing hand hygiene. They touched the resident and the resident's surroundings, and then exited the resident room without performing hand hygiene. They went straight to the dining room and brought the resident to a table. After Resident Care Companion #3 had gotten the resident settled, they went to the kitchen and performed hand hygiene. During an observation on 11/30/2023 at 12:22 PM, Resident Care Companion #4 poured drinks for 5 residents in the dining room while wearing gloves. Resident Care Companion #4 went from resident to resident, picking up the drinking glass that was placed in front of them at the table with one of their gloved hands, and poured from one of several drink containers from a rolling stand nearby with the other gloved hand. At one point, they leaned over and touched one resident on the shoulder while they asked them what they wanted to drink with one of their gloved hands before going to get the resident their drink. During that time, Resident Care Companion #4 also made three trips into the kitchen and did not change/discard their gloves or perform hand hygiene during the interactions. During an interview on 11/30/2023 at 12:28 PM, Resident Care Companion #4 stated hand hygiene was to be performed before and after going into and out of the kitchen, before and after touching a resident, before and after handling a resident's surroundings, and before and after taking gloves on and off. The same gloves should not be worn to work with multiple residents. They did not realize they had just worn the same pair of gloves while providing drinks to multiple residents. They stated they should not have done this and that it must have slipped their mind. Resident Care Companion #4 further stated that they should not have been wearing gloves to pass drinks to residents in the dining room since it was not facility policy. During an interview on 12/01/2023 at 12:22 PM, the Director of Nursing stated hand hygiene needed to occur before entering and after exiting the kitchen, between working with different residents, after handling items in the resident's surroundings, and before putting on or taking off gloves. Gloves needed to be removed prior to entering and exiting the kitchen, and hand hygiene was to be performed once gloves were removed. Gloves should not have been worn while working with multiple residents and should not have been worn to pass drinks to residents. The Director of Nursing further stated that hand hygiene should have been performed prior to Resident Care Companion #3 leaving the kitchen when they removed their gloves on 11/28/2023, and before entering the resident's room. On 11/30/2023, Resident Care Companion #4 had multiple opportunities to remove their gloves and perform hand hygiene, including prior to entering and exiting the kitchen each time, and after touching the resident on the shoulder. During an interview on 12/01/2023 at 1:49 PM, the Director of Nursing stated hand hygiene concerns had been on the facility's radar recently and had performed education and hand hygiene audits in July 2023. They thought hand hygiene issues had been corrected at that time. 10 NYCRR 415.19(b)(4)

Based on observation, record review and interviews during the recertification survey from 11/28/2023 through 12/2/2023, the facility did not ensure comprehensive person-centered care plans were implemented. This was evident for 1 (Resident #7) of 12 residents reviewed for Comprehensive Care Plans. Specifically, Resident #7 was found alone on the floor in the bathroom with a skin tear on their right forearm, and their safety awareness care plan documented staff were not to leave the resident alone in the bathroom. This is evidenced by: The policy and procedure titled Falls Management Policy and revised 12/2022 documented the facility would prevent and/or reduce the number of falls by providing an individualized, person-centered care approach with managing fall risk through the process of assessment, planning, implementation, and evaluation. The policy and procedure titled Care Plans - Comprehensive and revised 12/2022 documented the comprehensive care plan included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs; and was to be developed and implemented for each resident. Resident #7: Resident #7 was admitted to the facility on [DATE], with diagnoses of unspecified dementia, psychotic disorder with delusions, and epilepsy. The Minimum Data Set (an assessment tool), dated 10/30/2022, documented the resident could be understood, could understand, and had severe cognitive impairment. The comprehensive care plan titled Safety awareness deficit related to decreased strength/endurance, history of falls, seizure disorder, dated 12/30/2020, documented Resident #7 was not to be left alone in the bathroom. During an observation on 11/30/2023 at 11:30 AM, Resident #7 was in the living room engaging with staff and then was escorted to Occupational Therapy. Resident #7's room had a stop sign across the entrance. The facility investigative report documented Certified Nursing Assistant #8 left Resident #7 alone in their bathroom on the toilet on 10/30/2022, which resulted in Resident #7's fall. Certified Nursing Assistant #9 answered the call light in Resident #7's room and found the resident on the bathroom floor. It documented the resident sustained a skin tear on their right posterior forearm that measured 6 centimeters by 7 centimeters and required 6 steri-strips. Resident #7's care plan, care card and the safety first reminder sheet posted in the resident's bathroom documented for staff not to leave the resident alone in the bathroom. Certified Nursing Assistant #8 did not follow the plan of care which resulted in Resident #7 falling and sustaining an injury. The Incident Report Statement dated 10/30/2022 of Certified Nursing Assistant #8 documented they worked short on 10/30/2022, placed the resident on the toilet and went to the kitchen area to keep eye on other residents. During an interview on 11/30/2023 at 12:00 PM, Resident #7's Health Care Proxy stated they were made aware of the fall on 10/30/2022, that Resident #7 was non-verbal due to dementia, and that the Resident Coordinator now kept Resident #7 in high visibility areas for close monitoring. During an interview on 12/2/2023 at 9:30 AM, the Director of Nursing stated Certified Nursing Assistant #8 was counseled on their failure to follow the resident's care plan, and all Certified Nursing Assistants were re-educated on following resident care plans. The Director of Nursing further stated that safety sheets were also posted in all resident rooms/bathrooms for quick reference. 10 NYCRR 415.11(c)(1)

