Every finding on record at Elcor Nursing and Rehabilitation Center

Based on observations, interviews, and record review, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for two (2) of eight (8) residents reviewed (Resident #5 and Resident #247). Specifically, Resident #5 was observed on multiple occasions with long chin hair and unclean fingernails and had not received assistance with nail care, or facial hair removal. Resident #247 did not receive scheduled hygiene care including shaving, and the facility did not ensure care was completed, documented, or reattempted when missed.The findings include: The facility policy Activities of Daily Living dated September 2016 documented self-care needs included hair combing, bathing, grooming, shampooing, and shaving. The facility policy Care of Toenails and Fingernails dated September 2024 documented staff were to provide clean, trimmed nails to prevent infection or injury and were to soak the resident's hands for five (5) minutes and use a nail brush to remove debris.1. Resident #5 had diagnoses including necrotizing fasciitis (a life-threatening flesh-eating bacterial infection), type two diabetes, and chronic pain. The Minimum Data Set (a resident assessment tool) dated 03/06/2026 documented the resident was cognitively intact, required substantial assistance with personal hygiene including hair combing and shaving, and did not exhibit rejection of care.Review of Resident #5's Comprehensive Care Plan dated 03/13/2026 documented an activity of daily living self-care deficit related to impaired mobility, poor hygiene habits, and occasional urinary incontinence, and staff were to assist with baths or showers on Monday and Thursday evenings and provide assistance before and after meals.Review of Resident #5's progress notes and Point of Care (a report from the electronic health record used to record hygiene care including combing hair, brushing teeth, shaving, applying makeup, washing and drying face and hands, excluding baths and showers) documentation from 03/16/2026 through 04/16/2026 revealed no documented evidence Resident #5 received showers, facial hair removal, or nail care, and no documentation the resident refused or staff reattempted care.During an observation and interview on 04/14/2026 at 8:44 AM, Resident #5 was seated in the dining room with visible debris under several fingernails on both hands and chin hair approximately one (1) inch in length. Resident #5 stated they needed help with nail care and staff did not assist with hand hygiene prior to meals. A staff member delivered a meal tray and the resident began eating without hand hygiene being offered or performed.During an observation on 04/16/2026 at 1:30 PM, Resident #5 was in bed with long chin hair and unclean fingernails on the left hand.During an interview on 04/17/2026 at 3:03 PM, Certified Nursing Assistant #6 stated staff completed rounds prior to meals and provided hand hygiene and nail care, and on shower days staff assisted with shaving and grooming, and refusals were to be documented and reported.During an interview on 04/20/2026 at 10:40 AM, Licensed Practical Nurse #7 stated Resident #5 did not refuse grooming or nail care and would accept assistance if offered, and hand hygiene was typically performed after meals rather than before meals.During an observation on 04/20/2026 at 11:18 AM, Resident #5 continued to have visible chin hair.During an interview on 04/20/2026 at 11:20 AM, the Director of Nursing stated residents were expected to receive scheduled showers or have refusals documented, and staff were expected to assess skin, provide nail care, and remove facial hair during hygiene care, and provide hand hygiene prior to meals.2. Resident #247 had diagnoses including hemiplegia (one-sided paralysis) and hemiparesis (one (1)-sided muscle weakness) following cerebral infarction (brain tissue death from blocked blood flow), chronic diastolic heart failure (heart failure affecting the left side of the heart), and diabetes. The Minimum Data Set, dated [DATE] documented the resident was cognitively intact, required staff assistance with showering and personal hygiene, and did not exhibit rejection of care.During an observation and interview on 04/13/2026 at 11:42 AM, Resident #247 had beard growth approximately one (1) inch in length and stated they requested a shave three (3) days prior and had not received one.Review of Resident #247's Comprehensive Care Plan revised 04/08/2026 documented activities of daily living deficits due to a cerebrovascular accident (stroke) with right-sided weakness, and staff were to provide showers and hygiene care with the assistance of two (2) staff.Review of Resident #247's current Kardex (care plan reference tool used by staff to guide daily care) effective 04/16/2026 documented weekly showers on the Sunday overnight shift with assistance of two (2) staff.Review of Point of Care documentation from 03/23/2026 through 04/21/2026 revealed no documented evidence hygiene care was provided on 03/27/2026, 03/29/2026, 04/03/2026, 04/05/2026, 04/10/2026, 04/12/2026, 04/17/2026, and 04/20/2026, and no documentation the resident refused or staff reattempted care.Review of Resident #247's Treatment Administration Record from 03/01/2026 through 04/16/2026 revealed no documented evidence showers were provided.Additional record review revealed no documented evidence nursing staff identified missed hygiene care or implemented follow-up to ensure completion.During observations on 04/16/2026 at 4:40 PM and 04/17/2026 at 9:12 AM, Resident #247 continued to have beard growth approximately one (1) inch in length.During an observation and interview on 04/20/2026 at 10:31 AM, Resident #247 stated they received a shower on 04/17/2026 and requested assistance with shaving and follow-up did not occur.During an interview on 04/21/2026 at 11:18 AM, Certified Nursing Assistant #12 stated staff were expected to ask residents each shift if they wanted a shave and document all care and refusals in Point of Care.During an interview on 04/21/2026 at 11:34 AM, Licensed Practical Nurse #10 stated staff were expected to reapproach up to three (3) times if a resident declined hygiene care and document refusals in a progress note.During an interview on 04/21/2026 at 11:49 AM, Licensed Practical Nurse Manager #2 stated residents were to be shaved on shower days and as needed, and missed care was to be reattempted and reported.During an interview on 04/21/2026 at 12:54 PM, the Director of Nursing stated staff were expected to reattempt missed hygiene care and document refusals in a progress note or Point of Care.Title 10 New York Codes, Rules and Regulations 415.12(a)(3)

Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and did not ensure adequate supervision to prevent accidents for two (2) of eleven (11) residents reviewed (Residents #11 and Resident #49). Specifically, Resident #49 had multiple prepared medications left unattended at the bedside without an assessment or physician order for self-administration, and Resident #11 had unsafe smoking practices with access to smoking materials and an incomplete safety assessment.The findings include:Issue One (1):The facility policy, Medication Administration, last reviewed 08/12/2021, included medications shall not be left at the bedside unless the resident has a physician order and has been assessed for self-administration. The facility policy, Self-Administration of Medications by Residents, last reviewed 08/12/2021, included the interdisciplinary team determines if a resident is safe to self-administer medications.Resident #49 had diagnoses including mild dementia, diabetes, and chronic obstructive pulmonary disease (a lung disease that makes breathing difficult). The Minimum Data Set (a resident assessment tool) dated 01/30/2026 documented the resident was cognitively intact.Review of Resident #49's Comprehensive Care Plan last revised 12/14/2025 included risk for aspiration (food or liquid entering the lungs by accident) or choking related to dysphagia (difficulty swallowing). Review of Resident #49's electronic medical record revealed no assessment or physician order for self-administration of oral or inhaled medications.During an observation on 04/16/2026 at 9:00 AM, Resident #49 had multiple medications prepared and left unattended on the overbed table, including gabapentin (a medication used to treat nerve pain), metformin (a medication used to manage blood sugar), duloxetine (a medication used for mood and nerve pain), iron (a supplement), lactulose (a liquid medication used to treat constipation), Protonix (a medication used to reduce stomach acid), a nasal spray, and an inhaler. Licensed Practical Nurse #4 exited the room, leaving the medications unattended and accessible.During an interview on 04/16/2026 at 9:07 AM, Licensed Practical Nurse #4 stated they left the medications with Resident #49 and should not have.During an interview on 04/17/2026 at 1:52 PM, Registered Nurse Manager #1 stated medications should be administered at the bedside and not left with residents.During an interview on 04/20/2026 at 4:13 PM, the Director of Nursing stated residents may only have medications at the bedside if assessed and ordered for self-administration and leaving medications unattended is a safety concern.Issue Two (2):Review of the Resident Smoking Policy dated 12/16/2025 included residents must be assessed by the interdisciplinary team and deemed safe to smoke unsupervised, must store ignition devices in a secured location, must notify staff prior to smoking, and must smoke in designated areas at least 30 feet from the building.Resident #11 had diagnoses including hemiplegia (one-sided paralysis) and hemiparesis (muscle weakness on one side) following a stroke, and dementia. The Minimum Data Set, dated [DATE] documented the resident was cognitively intact.Review of Resident #11's Comprehensive Care Plan last revised 03/13/2026 included use of tobacco products against medical advice and required completion of a Smoking/Tobacco Safety Screen (a facility assessment tool) per facility policy. Review of the Smoking/Tobacco Safety Screen dated 03/18/2026 revealed Licensed Practical Nurse Manager #2 had electronically signed and four (4) required interdisciplinary team signatures were missing. Review of a progress note dated 01/09/2026 revealed Resident #11 exited the facility at 4:00 AM to smoke after obtaining the exit door code and had half-smoked cigarettes on the floor of the room with a smell of freshly lit cigarettes.During an observation on 04/13/2026 at 11:55 AM, a cigarette was observed on the floor of Resident #11's room near the dresser.During an interview on 04/14/2026 at 9:13 AM, Resident #11 stated they smoke, keep cigarettes and a lighter in the room, and go outside to smoke.During an observation and interview on 04/16/2026 at 10:58 AM, Resident #11's room was free of cigarette butts and the resident's hands and clothing were free of visible burn marks. Resident #11 stated they do not smoke in the room and only smoke outside.During an interview on 04/21/2026 at 10:39 AM, Occupational Therapist #3 stated the Smoking/Tobacco Safety Screen should include multiple disciplines and was not completed for Resident #11.During an interview on 04/21/2026 at 12:54 PM, the Director of Nursing reviewed the Smoking/Tobacco Safety Screen and stated the assessment was not complete and Resident #11 did not have a completed evaluation for safe smoking.Title 10 New York Codes, Rules and Regulations 415.12(h)(1)-(2)

Based on observations, interviews, and record review, the facility failed to ensure suitable, nourishing snacks were available and provided consistent with resident needs, preferences, and plan of care for two (2) of six (6) residents reviewed (Resident #45 and Resident #189). Specifically, Resident #45 and Resident #189 were offered only limited snack items and staff were unable to provide alternative snack options when those items were not desired or appropriate, and the facility did not sustain interventions to address ongoing concerns regarding snack availability.The findings include:The facility policy Resident Rights dated 02/05/2026 documented when providing care and services, staff must respect each resident's individuality and honor and value resident input to ensure self-determination and access to services within the facility.Resident #189 had diagnoses including protein-calorie malnutrition (a condition resulting from inadequate intake of protein and calories), anxiety disorder, and major depressive disorder. The Minimum Data Set (a resident assessment tool) dated 03/13/2026 documented Resident #189 was cognitively intact. An admission Minimum Data Set, dated [DATE] documented it was very important for Resident #189 to have snacks available between meals.Review of the comprehensive care plan revised on 12/08/2025 documented Resident #189 had potential for nutritional deficit related to depression and staff were to adjust meal plan based on intake with double portions of entree and vegetables at lunch and dinner. The care plan did not include interventions related to snacks between meals or resident snack preferences.Review of dietary progress notes documented on 10/21/2025 a dietary staff member met with Resident #189 to update food preferences and changes were made in the nutritional software system. Additional dietary progress notes did not reflect ongoing assessment or follow up related to snack preferences or availability.During an observation and interview on 04/15/2026 at 4:14 PM, Certified Nursing Assistant #8 distributed pudding, graham crackers, and soda to residents for snack. Certified Nursing Assistant #8 stated at times only pudding and applesauce were available to pass. Observation of the nourishment room revealed apple juice, orange juice, and milk in the refrigerator, saltine crackers and graham crackers in the cabinet, and the freezer was empty except for an ice pack and one (1) beverage.During an interview on 04/15/2026 at 4:48 PM, Resident #189 stated they received pudding for snack with no additional options offered and no one had discussed snack preferences. Resident #189 stated staff did not consistently provide double portions as ordered and produced a meal ticket dated 04/14/2026 documenting two (2) sandwiches were to be provided, however only one (1) sandwich was received.During an interview on 04/15/2026 at 8:43 AM, the Dietary Clerk stated they only had saltine crackers, graham crackers, applesauce, and pudding to serve residents. Dietary Clerk stated six (6) months prior the facility offered cookies, fig newtons, cheese crackers, and ice cream, however those items were no longer available. The Dietary Clerk stated residents complained daily regarding limited snack options and they reported concerns to the head of dietary and the Registered Dietitian, however, were told their hands were tied and additional snack options could not be provided.During an interview on 04/16/2026 at 10:15 AM, Licensed Practical Nurse #4 stated snacks available at the facility were limited and consisted primarily of crackers and pudding. Licensed Practical Nurse #4 stated some residents could not eat crackers and staff would purchase snacks outside of the facility for residents due to limited availability.Resident #45 had diagnoses including dysphagia (difficulty swallowing), congestive heart failure (a chronic, progressive condition where the heart cannot pump blood efficiently, causing fluid buildup in the lungs, legs, and body), and hypertension (high blood pressure). The Minimum Data Set, dated [DATE] documented Resident #45 was cognitively intact. An admission Minimum Data Set, dated [DATE] documented it was somewhat important for Resident #45 to have snacks available between meals.Review of current medical orders documented Resident #45 was ordered a regular diet with regular texture and thin liquid consistency.During an interview on 04/17/2026 at 1:53 PM, Resident #45 stated the facility did not regularly offer snacks and preferred snack items such as sandwiches, cookies, and ice cream were no longer available. Resident #45 stated only saltine crackers, graham crackers, and applesauce were offered.During an interview on 04/20/2026 at 11:10 AM, Certified Nursing Assistant #3 stated residents frequently complained there were not enough snacks available and snack options were limited to saltine crackers, graham crackers, and applesauce. Certified Nursing Assistant #3 stated staff purchased snacks for residents with personal funds due to limited options available in the facility.During an interview on 04/20/2026 at 1:48 PM, Administrator stated a food committee met monthly and staff attendance varied. Administrator stated snack availability and resident preferences had been an ongoing concern and prior efforts to obtain resident preferences were not effective due to lack of staff follow up and documentation. Administrator stated snack options were reduced due to cost considerations and the facility did not explore alternative options prior to reducing availability. Administrator acknowledged concerns raised by residents regarding food and snack options and stated dietary staff were responsible for follow up, however the process was not successful.Review of Resident Council Meeting Minutes dated 01/21/2026 included residents raised concerns regarding lack of snack availability including sandwiches, and an action was identified to stock nourishment rooms daily with bread, peanut butter, and jelly. Review of Resident Council Meeting Minutes dated 02/19/2026 included concerns regarding snack availability continued without evidence of resolution. Review of Resident Council Meeting Minutes dated 03/18/2026 included residents continued to request increased snack variety and improved food options without a documented action plan.Review of Food Committee documentation dated 03/19/2026 included residents expressed satisfaction with availability of bread and peanut butter and jelly, however peanut butter was not consistently stocked.Review of Food Committee documentation dated 11/20/2025 included a resident expressed concern regarding blood sugar levels and staff indicated bedtime snacks were available, however documentation did not reflect consistent availability or identification of specific snack items to meet resident needs.Title 10 New York Codes, Rules and Regulations 415.14(a)