Based on observation, record review, and staff interviews during the recertification survey from 11/28/2023 to 12/1/2023, the facility did not dispose of garbage and refuse properly. This was evident for 4 of 9 trash bins in the trash collection area. Specifically, trash bins located in the trash collection area overflowed with waste and the trash collection area was open. This was evidenced by: During an observation of the trash collection area on 11/30/2023 at 1:05 PM, four (4) trash bins overflowed with waste. Three (3) of the trash bins were not fully covered with trash overflowing the bins, and one (1) trash bin was left uncovered with trash overflowing the bin. The trash collection area to the trash bins had a fenced in area with double swing doors for access, with one door left open and unsecured. The policy titled Trash Removal-(facility name), last revised on 8/13/2018, documented step-by-step instructions on how the facility was to remove trash from buildings daily, with resident care coordinators to empty individual house trash bags and remove the trash bags to the trash collection areas after each meal and before specific times. The policy documented the outside trash company was to pick up trash bins on Tuesdays and Fridays. In an interview conducted on 11/30/2023 at 1:30 PM, the Director of Maintenance stated staff were not disposing trash appropriately when not completely closing the trash bin lids. 10NYCRR 814.14(h)

Based on record review and interviews during the recertification survey dated from 11/28/2023 to 12/01/2023, the facility did not ensure each resident was offered a pneumococcal immunization, unless the immunization was medically contraindicated, or the resident had already been immunized. This was evident for 1 (Resident #5) of 5 residents reviewed for immunizations. Specifically, Resident #5 was not offered a pneumococcal immunization upon admission. This was evidenced by: Resident #5 was admitted to the facility on [DATE] with diagnoses of hypothyroidism, osteoarthritis, and iron deficiency anemia. The Minimum Data Set (an assessment tool) dated 10/04/2023 documented the resident was able to make themselves understood, able to understand others, was cognitively intact. The Minimum Data Set documented the resident's pneumococcal immunization status was not up to date / not received. The Policy and Procedure titled Immunizations: Standard of Care and dated 6/30/2023 documented the resident and/or their designated representative would be provided with immunization information, and required to sign consents/declinations for Pneumococcal, Influenza, and COVID-19 immunizations. Pneumococcal immunization timing for adults would be referred to on admission to determine which Pneumococcal immunizations were appropriate for the resident. Pneumococcal immunizations would be scheduled in the electronic medical record for administration, and recorded under the Immunization tab. A document titled Immunization Report, dated 12/01/2023 did not include documentation of the resident's pneumococcal immunization status. There was no documented evidence that the facility offered a pneumococcal immunization to Resident #5 following their admission to the facility. During an interview on 12/01/2023 at 12:22 PM, the Director of Nursing stated pneumococcal vaccinations were to be offered to residents upon on admission, and pneumococcal immunizations were not a focus for the facility over the past few months because they were focusing on Influenza, COVID-19, and Respiratory Syncytial Virus (RSV). 10 NYCRR 415.19 (a)(3)

Based on observation, record review and interviews during an abbreviated survey (Case #NY 099), the facility did not ensure the resident has a right to receive visitors of his or her choosing at the time of his or her choosing, subject to reasonable clinical and safety restrictions for 2 (Resident #'s 3, and 4) of 4 residents reviewed. Specifically, the facility did not ensure that Resident #s 3 and 4 were permitted to have unrestricted indoor visitation. This was evidenced by: The Policy and Procedure (P&P) titled Skilled Nursing Facility Visitation (COVID-19) dated 7/19/2021, documented that the most current guidance issued by the New York State Department of Health (NYSDOH) on 7/8/2021 will permit visitation based on a facility's structure and residents' needs. It documented that each facility will consider scheduling visits for a limited length of time to help ensure all residents are able to receive visitors. The maximum amount of time of visitors at any one time will also be limited in consideration of the facility's ability to maintain the core principles of infection prevention and that all visitation will occur during established visiting hours. The P&P documented indoor visits will be suspended for unvaccinated residents if the nursing home's county positivity rate is > 10% and < 70% of residents in the facility are fully vaccinated. The New York State Department of Health (NYSDOH) Health Advisory: Revised Skilled Nursing Facility