Based on observations, interviews, and record review, the facility failed to ensure a sanitary, orderly, and comfortable environment for residents for three (3) of eight (8) resident units reviewed (Colonial Ridge South, Colonial Ridge North, and Maple Creek Meadows). Specifically, resident rooms and Resident #247's shared bathroom were observed in unsanitary condition, and Resident #48 who resided in a shared room did not have a privacy curtain in place to support a homelike and dignified environment.Issue One (1):The facility policy Daily Patient Room Cleaning and Common Areas revised 11/20/2018 documented bathroom toilets are cleaned inside and out with toilet cleaner, sanitizer is used on all horizontal surfaces, vertical surfaces are to be spot cleaned, and damp mop solution is used to mop the bathroom.Resident #247 resided in a shared room with access to a shared bathroom. The Minimum Data Set (a resident assessment tool) dated 04/01/2026 documented Resident #247 was cognitively intact.During an observation on 04/15/2026 at 11:18 AM, resident room [ROOM NUMBER] (Colonial Ridge South) had floors that were sticky and malodorous.During an observation on 04/15/2026 at 11:24 AM, resident rooms [ROOM NUMBERS] (Colonial Ridge South) had floors that were sticky and malodorous.During an observation on 04/16/2026 at 9:17 AM, Resident #247's shared bathroom (room [ROOM NUMBER] - Maple Creek Meadows) had brown liquid in the toilet bowl and a large quantity of clear malodorous liquid around the toilet on the floor.During an observation on 04/16/2026 at 4:40 PM, Resident #247's shared bathroom had yellow liquid and paper in the toilet bowl, yellow straw-colored liquid on the toilet seat, and a large quantity of clear malodorous liquid around the toilet on the floor.During an observation and interview on 04/20/2026 at 10:31 AM, Resident #247's shared bathroom had a strong smell of urine, and Resident #247 stated the bathroom is frequently in an unsanitary condition.During an interview on 04/21/2026 at 10:54 AM, Housekeeper #1 stated bathrooms are cleaned and sanitized once daily by Housekeeping staff, bodily fluids such as urine are to be cleaned by nursing staff, and Housekeeping staff disinfects the area after notification.During an interview on 04/21/2026 at 11:06 AM, the Housekeeping Supervisor stated resident rooms are cleaned and sanitized at least once daily, nursing staff are expected to clean larger volumes of bodily fluids, and Housekeeping staff disinfects the area after notification.During an interview on 04/21/2026 at 11:18 AM, Certified Nursing Assistant #12 stated nursing staff clean shared bathrooms daily and would clean any bathroom observed with urine, liquid around the toilet, or odor.During an interview on 04/21/2026 at 11:34 AM, Licensed Practical Nurse #10 stated nursing staff are expected to clean unsanitary bathrooms and notify Housekeeping staff.During an interview on 04/21/2026 at 11:49 AM, Licensed Practical Nurse Manager #2 stated shared bathrooms should be maintained in a sanitary condition and nursing staff are expected to clean and notify Housekeeping staff.Issue Two (2):The facility policy Resident Rights revised 02/05/2026 documented residents have the right to privacy, including maintaining private space through the use of privacy curtains in shared rooms.Resident #48 had diagnoses including dementia (a progressive condition affecting memory and cognition), heart failure (a condition in which the heart cannot pump blood effectively), and hypertension (high blood pressure). The Minimum Data Set, dated [DATE] documented Resident #48 had severe cognitive impairment and required assistance with personal hygiene and dressing.During an observation on 04/14/2026 at 2:58 PM, Resident #48 was observed in bed in a shared room on Colonial Ridge North without a privacy curtain in place, while three (3) other residents in the room had privacy curtains present.During an observation on 04/16/2026 at 9:44 AM, Resident #48 was sleeping in bed without a privacy curtain while another resident was seated in the room facing the bed.During an observation on 04/20/2026 at 10:24 AM, Resident #48 remained without a privacy curtain in place in the shared room.During an interview on 04/21/2026 at 9:02 AM, Certified Nursing Assistant #3 stated the privacy curtain should have been in place.During an interview on 04/21/2026 at 10:15 AM, Licensed Practical Nurse Unit Director #1 stated residents in shared rooms should have privacy curtains, and if a curtain is removed it should not be absent for longer than one (1) day.During an interview on 04/21/2026 at 11:38 AM, the Administrator stated residents in shared rooms should have privacy curtains in place.Title 10 New York Codes, Rules and Regulations, 415.5(a)(1), (h)

Based on observations, interviews, and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for one (1) of one (1) kitchen observed. Specifically, the facility did not ensure implementation of its established kitchen cleaning schedule, resulting in unsanitary kitchen conditions including grease accumulation on cooking equipment, damaged and dirty ventilation hood filters, and broken flooring with standing water and debris, which created the potential for food contamination. Additionally, there was a shortage of non-disposable plates and utensils for meal service.The findings include:Record review conducted on 04/21/2026 at 10:00 AM revealed the facility maintained a kitchen cleaning schedule which identified required cleaning frequencies, including ventilation hood system cleaning quarterly, kitchen floor cleaning daily, and oven and range cleaning semi-annually in May and November. There was no documented evidence to demonstrate the identified cleaning tasks were completed in accordance with the facility's established schedule.During an observation and interview on 04/13/2026 at 10:10 AM, the ventilation filters (devices designed to capture grease and vapors from cooking equipment) under the kitchen exhaust hood near the left side of the cook top area were observed to be damaged and open, creating spaces where grease and vapors could bypass the filtration system. Further observations revealed significant soiled black areas of grease and food debris on the backsplash, front, and sides of the oven and cook top units, creating a potential for contamination and pest attraction. The Food Service Director stated they were not aware the ventilation hood filters were damaged or not fitting properly and indicated they would notify maintenance. The Food Service Director stated they would arrange for cleaning of the cooking equipment and were not sure how often deep cleaning was completed.During an observation on 04/13/2026 at 10:12 AM, an approximately three (3) feet by three (3) feet section of broken floor tiles was observed under the steamer in the main kitchen, with standing water and food debris present, creating conditions conducive to bacterial growth and contamination.During an observation on 04/15/2026 at 11:30 AM, the ventilation hood filters remained damaged and ajar, the section of flooring remained in disrepair with standing water and debris, and the oven and cook top units remained heavily covered in grease and food debris. During an observation and interview on 04/15/2026 at 11:57 AM, on the kitchen tray line disposable plates were being used for meal service. The Food Service Director stated there were not enough non-disposable plates, more had been ordered about one (1) month ago and were on back order. The Food Service Director stated plates and silverware would just go missing and the kitchen was estimated to be short approximately 60 pieces of silverware and 100 plates.During an observation on 04/15/2026 at 12:10 PM, on the kitchen tray line disposable utensils were placed on trays being delivered to Maple Creek Unit and to Colonial Ridge Unit.During an interview on 04/15/2026 at 12:32 PM, Resident #45 was sitting at the Colonial Ridge Unit nurses' station eating their lunch. Resident #45 stated it would be nice if they could use real silverware and plates during their meals.Title 10 New York Codes, Rules and Regulations 415.14(h); Subpart 14-1.95, 14-1.96, 14-1.110(d), 14-1.170, 14-1.171(a), 14-1.175(b)

Based on observations, interviews, and record review, the facility failed to ensure an effective pest control program for one (1) of eight (8) resident units reviewed (Colonial Ridge South). Specifically, the facility did not ensure resident rooms were included in routine pest control inspections and treatments, resulting in the presence of small black flies within and around resident rooms.The findings include:Record review on 04/16/2026 at 2:00 PM revealed an undated pest control policy which documented procedures: A technician from a contracted licensed extermination service would make monthly and as needed visits to the facility Daytime services would involve making rounds to resident floors, administrative offices, common areas, pantries, day rooms, utility areas, as well as follow up on complaint sites.Record review of weekly pest control records from 11/26/2025 through 04/01/2026 revealed no documented evidence of inspection or treatment of resident rooms. There was no additional pest control documentation available for review after 04/01/2026.During an observation and interview on 04/15/2026 at 11:18 AM, there were four (4) small black flies on the wall within the bathroom of resident room [ROOM NUMBER] (Colonial Ridge South). The bathroom floors were sticky and there was a foul odor. During an interview at that time, a resident family member stated the presence of flies had been ongoing and previously brought to the facility's attention, and they used towels in the bathroom to swat the flies.During an observation and interview on 04/15/2026 at 11:24 AM, there were three (3) small black flies on the wall within the shared bathroom between resident rooms [ROOM NUMBERS] (Colonial Ridge South). The bathroom floors were sticky and there was a foul odor. The Director of Maintenance stated the residents' bathrooms in the Colonial Ridge building did not have exhaust, they were not aware of flies in resident rooms, and the pest control vendor was expected to handle all treatments and inspections.Title 10 New York Codes, Rules and Regulations 415.29(j)(5)

Based on observations, interviews, and record review conducted during an Abbreviated Survey (NY00333741) for six (Residents #16, #17, #18, #19, #20, and #21) of six residents reviewed, the facility did not ensure the environment remained free from accident hazards. Specifically, the facility did not ensure that all six residents who were identified as cigarette smokers had been assessed and care planned for safe smoking. This is evidenced by, but not limited to, the following: 1. Resident #16 had diagnoses including peripheral vascular disease and congestive heart failure. The Minimum Data Resident Assessment, dated 09/26/2024, documented that Resident #16 was cognitively intact. During an observation on 11/12/2024 at 8:05 AM, Resident #16 was seated in a wheelchair behind a stop sign on facility property, approximately 200-300 feet away from the facility, smoking a cigarette. During an observation on 11/13/2024 at 11:55 AM, Resident #16's cigarettes and lighter were in an unlocked drawer in their room, and an additional lighter was on the tray table. During an interivew at this time, Resident #16 stated that they put the cigarette butts in their pocket and then later give them to a family member to put in the garbage at home. 2. Resident #17 had diagnoses including peripheral vascular disease and heart failure. The Minimum Data Resident Assessment, dated 10/09/2024, documented that Resident #17 is cognitively intact. During an observation on 11/12/2024 at 8:20 AM, Resident #17 was observed seated in a wheelchair outside the facility door by the dumpsters, approximately 10-15 feet from the facility entrance. Approximately six cigarette butts were observed on the pavement by the dumpsters. 3. Resident #20 had diagnoses including cerebral infarction and conversion disorder with seizures or convulsions. The Minimum Data Resident Assessment, dated 10/12/2024, documented that Resident #20 is cognitively intact. During an observation on 11/04/2024 at 8:00 AM, Resident #20 was seated in a wheelchair approximately 10 feet from the Hickory [NAME] facility entrance smoking a cigarette. Four cigarette butts were observed on the pavement by the entrance. During an observation on 11/12/2024 at 8:10 AM, Resident #20 was seated in a wheelchair approximately 10 feet from the Hickory [NAME] facility entrance. A blanket was placed over their head and body with an opening at the face and mouth. A lit cigarette was sticking out of the opening. Five cigarette butts were observed on the pavement by the entrance. The facility was unable to provide any smoking assessments or care plans related to smoking for any of the six residents identified by the facility as smokers. During an interview on 11/06/2024 at 9:20 AM, the Director of Nursing stated that receptables for cigarettes butts are not provided by the facility because smoking is not allowed on facility property. The Director of Nursing said safety assessments for smokers and care planning for safe smoking are not completed because the facility is smoke-free, and maintenance staff pick up cigarette butts. During an interview on 11/12/2024 at 8:20 AM, the Director of Resident Care Services stated Resident #17 is not supposed to be smoking there, and that the facility is a smoke-free facility. During an interview on 11/12/2024 at 8:30 AM, the Director of Nursing stated providing receptacles may encourage residents to smoke. The Director of Nursing approached Resident #17 and asked them where they put their cigarette butts. Resident #17 stated the butts were thrown on the ground outside. During an interview on 11/13/2024 at 3:15 PM, the Assistant Director of Nursing stated residents' smoking paraphernalia should be locked up in a metal lock box as that is what was usually done when there were designated smoking areas. Review of the facility policy No Smoking, effective 03/13/2018 and revised 05/17/2024, revealed smoking is forbidden in all indoor and outdoor areas of the facility for residents, staff members, and visitors. Review of undated Admission Agreements, dated and signed by Residents #16, #17, #18, #19, #20, and #21, revealed that effective 12/09/2016, new admissions will not be granted smoking privileges on the campus. If the resident is admitted after this date, and wishes to smoke, they will have to find a location off campus to do so. All cigarettes and other smoking materials will be locked in the nursing supervisor's office and will not be allowed to be kept in the resident's room. 10 NYCRR 415.12(h)(1-2)

Based on observations, interviews, and record review conducted during an Abbreviated Survey (NY00339596, NY00342850, NY00343008), for six of six residents (Resident #6, #11, #12, #15, #16, and #23) reviewed, the facility did not ensure that the residents on multiple units were treated in a respectful and dignified manner. Specifically, Resident #6 stated staff do not like them and staff are not mean, but not nice either. Resident #11 was repeatedly ignored by a staff member during care when asking questions about their care, Resident #12's family member stated they overheard a staff member using foul language in the resident's presence, Resident #15 stated the Registered Nurse speaks nasty to them, Resident #16 stated that staff were not always respectful, and Resident #23 stated the nurse was nasty to them. This was evidenced by, but not limited to, the following: Review of the facility policy Resident Rights, revised 03/18/2024, revealed the policy aims to promote a resident-centered approach where residents are treated with dignity, respect, and sensitivity to their individual needs and preferences. 1. Resident #11 had diagnoses of paraplegia and depression. The Minimum Data Set Resident Assessment, dated 10/11/2024, documented that Resident #11 was cognitively intact. Review of Resident #11's current Comprehensive Care Plan included maintaining a friendly, pleasant, non-confrontation approach, demeanor, and attitude. During an observation on 11/06/2024 at 2:10 PM, Registered Nurse #1 entered Resident #11's room to complete a skin assessment. Resident #11 asked Registered Nurse #1 where they wanted to start and if they were checking the abdomen first. Registered Nurse #1 did not respond. Resident #11 asked how they wanted them to turn. Registered Nurse #1 again did not respond. Resident #11 stated this is what they (staff) do, they ignore the resident, they do not answer when the resident speaks, and act like the resident is not there. 2. Resident #15 had diagnoses including anxiety and severe depressive disorder. The Minimum Data Set Resident Assessment, dated 09/30/2024, documented that Resident #15 was cognitively intact. During an interview on 11/13/2024 at 12:45 PM, Resident #15 stated that they (staff) do not care. They also stated Registered Nurse #1 is a robot/android, speaks to them nasty, is short with them, not respectful, and acts like they do not care. 3. Resident #16 had diagnoses that included severe depressive disorder. The Minimum Data Set Resident Assessment, dated 10/11/2024, documented that Resident #16 was cognitively intact. During an interview on 11/13/2024 at 11:55 AM, Resident #16 stated that they (staff) call them sweetie, honey, or baby, and they should not call them by those names. Resident #16 stated they (staff) talk down to them like they are a child, and some staff are snotty and stuck up. Resident #16 stated the nurses and aides have answered their cell phones multiple times in the middle of care, specifically when changing their incontinence brief. During an interview on 11/13/2024 at 2:05 PM, the Director of Resident Care Services stated no one should be called honey, baby, or sweetheart. The Director of Resident Care Services also stated they have spoken to Registered Nurse #1 about how they come across to residents and that they should respond to Resident #11's questions. During an interview on 11/13/2024 at 2:45 PM, the Assistant Director of Nursing stated new employees receive a handbook at orientation that includes resident rights (to be treated with dignity). 10 NYCRR 415.5