Visitation dated 7/8/2021 documented in accordance with Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidance, facilities should allow indoor visitation at all times and for all residents (regardless of vaccination status), except for a few circumstances when visitation should be limited to compassionate care situations due to a high risk of COVID-19 transmission. Consistent with 42 CFR 483.10(f)(4)(v), a nursing home shall not restrict visitation without a reasonable clinical or safety cause. It documented to consider scheduling visits for a specified length of time to help ensure all residents are able to receive visitors; provided scheduling shall not limit access to required visitors. Any visitation schedule should allow residents to receive visitors for their desired length of time, to the extent possible in consideration of the Core Principles of infection control and as necessary to respect the privacy of other residents in the event a resident shares a room. A letter from the facility to Families and Friends dated 9/10/2021, documented Families and Friends were to contact the Guide Manager (GM - responsible for scheduling visitation) or the Administrator (ADM) for visitation scheduling or questions. Office phone numbers and e-mails were provided for both the GM and the ADM. There was no contact phone number listed for visitors to call on the weekend to schedule visitation. The Director of Nursing and the Supervisor were not listed as visitation contacts. The New York State website Percentage Positive Results by County Dashboard documented that on 9/14/2021, the daily COVID-19 positivity rate for [NAME] County was 4.7%, the 7-day rolling average for [NAME] County was 4.5% and the 14-day rolling average for [NAME] County was 4.6%. In an email from the facility to the New York State Department of Health surveyor, dated 9/29/2021 at 2:31 PM, the facility documented that as of 9/14/2021 their COVID-19 vaccination rates were 100% for residents, and 80% for staff. During an observation on 9/14/2021 at 11:45 AM, signs were posted outside the main entrances of buildings #s 21 and 31, and the staff entrance for building #31 that read, No visitors or vendors allowed at this time. Please ring the doorbell if you need assistance from the staff. During an interview on 9/14/2021 at 9:30 AM, the Director of Nursing stated there was no known COVID-19 in the facility for residents or employees at that time. Resident #4: Resident #4 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) documented the resident was cognitively intact, able to make themselves understood, and could understand others. A Visitor Log documented scheduled time daily visitation time blocks were between 10:00 AM - 11:00 AM and 1:00 PM - 3:00 PM for resident visitation. During an interview on 9/14/2021 at 1:34 PM, Resident #4 stated family lived close by and was permitted to visit every Monday, Wednesday, and Friday, and that all visits needed to be cleared by someone in charge. Resident #4 stated they did not think visits could be arranged at any time and date of their family's choosing and that clearance for all visits needed to be discussed with someone in charge. During an interview on 9/14/2021 at 2:55 PM, Family Member (FM) #1 stated that visitation needed to be arranged by contacting GM at the facility. FM #1 stated that they had typically been scheduled for visits on a Monday, Wednesday, and Friday visitation schedule. FM #1 stated that they were not permitted to eat with their family members, which was concerning to them because they used to eat together every day and have fun with some of the other residents and this was no longer possible. FM #1 stated that they were not aware of any way to make a last-minute visitation request, and they didn't know who they should call to make a visitation appointment on the weekend if desired. Resident #3: Resident #3 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident was cognitively intact, able to make themselves understood, and could understand others. During an interview on 9/14/2021 at 4:17 PM, FM #2 stated that, to schedule a time slot for visitation they have to call the GM. This process made it difficult for them to visit during the week, due to their work schedule. They had been told that they would not be permitted to visit indoors during non-visiting hours because the facility did not have a screener available, so they would be restricted to window visits during those times. FM #2 stated that there had been one or two times that they had requested visitation dates and times that they have been told were not available and had to settle for alternative visitation dates and times. Additional Interviews: During an interview on 9/14/2021 at 1:44 PM, Certified Nursing Assistant (CNA) #2 stated visitation occurred in scheduled one hour time blocks that visitors must schedule in advance with the GM. CNA #2 reviewed a copy of the visitor log from 9/14/2021, which showed scheduled visiting hours of 10:00 - 11:00 AM and 1:00 - 4:00 PM. CNA #2 stated that those hours were the same daily. One to two visitors could be scheduled for up to two residents in each time block, and that visitors were not supposed to be in the facility during mealtimes, so visitation was not routinely scheduled from 11:00 AM - 1:00 PM. Visitors could be permitted during mealtime only if they remained in the resident's room with the resident. CNA #2 stated that they were not aware of the signs posted on the facility entrance doors regarding no visitation. During an interview on 9/14/2021 at 2:33 PM, the GM stated visitation needed to be scheduled unless it was a compassionate care visit. The GM stated visiting hours were scheduled between 10:00 AM and 4:00 PM seven days a week; however, visits were not scheduled during mealtimes. The GM stated that each house could accommodate four visitors per one-hour time block, and that if more than four visitors wished to visit inside the facility at one time during a one-hour period in a particular house, the facility would have to ask some of them to leave to get the total indoor visitor number down to four. If a visitor arrived at the facility without an appointment, they would attempt to accommodate the visit if the house was under their four-visitor limit. The Director of Nursing (DON) was the secondary scheduler for visitation appointments, and families could e-mail appointment requests in addition to calling in their requests. The GM stated that about a month ago they received a complaint from a family member that they wanted to visit at 10:00 AM, and there was no 10:00 AM time block available for visiting hours, so the facility scheduled them for an 11:00 AM appointment instead. During an interview on 9/14/2021 at 2:16 PM, Licensed Practical Nurse (LPN #1) stated visitors were expected to call ahead of time to set up an appointment for visitation with the GM or the DON and that there was no visitation at mealtime. Visitation started at 10:00 AM and ended at 4:00 PM, and there was a two-visitor limit for each visitor. The visitation process has been in place for several months without change. LPN #1 stated that if a visitor showed up without an appointment, they would be permitted to visit, only if the resident was available and there were not two visitors already onsite. During an interview on 9/14/2021 at 3:25 PM, the DON stated visiting hours started at 10:00 AM so residents had an opportunity to wake up and eat, and ended around 3:30 PM- 4:30 PM, so visits were completed before dinner. Visiting hours were not scheduled during mealtimes, and visitors were not permitted to sit with residents at mealtimes due to social distancing concerns. Visitors who wished to visit during mealtimes must either sit with the resident in their room or go outside. The DON stated that visiting hours could be scheduled by calling or e-mailing either the GM or the DON, and on weekends visitors would contact the nurse cell phone number which was given out upon admission. The facility also sent out regular update e-mails and letters that reminded family members and loved ones who to contact to schedule visitation. The e-mail distribution list was updated every day with new admission contacts, so it was always up to date. The signs posted on the outside of the main entrances to buildings #s 21 and 31, and the staff entrance to #31 regarding visitor and vendor restrictions referred to the need for visitors to be screened upon entry to the facility. The DON stated that the four-visitor limit had been determined for the facility based on infection control practices. During an interview on 9/14/2021 at 4:30 PM, the ADM stated their visitation policy was based on New York State (NYS) core infection control principles. Visitation was initially started at a percentage of the facility census; however, since their census was so small that did not work for them. The ADM stated that the facility then decided that four visitors at a time per house would work best based on the facility's ability to provide staffing for screening. The ADM stated that if visitors were unable to visit during the week during regularly scheduled visiting hours, they could visit on the weekend or have outdoor visits. The ADM stated that families who wished to have more than two visitors were encouraged to have outdoor visits as well when weather permitted. The ADM stated that the main concerns that families had expressed regarding visitation had centered around having limited access to family members and loved ones due to visitation restrictions and having to make visitation appointments. 10 NYCRR 415.26(4)(vi)

Based on observation, interview and record review during a recertification survey, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infection for 1 (Resident #3) of 1 resident. Specifically, the facility did not ensure standard precautions were maintained during a dressing change. This is evidenced by: Resident #3: The resident was admitted on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 513/19, documented the resident was severely impaired for cognition; sometimes understood others and was understood by others. A Policy and Procedure for Clean Dressing Change Procedure dated 6/7/17 documented: -Set supplies on clean field. (MONTH) begin to open packaging and date new dressing. -Don clean gloves. -Remove gloves and cleanse hands and apply clean gloves. An Admission Progress Note dated 3/26/19 at 3:18 PM, documented the resident returned to the facility with a hospital acquired pressure ulcer, deep tissue injury to her right right buttock/sacral/coccyx area measuring 12 cm x 6 cm dark purple, with slough (dead tissue, usually cream or yellow in color) note throughout. Weekly Wound Tracking dated 7/18/19 documented wound measurements to left buttock were 1.4 cm x 2.8 cm x 1.0 cm with undermining (occurs when the tissue under the wound edges becomes eroded resulting in a pocket beneath the skin at the wound's edge) at 0.5 cm. Wound bed was filled with 100% granulation (new tissue on the healing surface of a wound) tissue, moderate of serosanguineous (contains both blood and the liquid part of blood) drainage. A physician's orders [REDACTED]. Cover with [MEDICATION NAME] (absorbent and antimicrobial) dressing. Change daily and when soiled. During an observation on 7/22/19 at 02:10 PM, Licensed Practical Nurse (LPN) #1: -removed her gloves and put on a new pair without washing her hands after she wiped the scissors. She opened the [MEDICATION NAME] dressing, dated and initialed it. - opened the [MEDICATION NAME] package and cut a piece of it. She then cut the [MEDICATION NAME] dressing to size. The LPN did not remove