Based on observations, interviews, and record review conducted during an Abbreviated Survey (NY00359178), for two (Residents #22 and #23) of three residents reviewed, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than two hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials in accordance with State law through established procedures. Specifically, the facility did not report allegations of abuse, neglect, or mistreatment involving Residents #22 and #23. The findings are: The facility policy Recognizing and Reporting Elder Abuse/Neglect - Criteria, revised 10/10/2024, included the results of all investigations must be reported to the Administrator or designated representative and to other officials in accordance with state law (including the state survey and certification agency). The policy included verbal and physical abuse. 1. Resident #22 had diagnoses including schizoaffective and bipolar disorders and malingering behavior (intentional act of exaggerating physical and psychological symptoms). The Minimum Data Set Resident Assessment, dated 11/05/2024, included the resident had moderate impairment of cognitive function. Review of statements obtained by the facility included: In a report titled Alleged Incident Date: 10/27/2024, the Assistant Director of Nursing documented that Resident #22 had reported to Registered Nurse Supervisor #1 that the nurse had the pulled them down the hall to their room on their stomach by their arms. Registered Nurse Supervisor #1 reported this allegation to the Director of Residential Care Services immediately. During an observation and interview on 11/04/2024 at 4:30 PM, Resident #22 had black and blue bruising to both knees. Resident #22 stated the nurse held their hands and dragged them down the hall on their stomach which caused the bruises on their knees. 2. Resident #23 had diagnoses including bipolar and conversion disorders (forms of mental illness). The Minimum Date Set Resident Assessment, dated 10/04/2024, included the resident was cognitively intact. Review of an undated and unsigned form titled Resident Interview and Observation revealed when Resident #23 was asked if staff, a resident, or anyone else at the facility had abused them, including verbal, physical, or sexual abuse, the resident's response was yes that they felt that the nurse had verbally abused them. The facility investigation, dated 11/08/2024, included that Resident #23 felt the Licensed Practical Nurse had verbally abused them. During an interview on 11/06/2024 at 3:00 PM, Resident #23 stated that they reported verbal abuse because the nurse is nasty and does not treat them appropriately. Additional interviews conducted on 11/06/2024 included the following: - At 8:40 AM, the Administrator stated they use the 2016 complaints manual and if the allegation is ruled out after two hours, the allegation is not reportable to New York State Department of Health. - At 11:05 AM, the Director of Resident Care Services stated they know they only have two hours to report, and after talking to staff, the allegation was unfounded and not reportable to New York State Department of Health. - At 11:20 AM, the Assistant Director of Nursing stated they interpreted Resident #22's and Resident #23's allegations as not reportable. - At 12:47 PM, the Director of Nursing stated that the definition of abuse included verbal and physical abuse, neglect, mistreatment, and misappropriation. They also stated if suspected abuse is reported, the investigation is started, and they have two hours to determine if abuse is suspected. If abuse is suspected, the allegation is reported to New York State Department of Health. If abuse is not concluded, the investigation is completed in 24 hours, and written up with the conclusion that abuse is not substantiated and not reportable. The Director of Nursing added that the 2016 (New York State) complaint manual is used (versus the federal guidelines). 10 NYCRR 415.4(b)(1)(i)

Based on observations, interviews, and records review conducted during the Recertification Survey completed 11/27/23 to 12/1/23 it was determined that for one (Hickory [NAME] Upper Level) of eight resident units, the facility did not maintain an effective pest control program. Specifically, small brown flies and fruit flies were present and untreated. The findings are: Observations on 11/27/23 at 12:11 PM included multiple small brown flies that appeared to be fruit flies in resident room [ROOM NUMBER] (Hickory [NAME] Upper Level). Observation on 11/27/23 at 12:42 PM included two visible fruit flies near a meal cart in the Hickory [NAME] North Hallway. Observations on 11/27/23 at 1:09 PM included a fruit fly in resident room [ROOM NUMBER]. Observations on 11/28/23 at 10:43 AM included several fruit flies in resident room [ROOM NUMBER] and several napkins and tissues on the floor with several fruit flies. During an interview at this time, Resident #41 stated that they (facility) have not done anything, and they (the flies) are in other rooms too. Observations on 11/28/23 at 12:45 PM included more than a dozen small brown flies that appeared to be fruit flies located in resident room [ROOM NUMBER] (Hickory [NAME] Upper Level). The flies were in the air, on the wardrobe, the wall, the door frame, and on the privacy curtain. During an interview at this time, Resident #41 stated the fruit flies get on their food and then it is contaminated. Observations on 11/28/23 at 2:45 PM included dozens of small brown flies in the Hickory [NAME] Upper Level soiled utility room. The flies were in the air, on the walls, on the soiled linen and on the trash bags. During an interview at this time the Maintenance Technician stated that they have a pest vendor that comes in but is not sure how often. Record review on 11/30/23 at 9:20 AM included a pest vendor service report dated 11/28/23 that included treatment of room [ROOM NUMBER] for fruit flies. The report also listed the comment: 'unable to locate the source of fruit fly activity.' There were no additional pest vendor reports provided to show that fruit flies had been identified or treated. During an interview at this time, the Director of Facilities (DOF) stated that if staff notice pests, they generally call maintenance or the administrator to have them follow up with the vendor. The DOF also stated that they searched the past couple months of work orders and could not find anything related to fruit flies. Observations on 12/1/23 included a significant amount of fruit flies in the Hickory [NAME] Upper Level soiled utility room and the exhaust ventilation in the room was not functional. 10 NYCRR: 415.29(j)(5)

Based on observations, interviews, and record review conducted during the Recertification Survey 11/27/23 to 12/1/23, it was determined that the facility did not ensure compliance with all applicable State codes. Specifically, the facility was not in compliance with Section 915 of the 2015 Edition of the International Fire Code as adopted by New York State, which requires the use of carbon monoxide (CO) detection in a building that has fuel-burning appliances. The findings are: On 11/27/23 at 10:43 AM it was observed that a Universal-brand, single-station CO detector was located on the wall in the corridor next to room [ROOM NUMBER] (Colonial Ridge). In an interview at this time, the Maintenance Technician (MT) stated that the detector is battery-operated, and they had tested it maybe two to three months ago. On 11/27/23 at 11:49 AM it was observed that a single-station, CO detector was located on the top of the light switch in the boiler room (Hickory [NAME] lower level). Further observations in this room included natural gas-powered boilers. In an interview at this time, the MT stated that the CO detector was removed from the wall because it was beeping. On 11/28/23 at 9:28 AM it was observed that a Universal-brand, single-station CO detector was located on the wall in the boiler room (Maple Creek lower level). Further observations included printed instructions by the manufacturer on the back of the CO detector which included 'press test/silence button weekly.' On 11/28/23 at 9:54 AM it was observed that a First Alert-brand, single-station CO detector was located on the wall in Laundry next to four natural gas-powered dryers (Maple Creek lower level). Record review on 11/28/23 at 11:04 AM included a facility log titled 'Carbon Monoxide Detector Test.' The log included documentation that some of the CO detectors in the facility were tested on [DATE]. Further review included that the CO detectors located in the Hickory [NAME] and Maple Creek boiler rooms had not been tested since 5/8/23. No documentation was provided to show that the CO detector in the Laundry had been tested or that other CO detectors in the facility had been tested at least monthly. In an interview at this time, the MT stated that they are testing CO detectors quarterly, and that when they changed the log form in August, they forgot to include the boiler room CO detectors on the new log. The 2015 Edition of the International Fire Code requires that carbon monoxide alarms shall be maintained in accordance with NFPA 720. The 2012 Edition of NFPA 720, Standard for the Installation of Carbon Monoxide Detection and Warning Equipment, requires that single-station carbon monoxide alarms shall be inspected and tested in accordance with the manufacturer's published instructions at least monthly. 10NYCRR: 415.29(a)(2), 711.2(a)(1), 42 CFR: 483.70(b), 2015 IFC: Section 915, 915.6 2012 NFPA 720: 8.7.1

Based on observations, interviews, and record review conducted during the Recertification Survey completed on 11/27/23 to 12/1/23, it was determined that for six (Colonial Ridge North, Colonial Ridge North, Maple Creek Meadows, Maple Creek Valley, Hickory [NAME] Upper Level, Hickory [NAME] Lower Level) of eight resident units the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically: furniture and equipment were damaged, exhaust ventilation was not functional, there was wall damage and missing ceiling tiles, fabric lining corridor walls was pilling and had stains, floors and walls were dirty, there were damaged heater covers, and a dirty oxygen concentrator. The findings are: Review of the facility policy titled 'Daily Patient Room Cleaning and Common Areas' last revised 11/20/18 included the following: a) Spot clean walls: vertical surfaces to be spot cleaned. b) Mop underneath beds and move furniture as necessary. Observations on 11/27/23 at 11:08 AM included the exterior surfaces of the Airsep-brand oxygen concentrator located in resident room [ROOM NUMBER] (B-Bed, Colonial Ridge North) was soiled. In an interview at this time, the Maintenance Technician (MT) stated that the concentrator needed to be cleaned. Observations on 11/27/23 at 11:24 AM included seats on two wheeled stools in the Colonial Ridge North dining room had no vinyl covering exposing the underlying foam. Observations on 11/27/23 at 1:25 PM included the Maple Creek Meadows soiled utility room next to room [ROOM NUMBER] contained multiple bins of soiled linen and lacked a hand washing sink. Water valves were present extending from the wall, however, there was no hand-wash sink fixture. Observations on 11/27/23 at 1:36 PM included that the monitor on the Dectecto-brand electronic scale located in the corridor on Maple Creek Meadows was broken off the swivel ball socket below and was being held together with zip ties. Further observations included that the protective wire insultation was worn where electrical wires entered the scale monitor, exposing a portion of the wires. In an interview at this time, the MT stated that they put the zip ties on to hold the top of the scale together to the piece of rubber that would normally be there. Observations on 11/27/23 at 2:22 PM included that there was no exhaust ventilation grate present in the ceiling tiles of the bathroom in resident room [ROOM NUMBER] (Maple Creek Valley). Observations on 11/28/23 at 12:45 PM included wall damage in the bathroom of resident room [ROOM NUMBER] (Hickory [NAME] Upper Level). There was an approximately two-inch by six-inch section of the wall near the grab bar that was cracked and damaged and several small holes where it appeared that screws had been pulled out of the wall. Observations on 11/28/23 at 2:38 PM included the heater cover in the 500 unit shower room (Hickory [NAME] Upper Level) was rusty, bent, jagged at the base, and had come off of the heating unit. Observations on 11/29/23 at 2:00 PM included large sections of missing drywall exposing the wall studs located around electrical panels in the Maple Creek Valley soiled linen room. Further observations in this room included multiple ceiling tiles were missing. Observations on 11/29/23 at 2:12 PM included the exhaust ventilation was not functioning in the Hickory [NAME] Upper Level men's bathroom and the Hickory [NAME] Lower Level men's locker room. In both rooms there was a heavy urine and fecal odor and when a small piece of paper was placed against the ceiling exhaust grates there was no air draw observed. On 11/30/23 at 8:53 AM the Surveyor was provided with a facility binder titled 'Rooftop/exhaust Vents' for review. Review of this binder revealed quarterly preventative maintenance checklists of rooftop ventilation items including, but not limited to: check [NAME] alignment, check electrical connections in motor switches, check belt tensions. Further review included that the last time that the rooftop/exhaust units were documented to be checked by facility staff was 4/12/18 (Colonial Ridge), 1/4/19 (Maple Creek), and 1/10/19 (Hickory [NAME]). During a interview at this time the Director of Facilities (DOF) stated that they didn't give the surveyor the right binder and they thought they had a new one. During an interview on 11/30/23 at 10:15 AM, the MT stated that the new ventilation check log got damaged by water around September of this year. During an interview on 11/30/23 at 3:06 PM, the MT stated after review of the bathroom in resident room [ROOM NUMBER] (Maple Creek Valley) it looked like the construction crew had not fully connected the grate to the exhaust ventilation. Observations on 12/1/23 at 9:20 AM included a dried, brown spill measuring approximately three feet long by one foot wide under the head of the bed in resident room [ROOM NUMBER] (A-bed, Colonial Ridge North). Further observations included brown splatter present on the wall behind this bed. Additional observations included the resident's television was placed on top of a small, unstable box on top of a nightstand. In an interview at this time, Resident #54 stated: that they had not spilled anything in their room in several days and they could not see their television without it being on top of the box. The Minimum Data Set assessment dated [DATE] documented that the resident was cognitively intact. Observations on 12/1/23 at 9:30 AM included that the red fabric lining the lower three feet of the corridor walls on Colonial Ridge South (East Wing) had significant pilling in sections throughout and had multiple stains. In an interview at this time, the Registered Nurse Assistant Director for Resident Care stated that residents will sit in chairs along the wall, which slides against the fabric causing the pilling. Observations on 12/1/23 at 9:47 AM included the exhaust ventilation was not functioning in the Hickory [NAME] Upper Level soiled utility room (near the 700/800 Nurse Station). When a small piece of paper was placed against the ceiling exhaust grates there was no air draw observed. Observations on 12/1/23 at 10:05 AM included the exhaust ventilation was not functioning in the Hickory [NAME] Upper Level tub room across from resident room [ROOM NUMBER]. When a small piece of paper was placed against the ceiling exhaust grate there was no air draw observed. Observations on 12/1/23 at 10:09 AM included the exhaust ventilation was not functioning in the Colonial Ridge North soiled utility room (near the entrance to unit). When a small piece of paper was placed against the ceiling exhaust grate there was no air draw observed. During an interview on 12/1/23 at 10:41 AM, the DOF stated that they would check on the ventilation and it was possible that a belt broke in the last month or so. During an interview on 12/1/23 at 12:29 PM, the DOF stated that the exhaust ventilation in the Hickory [NAME] Upper soiled utility room works if you hold a tissue to the grate, but the ventilation in the other rooms appeared to not be pulling. 10 NYCRR: 415.29, 415.29(B), 415.29(d), 415.29(i)(3), 415.29(h)(1), 415.29(j)(1), 713-2.5(c)(6)

Based on observations, interviews, and record review conducted during a Recertification Survey 11/27/23 to 12/1/23, it was determined that for one of one main kitchen and two (Maple Creek Valley, Hickory [NAME] Upper Level) of eight resident units the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically: potentially hazardous foods were not cold held at or below 45 degrees ( ) Fahrenheit (F), cooking equipment was not maintained in good working order, non-food contact surfaces were dirty, food items and utensils were stored beneath unprotected sewer pipes, there was moldy bread, and food was not protected from contamination. The findings are: Review of the facility policy 'Food Preparation' last revised 7/6/23 included the following: a) All staff will practice proper hand washing techniques and glove use. b) Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. c) All foods will be help at appropriate temperatures, greater than 135 F (or as state regulation requires) for hot holding, and less than 41 F for cold food holding. Review of the facility policy 'Food Storage' last revised 7/6/23 included the following: a) Dry food supplies will be stored at least six inches above the floor in a clean, dry, ventilated room that is not subject to wastewater back flow. b) Spoiled food should be removed from storage promptly to prevent contamination of other foods. Observations in the main kitchen on 11/27/23 at 10:20 AM included stainless steel pans of pureed macaroni salad, pureed turkey, and pureed chicken being held in a steam table. When measured by the surveyor using a 'EXTECH' digital thermometer the temperatures were as follows: pureed macaroni salad - 78 F to 81.4 F, pureed turkey - 53 F, and pureed chicken - 65 F to 69 F. When interviewed at this time, the Food Service Director (FSD) stated the temperatures are too warm and that these items are for the lunch meal that starts serving at 11:00 AM. Further observations included that the water below the pans in the steam table was 61 F and one of the bays of the steam table adjacent to the pureed items was set for hot holding of a separate food item. Further interview with another food service worker (cook) revealed the items had been prepared about 20-minutes ago. Observations in the main kitchen on 11/27/23 at 10:27 AM included a two-compartment 'Cleveland' brand convection steamer and a large soup kettle that were not currently in use. When interviewed at this time, the FSD stated that they did not believe the steamer and soup kettle worked. During a subsequent interview, a Food Service Worker stated that neither item has worked for about two years and they believed that they had sent a work order to maintenance a long time ago. Observations in the main kitchen on 11/27/23 at 10:32 AM included the exhaust hood and grease traps located above the skillet, range, and deep fryers were heavily coated in dust and grease. Additionally, two of the grease traps were observed to be damaged and not tightly fitting into the hood. During an interview at this time, a Food Service Worker stated that they have been cleaning them and the last time was probably seven-months ago. The Food Service Worker also stated that they did not think a vendor comes in to clean the exhaust hood. Observations on 11/27/23 at 2:01 PM included a black-speckled substance on the interior upper lip of the ice machine located in the Maple Creek kitchen. Observations on 11/27/23 at 2:05 PM included open boxes of straws, spoons, single use containers of jellies, and other assorted condiments stored in a cabinet directly under the drainpipe for the handwash sink located in the Maple Creek Valley nourishment room. Observations on 11/28/23 at 2:42 PM included small spots of bluish-gray mold on a loaf of bread located on top of the refrigerator in the Hickory [NAME] upper level 500-Unit nourishment room. The plastic bag for the bread was marked '100% Whole Wheat Best By 10/25/23'. Observations in the main kitchen during food service tray line on 11/30/23 from 11:27 AM to 12:00 PM included a dietary aide removed pureed food off a plate with a gloved finger, handled dirty bowls, and then used the same gloved hand to grab a handful of lettuce salad and put it in a bowl on a tray for service. Additionally, a dietary cook was observed to wipe their gloved hands on a dish towel that had spaghetti sauce on it, then proceeded to pick up garlic bread with the same gloved hands and placed it on a plate for service. 10 NYCRR: 415.14(h); 10 NYCRR: Subparts 14-1.31(a), 14-1.40(a), 14-1.43(b), 14-1.20(b), 14-1.95, 14-1.110(d) 47642