her gloves, wash her hands and put on new gloves after touching the outside of the packages and before touching the dressings. - removed her gloves and put on a new pair without washing her hands. - opened a package of 4 x 4 gauze, squirted normal saline onto it from a single use container, removed the gauze from the package and cleansed the wound. She followed this process twice. She did not remove her gloves and wash her hands and put on new gloves after touching the outside of the dressing packages and containers of saline and proceeding with cleansing the wound. -opened another package of gauze, removed the gauze and dried the wound without first removing her gloves, washing her hands and donning a new pair of gloves. During an interview on 07/22/19 at 02:33 PM, LPN #1 stated she thought she had washed her hands when she changed her gloves. She stated she was not aware the outside of dressing packages were considered to be contaminated and gloves would need to be removed and hands washed prior to touching dressing supplies and proceeding with the dressing change. During an interview on 07/22/19 at 02:39 PM, Registered Nurse Manager (RNM) #1 stated the LPN should have washed her hands whenever she removed her gloves. She also should have removed her gloves and washed her hands after touching the outside of the dressing packages. She had been inserviced on proper procedure to follow during a dressing change and had been observed on multiple occasions performing this dressing change. 10NYCRR415.19(a)(1-3)

Based on observation, and staff interview during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Foods time/temperature controlled for safety (TCS foods), formerly identified as potentially hazardous foods, are to be cooled to 41 degrees Fahrenheit (F) within specific time limits, and kitchen surfaces are to be cleaned. Specifically, tuna salad was not cooled to 41 F and non-food contact surfaces were not clean. This is evidenced as follows. The main kitchen was inspected on 08/20/2018 at 10:15 AM. In House 31, when checked, the temperature of tuna salad stored in the reach-in refrigerator was 50 F. In Houses 21 and 31, the refrigerator door gaskets, cabinets, walls, and floors were soiled with food particles, dust, and/or dirt. The Director of Dietary Services stated in an interview conducted on 08/20/2018 at 11:24 AM, that she will in-service staff on pre-chilling tuna salad ingredients and cleaning. 10 NYCRR 415.14(h); State Sanitary Code Subpart 14-1.40(b), 14-1.40, 14-1.110, 14-170, 14-171

Based on observation, record review and interview the facility did not ensure it developed and implemented a comprehensive person-centered plan for each resident that included measurable objectives and time frames to meet medical and nursing needs for one (Resident #2) of 5 residents reviewed for unnecessary medications during the recertification survey. Specifically, the facility did not develop a Comprehensive Care Plan (CCP) for the resident to self administer a pain relief cream. This is evidenced by: Resident #2 The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set of 5/25/18 assessed the resident understands, was usually understood and had no cognitive impairment. It documented the resident had frequent pain at a level of 7 (on a pain scale of 1-10). The resident received scheduled and as needed pain medication and non medication pain intervention. A physician order [REDACTED]. The resident may self apply (the cream) and leave at bedside. A Self Administration of Medication Assessment on 7/12/18, documented the resident did not desire to self administer the medication. Review of the CCPs on 8/23/18, revealed that there was no CCP with goals and objectives for the resident to self administer the Blu Emu cream or who was responsible for the storage and documentation of the administration of the cream. On 8/23/18 at 9:30 am, this surveyor and LPN # 1 went into the resident's room. LPN #1 opened his night stand drawer and showed this surveyor the jar of Blu Emu cream. LPN #1 said there is documentation on the Treatment Administration Record that the resident does it himself. He does not report any problems doing it. I have not watched him do it. Sometimes I ask him if he has done it himself, but not always. If I see it out in the room or bathroom I assume he did it. During interview on 8/23/18 at 9:22 AM, the Registered Nurse Manager stated ideally there should be a care plan if the resident is applying the cream himself. During interview on 8/23/18 at 9:56 AM, the resident said he has not used the Blu Emu cream in a week. He uses it when needs it, the pain comes and goes. 10NYCRR415.11(c)(1)

Based on record review and interview during the recertification survey, the facility did not ensure it developed a policy and procedure for the medication regimen review (MRR) that included time frames for the different steps in the process. Specifically, the policy provided did not include time frames for all the steps needed when the pharmacist identifies an irregularity that requires urgent action to protect the resident. This is evidenced by: The facility provided the policy Drug Regimen Review dated 7/11/18. This policy documented under General consideration: 2. Consultant Pharmacist will alert medical staff with any serious concern immediately. Under Procedure, bullet 4: Notification of irregularities to the facility is dependent on severity. Some clinically significant medication issues require urgent attention. If there is a potential for serious harm, the consultant pharmacist will notify the facility immediately. The facility will be responsible for reaching the attending physician or Medical Director for necessary interventions. Mode of notification can be via phone, or electronically, fax or email. The facility and the consultant pharmacist may collaborate to identify the most effective means for assuring appropriate notification. There were no time frames for the facility notifying the attending physician or Medical Director or for the physician to take action. During interview on 8/22/18 at 1:25 PM, the Registered Nurse Case Manager stated she did not see time frames specifically spelled out. 10NYCRR415.18(c)(2)