Based on observations, interviews, and record reviews conducted during the Recertification Survey from 11/27/23 to 12/1/23, it was determined that for one (Hickory Knolls) of four medication carts reviewed for medication storage, the facility did not ensure that all drugs and biological were properly stored in accordance with State and Federal Laws. Specifically, multiple loose unlabeled pills were observed stored in a drawer of one medication cart. This is evidenced by the following: The facility Nursing Home Policy and Procedure, Drug Procurement, Storage, and Inspection, dated 2/20/12 documented that the responsibility for control of medications within this facility rests with Professional Nursing Staff (Registered Nurses-RNs and Licensed Practical Nurses-LPNs). During an observation on 11/29/23 at 8:46 AM, 39 loose unlabeled pills (medications) of varying colors, size and shape were in a drawer of one of the medication carts on the Hickory Knolls resident care unit. LPN #2 stated at this time they were unable to identify the pills. LPN #2 stated they were not sure who was responsible for cleaning medication carts. During an interview on 11/29/23 at 9:20 AM LPN #3 Unit Manager stated it was the responsibility of the medication nurse to clean the top of the medication cart and check medication expiration dates but was unsure of who was responsible for cleaning the drawers. In an interview on 11/29/23 at 12:35 PM the Director of Nursing (DON) stated the responsibility of the medication cart cleanliness is the night nurse. The night shift Shift Charge Nurse Duties form, reviewed with the DON at this time, did not include the responsibility for cleaning the medication cart drawers. 10 NYCRR 415.18(e)(1-4)

Based on observations and interviews, conducted during the Recertification Survey from 11/27/23 to 12/1/23, it was determined that the facility did not implement the appropriate standard for use of Personal Protective Equipment (PPE) and transmission-based precautions (TBP) by all staff on one of six resident care units reviewed for TBP. Specifically, a medical professional was observed on multiple occasions with inappropriate wearing of a face mask while on a TBP unit with several positive COVID-19 residents. This is evidenced by the following: The facility policy, COVID- 19 Vaccine Policy and Procedure documented; All staff and visitors should adhere to the core principles of COVID- 19 prevention (hand hygiene, face covering, instruction signage throughout the facility, proper visitor education on COVID- 19 signs and symptoms, frequent cleaning/ disinfection of high-touch surfaces, appropriate PPE use, effective cohorting of residents, and resident and staff testing). During an observation on 11/29/23 at 12:13 PM, Physician #1 was walking on a resident care unit that had multiple active positive COVID-19 cases including observed speaking with a resident who was on TBP for COVID-19. Physician #1 had their face mask pulled down with both their nose and mouth uncovered. During an observation and interview on 12/1/23 at 12:13 PM, Physician #1 was on a TBP unit (currently with multiple COVID-19 positive residents residing) conversing with staff who were approximately two feet away. Physician #1 again had their face mask pulled down under their chin exposing their mouth and nose and a resident within six feet proximity. During an immediate interview Physician #1 stated that all facility staff were required to wear a face mask, but that they did not believe in masking because it has yet to prevent the spread of COVID- 19 and that further they also remove their mask when talking to residents who are positive with COVID-19. During interviews on 12/1/23 at 12:33 PM and at 1:12 PM, with the Infection Preventive (IP) and the Director of Nursing (DON), the IP stated that all staff were expected to appropriately wear a face mask including the medical providers. The IP said that they have had to speak to Physician #1 regarding masking concerns in the past. The IP said the mask requirement was reinstated at the beginning of October 2023 and they have signage on all entrance doors and throughout the facility regarding positive COVID-19 in the facility. Additionally, Physician #1 is part of their call system that updates staff when face masks were to be worn. The DON stated that Physician #1 has also been heard discouraging residents from getting the COVID-19 vaccine and has repeatedly been told to mask while in the facility. 10 NYCRR 415.19

Based on observations, interviews and record review conducted during the Recertification Survey and complaint investigation (#NY00316076) from 11/27/23 to 12/1/23, for one (Resident #41) of two residents reviewed for personal funds, the facility did not act as a fiduciary (trustee) of the resident's funds and hold, safeguard, manage, and account for the residents' personal funds deposited with the facility. Specifically, Resident #41 did not receive their entitled monthly Medicaid funds for an extended period of time or notify the resident if funds were no longer available to the resident. This is evidenced by the following: Review of facility policy Resident Personal Funds, dated reviewed June 2022, included that a computerized accounting system was used to maintain individual ledgers for each account and that full accounting of all transactions are maintained by the Business Office in accordance with all applicable government regulations. Resident #41 was admitted to the facility with diagnoses that included obsessive compulsive disorder (OCD), generalized anxiety, and bipolar disorder. The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #41 was cognitively intact. Review of Resident #41's Admission Record Payer Information revealed Medicaid as the primary payer and Medicare as a subsequent payer. During an interview on 11/29/23 at 1:15 PM, Resident #41 said they did not have any money to pay for a haircut, and last received a haircut in June 2023. During an interview on 11/29/23 at 2:04 PM, the Business Office Manager (BOM) said that when Resident #41 was originally admitted in June 2020, they received Social Security Income (SSI) payments ($35 per month) and had a private representative payee (also known as rep-payee or person or organization who receives and manages Social Security or SSI benefits for an individual who cannot self-manage). The BOM said that on 1/11/21, the facility applied to become the Resident #41's 's rep payee, which was accepted, and on 1/12/21, payments stopped due to the former rep payee returning the monies. The BOM said that the facility never received any money for Resident #41 and that Social Worker (SW) #2 contacted them on 11/28/23 (after surveyor intervention) and they reapplied for direct deposit of the resident's monies and submitted for SSI payments to be sent directly to the facility. During an interview on 11/30/23 at 1:26 PM, Resident #41 stated that until June 2023, they were cutting their hair themselves and they could not recall if a staff member had ever asked if they wanted a haircut. Resident #41 stated that a church member had offered them $40 for a haircut when at the time, their hair was approximately a foot long and getting in their mouth. During an interview on 12/1/23 at 11:13 AM, the Administrator stated they paid for Resident #41's haircut in June (2023) because the resident wanted one and did not have any money. The Administrator said at that time, they reached out to the BOM and requested they look into the resident's source of income. Upon review of emails, the Administrator said an email dated 6/6/23 from the BOM included that Resident #41 had never had any money in their personal account and did not have any resident income. The Administrator said they were unsure of what occurred between January 2021 and the present to the resident's source of income. During an interview on 12/1/23 at 10:49 AM, SW #2 said the facility was investigating this issue (lack of resident's income) for some time. SW #2 said that per the BOM, there was a hold on the resident's funds (unsure why) and that the facility was approved to be the resident's rep payee the day prior. Between January 2021 and current, SW #2 stated they were unsure what happened to the resident's income, as other Social Workers had been assigned to Resident #41. 10 NYCRR 415.3(h)(1)