Based on observation and interview during a recertification survey, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of disease and infection for one (Resident #17) of one resident reviewed for pressure ulcers. Specifically, standard precautions were not maintained during a dressing change. This is evidenced by: Resident #17: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set of 6/15/18 assessed the resident understands, was understood and had no cognitive impairment. The facilities protocol Dressing Change Clean Technique dated 6/14/17, documented the following: 4. Place garbage next to working area. 5. Wash hands prior to start of procedure. 6. Set up clean field. Place supplies on clean field. (MONTH) prep dressings (open packaging etc). 7. Position resident. 8. Wash hands, don gloves and any other PPE (personal protective equipment) as required. Perform dressing change as ordered. a.) Remove soiled dressing. Dispose in plastic bag. b.) Observe wound. c.) Change gloves and cleanse hands. d.) Don clean gloves. e.) cleanse wound with prescribed solution. f.) Complete treatment as ordered. g.) Remove gloves and wash hands. 10. Ensure dressing has been dated and initialed. 11. Dispose of trash. Remove supplies. 12. Wash hands after completing procedure. A nurses note dated 8/17/18, documented the resident returned from the hospital at 12:10 PM. There was a pressure ulcer on the residents right upper buttock measuring 1.6 cm (centimeter) by 1.1 cm. Continue with santyl, cover with [MEDICATION NAME]. A physician order, dated 8/22/18, documented: Cleanse with normal saline right buttock open area apply cut to fit [MEDICATION NAME] AG cover with [MEDICATION NAME] daily until resolved. During observation on 8/22/18 at 9:50 AM, the Registered Nurse Manager (RNM) turned the resident on his right side and removed the old dressing exposing the area to be treated. Licensed Practical Nurse (LPN) #1 placed the [MEDICATION NAME] dressing package, cover dressing package, scissors, saline individual, and 2x2 gauze on the resident's bed next to his upper legs. LPN #1 cleansed the area with normal saline and patted the area dry with gauze. LPN #1 cut a small piece of [MEDICATION NAME] dressing from the larger piece and placed it on the wound and covered the dressing with the [MEDICATION NAME]. LPN #1 removed a pen from her pocket and wrote on the cover dressing and placed the pen back in her pocket. LPN #1 then gathered up the old dressing and threw it in the trash. She gathered up the scissors and [MEDICATION NAME] dressing package and set them on top of the medication/treatment cart. She took small alcohol wipe and wiped the scissors then placed them on top of the [MEDICATION NAME] dressing package. As LPN #1 went to pick up the [MEDICATION NAME] dressing package this surveyor asked what she was planning to do with it, she stated she should have put the [MEDICATION NAME] dressing in the resident's cabinet. During interview on 8/22/18 at 12:03 PM, LPN #1 stated the dressing package should have been put in the treatment cabinet, she would not have normally put it on the cart. Scissors are cleaned between all uses. She would have normally signed the dressing cover at the treatment cart before entering the room. During interview on 8/23/18 at 8:20 AM, the RNM stated LPN #1 was nervous with all the staff in the room during the dressing change. Nurses know they should never snip a piece of dressing and the remaining piece should remain in the room. 10NYCRR415.19(a)(1-3)

Based on observation, record review, and interview during an abbreviated survey (Case #'s NY 913 and NY 033), the facility did not ensure the resident's right to be free from neglect for one (Resident #1) of three residents reviewed. Specifically, for Resident #1, the facility did not ensure interventions were implemented to protect the resident from the effects of high outdoor temperatures on 7/15/18, resulting in a transfer to the hospital and treatment for [REDACTED]. Resident #1: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severely impaired cognition, the resident was able to make self understood, and was able to understand others. The facility Heat, Summer Precautions Policy and Procedure (P&P) dated 10/25/10 documented the facility staff under the guidance of the Medical Director, alerts and informs staff regarding high temperature alert and about appropriate measures for management. The P&P documented to assure adequate fluid uptake and does not permit residents to sit or lie in direct sunlight. The National Weather Service - Climate Data Climatological Report documented the maximum temperature to be 93 degrees Farenheit at 4:22 pm for Albany, New York. The facility is located approximately 5 miles away from Albany. The facility Student and Group Transcript Report printed on 7/17/18, documented Resident Care Companion (RCC #1) received abuse and neglect training on 6/22/18. During review of video footage on 7/17/18 at 11:59 am of the outdoor patio located outside of House 31 on 7/15/18 from 2:30 pm through 5:00 pm, the following was observed: At 2:55:20 pm, RCC #1 exits the house with Resident #1 and assists the resident onto the patio. At 2:55:47 pm, RCC #1 re-enters the house. At 2:56:48 pm, Resident #1 seats herself in a chair, located in direct sunlight. At 3:13:34 pm, a staff person enters the patio from the courtyard, walks past the resident, and enters the house. At 4:45:12 pm, RCC #1 and RCC #2 exit the house and attends to the resident. The resident was sitting in the chair with her chin resting on her chest. RCC #1 appeared to be talking to the resident, while she was rubbing the resident's left arm. There was no movement observed from the resident. At 4:45:50 pm, RCC #1 re-enters the house and returns to the patio with a wheel chair. At 4:47:06 pm, RCC #1 and RCC #2 bring the resident back into the house. The resident was observed sitting in the direct sunlight from 2:56:48 pm until 4:45:12 pm, almost 2 hours. The Resident Accident & Incident (A&I) Report dated 7/15/18 at 5:00 pm, written by Licensed Practical Nurse (LPN) #1, documented the RCC reported the resident was unresponsive. Per the RCC, the resident was out in the sun/heat for a minimum of 2 hours. LPN #1 was not informed the resident was outdoors. The resident's skin was red, hot to touch, and was slumped down, chin to chest. Initial VS (vital signs) T (temperature) 101.4 (normal is 98.6), blood pressure 130/92 (normal is 120/80), heart rate; 80 beats per minute (normal is 60 - 100), respirations; 16 breathes per minute (normal is 12-16), O2 Sat (oxygen saturation level) 88% (normal is 95-100 %). Chest rubs to stimulate resident were ineffective. Oxygen 2 liters via nasal cannula was applied. Cold cloths were applied to the back of the neck and forehead. The Nursing Progress Note dated 7/15/18 at 5:33 pm, written by LPN #1 documented the RCC reported the resident was out in the sun for approximately 1.5 - 2 hours. The resident was at her normal baseline when she went outside, walked around, and sat in the sun with her glass of water. When the RCC went to bring the resident in for dinner, the resident was unresponsive. The VS and treatments from the A&I dated 7/15/18, were documented in the note. The MD/family were called. The resident was sent to the hospital. The Facility Investigation/Root Cause Analysis Summary for occurrence on 7/15/18 from 2:55 pm to 4:48 pm, documented the following conclusion; The resident was assisted outside by a staff member and was not checked on in person until almost 2 hours later when she was discovered unresponsive. The Hospital General Medical Audit - ED (emergency department) Provider Note dated 7/15/18 at 6:30 pm, documented a diagnostic impression of heat exhaustion: The patient was left out in the hot sun with a skin temperature of 101. The Hospital Medication Administration Record [REDACTED]. The Hospital Discharge Instructions dated 7/15/18, documented the resident was seen in the ED on 7/15/18 at 5:51 pm, with a chief complaint of AMS (altered mental status), heat and a [DIAGNOSES REDACTED]. During an interview on 7/17/18 at 10:44 am, the Director of Nursing (DON) stated the resident loves to go outside and sit in the sun. The resident is independent with transfers and ambulation. The resident wears a pendant and usually pushes it when she wants to go back inside. RCC (#1) reported the resident asked to go outside, the RCC tried to dissuade her, but the resident insisted. RCC #1 brought the resident outside onto the patio. The inside cameras were viewed. The RCC did not physically go outside to check the resident; she just looked at her through the window. It was very hot that day. The nurse working is responsible for supervising staff. The nurse (LPN #1) was not aware the resident was outside. The facility does not have a RN supervisor for evenings. The DON was on-call that day and was called about the incident. During an interview on 7/18/18 at 10:16 am, the Administrator stated there was a P&P related to extreme outdoor temperatures in effect at the time of the incident. The P&P was revised on 7/16/18, to include resident-specific instructions. There was no specific guidance given to staff to tell them to not permit the residents to go outside. It has been talked about informally, but if there is high heat, there is nothing in place to say don't go outside. During an interview on 7/18/18 at 10:35 am, Resident #1 stated that she was in the hospital earlier in the week. She said she spent a little too much time in the sun. She was given IV fluids in the hospital. Her daughter told her that she cannot go outside unless she's there. During an interview on 7/18/18 at 11:54 am, the DON stated she was not familiar with the facility's P&P for weather precautions until just recently. They make sure the residents have sunscreen and sunglasses for protection. She expects staff to know where the residents are, and staff need to check on them. She did not give instructions to staff regarding the high outdoor temperatures on the day of the incident. Aside from the P&P, it's common sense that the residents need to be checked. During a phone interview on 8/7/18 at 1:49 pm, LPN #1 stated that she wrote the incident report. She said RCC #1 told her the resident was unresponsive. She found the resident in her room, sitting in a wheel chair with a cold washcloth on her forehead and on the back of her neck. The resident's head was slumped to her chest. She rubbed the resident's chest vigorously, but the resident would not respond. The paramedics came and once they moved her, she started to talk a little bit. She was not aware the resident was outside. The resident does usually go outside and sit. When she does, she checks on her to see if she is ok. The RCC's are supposed to let her know when they bring a resident outside. She was not sure if there was a P&P for weather precautions in place at the time of the incident. She did not receive any direction from management regarding the high outdoor temperatures. During a phone interview on 8/15/18 at 9:37 am, RCC #1 stated the resident was adamant about going outside that day. RCC #1 asked the resident if she could stay with her, but the resident said no. The resident is not a safety check; she always used her pendant. She was not aware of the facility's P&P for weather precautions dated 10/25/10, but said there was a policy that was created the next day (7/16/18). It was over 85 degrees on the day of the incident. No one directed her to not bring residents outside. She told the nurse who came in at 3:00 pm that the resident was outside. It was a statement in passing, while the nurse was on her way to one of the rooms with the medication cart. It was dinnertime when she noticed the resident was still outside. When she saw the resident in her chair, it looked like she was asleep, but then realized she wasn't. There was a small amount of drool coming off the side of her mouth. The resident's neck was hot and she wasn't responding. RCC #2 helped her bring the resident into the house. During a phone interview on 8/16/18 at 1:11 pm, the MD/Medical Director (MD#1) stated she was aware of the P&P for Heat Precautions, but doesn't regulate how things are managed when it is hot outside. The resident was definitely left outside too long. It's inexcusable. The resident has her mind made up about things, but monitoring still needs to be done. The facility encourages all residents to go outside. On hot days, the residents should only be outside for short periods of time; 10-15 minutes, with plenty of fluids. The resident was given fluids, but not enough for her, for that period of time. 10 NYCRR 415.4(b)(1)(i)

Based on observations, record reviews and interviews during a recertification survey, the facility did not ensure that residents food was prepared and served in a form designed to meet individual needs for two (Resident #'s 8 & 9) of 6 resident's reviewed and six resident's reviewed off sample (Resident #s 1, 4, 14, 15, 16, and # 19) observed during a phase one dining observation. Specifically, the facility did not ensure that residents were served the correct consistency meals. Observations: During Dining observations on 3/9/17 from 12:00 -1:00 pm, in Houses 21 and 31, 4 residents in each house were observed eating foods that were not of the consistency ordered for the individual resident. The meal consisted of boneless skinless chicken, rice and Brussel sprouts. The chicken was rough-cut in pieces that were approximately 2 x 1 and the Brussel sprouts were served whole. Resident #8: The resident was admitted to the nursing home on 12/1/16, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having moderately impaired cognitive skills for daily decision making. It documented that the resident understood and was understood by others. An Interdisciplinary Progress note dated 12/14/16, by the Speech Therapist (ST), documented that the family requested the resident's diet be changed from ground to cut up meat. Additionally, the ST documented that the daughter reported if the resident had difficulty they would change it back to ground. A Physician order [REDACTED]. Resident #9: The resident was admitted to the nursing home on 2/17/15 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having moderately impaired cognitive skills for daily decision making. It documented that the resident understood and was understood by others. A Physician order [REDACTED]. A Speech Therapy, SLP (Speech, Language Pathology) evaluation and Plan of Treatment dated 2/16/17, documented clinical signs and symptoms of mild dysphagia, and resident is on mechanical soft diet which she is doing ok with. Interviews: During an interview on 3/9/17 at 12:15 pm, when RCC #2 was shown the diet book and the residents food she was eating, RCC #2 stated that Resident #9 did not have her meat cut and she should have. Additionally, RCC #2 stated that it was everyone's responsibility to check the diet book to ensure residents are getting the right consistency. During an interview on 3/9/17 at 1:35 pm, RCC #3 stated that it was the Registered Dietitian's (RD) responsibility to ensure that the diet book was correct, and the cook usually cut everything up. Additionally, RCC #3 stated that she saw the RCC #4 cutting the food, so she did not think about it. During an interview on 3/9/17 at 1:45 pm, the RD stated that she came to the facility on ce a week and as part of her duties monitored a meal to ensure that the correct level of assistance was being used, and that the resident was receiving the proper consistency diet. Additionally, the RD stated that she did watch the meal, but did not look at the diet book and did not recognize that the consistencies were incorrect until the Department of Health Surveyor brought it to her attention. During an interview on 3/9/17 at 12:10 pm, RCC #4 (observed serving plates to residents) was asked how she knows what consistency each resident should have. RCC #4 reported that RCC #5 hands her the plates and tells her which resident it is for, and she does not know what the residents should have. During an interview on 3/9/17 at 12:15 pm, RCC #5 (observed plating food and handing plates to RCC #4) was asked how he knew what consistency each resident should have. RCC #5 reported the diet information is in the black binder. RCC #5 then retrieved the black binder from where it had been located during the meal service, on top of the microwave (not within RCC #5's view while plating food). When asked if Resident #16's food was the cut to dime size pieces, as ordered, RCC #5 responded, I thought so, but I guess I should have cut up the Brussel sprouts. During an interview on 3/9/17 at 1:45 pm, the Director of Nursing (DON) agreed that some residents were not served the proper consistency during the lunch meal. The DON reported that all staff present today have been re-educated regarding diet consistency and following the information provided in the black binder while serving the residents. The DON further reported that all staff will receive this re-education prior to being allowed to prepare or serve any foods. 10NYCRR415.14(d)(3)