Based on interviews and record reviews conducted during a Recertification Survey from 11/27/23 to 12/1/23, it was determined that for three (Residents #75, #241 and #242) of three residents reviewed for transfer and/or discharge, the facility did not notify the resident, the resident's representative, and/or the Ombudsman of the transfer and/or discharge and the reasons for the transfer and/or discharge in writing in a language and manner that they understood. Specifically, the facility could not provide evidence that the notification of a transfer and admittance to the hospital (Resident #75) was provided in writing to the resident, the resident's representative, or the Ombudsman and could not provide evidence that the Ombudsman was notified of facility initiated discharges home (Residents #241 and #242). The findings are: The facility Policy Notice of Transfer/discharge date d reviewed on 8/23/21, documented to notify residents, and if known, family members/legal representatives of discharges/transfers before they occur and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. The policy also documented Social Services or designee will complete and give discharge/transfer notices. 1.Resident #75 had diagnoses including diabetes, urinary retention, and enterocolitis due to clostridium difficile (inflammation of the colon caused by a bacteria). The Minimum Data Set (MDS) Assessment, dated 10/10/23, documented Resident #75 was cognitively intact. Review of progress notes revealed Resident #75 was sent to the Emergency Department on 10/4/23 and admitted to the hospital. The resident's emergency contact was notified of the transfer on 10/4/23 at 11:15 AM verbally. There was no documented evidence that a written notification of the reason for the transfer/discharge in a language and manner that they understood was provided to the resident or their representative or to the State Ombudsman Office per the regulations. 2. Resident #241 was admitted to the facility with diagnoses that included a femur (leg) fracture, hypertension, and muscle weakness. The Discharge MDS Assessment documented the resident was discharged from the facility to home on 11/1/23. 3.Resident #242 was admitted to the facility with diagnoses including a femur fracture, osteoarthritis, and tremors. The Discharge MDS Assessment documented that the resident was discharged from the facility to the hospital on 10/11/23. Review of a Social Work Progress Note dated 10/13/23 revealed that the resident was discharged home (not to the hospital) on 10/13/24 (not 10/11/24 per the MDS). During an interview on 11/29/23 at 5:25 PM the Administrator stated that medical records should notify the Ombudsman of transfers and discharges and this was usually done once a month per the Ombudsman request. In an interview on 12/1/23 at 8:17 AM Medical Records Staff Member #1 stated the Ombudsman notification was completed by the Social Worker (SW). During an interview on 12/1/23 at 8:21 AM SW #1 stated they notify the Ombudsman of a transfer to the hospital if the Ombudsman was working with a specific resident and requested it but that they do not notify the Ombudsman regarding all transfers and discharges. SW #1 stated they were unsure if the Ombudsman got a document monthly (from the facility) related to discharges as medical records department does not provide that. In an interview on 12/1/23 at 8:49 AM SW #2 stated they were not sure if the residents or family (representatives) were notified in writing when a resident is transferred to the hospital. SW #2 was aware the Ombudsman had stopped receiving the transfer and discharge notifications since the previous Administrator was at the facility approximately two years ago. During an interview on 12/1/23 at 8:55 AM the Administrator stated Social Work is responsible for sending the transfer notices to the resident and/or family and medical records would be responsible for sending a copy to the Ombudsman Office monthly. The Administrator stated there was a breakdown in communication and they were not aware written notification was not being provided. Documented evidence of Ombudsman notification was requested and in an emailed correspondence dated 12/1/23 at 9:44 AM, the Administrator wrote that there was no Ombudsman notification of the discharges. 10 NYCRR 415.3(i)(1)(iii)(a-c)

Based on interviews and record reviews conducted during a Recertification Survey from 11/27/23 to 12/1/23, it was determined that for one (Resident #75) of three residents reviewed for transfer and/or discharge, the facility did not ensure that residents or resident's representatives were notified in writing of the facility Bed Hold Policy. Specifically, Resident #75 was transferred to the hospital and the facility was unable to provide evidence that the facility Bed Hold Policy was given to the resident or their representative. The findings are: The facility Policy Bed Holds and Therapeutic Leaves reviewed 8/3/21, documented the facility shall provide written information to the resident and/or to their family member or legal representative about the bed hold policy when a resident is transferred to the hospital. Resident #75 had diagnoses including diabetes, urinary retention, and enterocolitis due to clostridium difficile (inflammation of the colon caused by a bacteria). The Minimum Data Set Assessment, dated 10/10/23, documented Resident #75 was cognitively intact. Review of progress notes revealed Resident #75 was sent to the Emergency Department on 10/4/23 and was admitted to the hospital. There was no documented evidence that the facility provided the facility's Bed Hold policy to the resident and/or the resident's representative. During an interview on 11/29/23 at 1:15 PM Unit Clerk #1 stated that when a resident was being transferred to the hospital that they would call medical records and medical records would call the family and go over the bed hold information. In an interview on 12/1/23 at 8:17 AM Medical Records staff #1 stated that medical records do not send out the bed hold policy information to the resident and/or the resident's representative. During an interview on 12/1/23 at 8:21 AM Social Worker (SW) #1 stated the Bed Hold policy information was in the admission paperwork and is not provided upon transfer as it was only provided to the residents and/or the residents representative on admission to the facility. In an interview on 12/1/23 at 8:49 AM SW #2 stated providing the Bed Hold policy was based off a certain census number and they were not sure of what that number was and that they should reinitiate providing the policy with transfers (to the hospital). During an interview on 12/1/23 at 8:55 AM the Administrator stated Social work is responsible for sending the Bed Hold policy to the resident and/or family. The Administrator stated there was a breakdown in communication and they were not aware the policy was not being provided. 10 NYCRR 415.3(i)(3)(i)(a)

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of one main kitchen, the facility did not store, prepare, distribute and serve food under sanitary conditions. Specifically, food was contaminated by condensate in the walk-in freezer and a drain pipe from an ice machine was below the top of the funnel going into the sewer system. This is evidenced by the following: 1. Observation conducted on 11/26/18 at 10:23 a.m., during the initial walk through of the Main Kitchen with the Director of Food Service and Assistant Director of Food Service, there was condensation dripping from the insulated line below the evaporator in the walk-in freezer. There was frozen condensate found on boxes of frozen potato wedges and frozen egg patties. The Director of Food Service said that was a new concern and he would contact maintenance for repair. During an obseration on 11/28/18 at 10:43 a.m., there was condensation dripping from an insulated line below the evaporator in the walk-in freezer. Frozen condensate was found on boxes of frozen formed potatoes, frozen potato chips and a box of hamburger patties which contained an open bag. In an interview at that time, the Director of Food Service stated that he would be more concerned if the items were not in plastic packaging. He said the burgers would be more of a concern. The Director of Food Service did not take corrective action while the surveyor was present. During an observation and interview on 11/30/18 at 11:20 a.m., the Director of Food Service and the surveyor returned to the walk-in freezer. The Director of Food Service said that he had removed the ice buildup but it was starting to build back up. There were three boxes of frozen food on the top shelf with a small amount of ice buildup. There was a box of potato wedges and an open box of frozen egg patties below the condensate line of drip. The Director of Food Service said maintenance had contacted the refrigerant contractors but they had not shown up yet. 2. In an observation on 11/26/18 at 2:24 p.m., the drain for the ice machine in the Hickory Knoll Dining Room was below the top of the funnel for the sewage system. In an interview at that time, a Maintenance Worker stated that he was unaware that the drain was not right. He said he would cut the drain pipe a little. (10 NYCRR14-1.43, 14-1.44)

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #134) of five residents reviewed for pain, the facility did not develop a person centered Comprehensive Care Plan (CCP) that included measurable goals and interventions to meet the resident's medical, physical, and nursing needs. Specifically, there was no care plan, developed that addressed the presence of or management of the resident's pain. This is evidenced by the following: The facility policy, Pain Assessment/Management, revised (MONTH) (YEAR), included for staff to document the resident's pain management plan on their CCP. Resident #134 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 9/17/18, revealed that the resident had moderately impaired cognition, no speech, and was rarely or never understood. The pain interview was not able to be completed with the resident and staff reported no signs or symptoms of pain observed. The current CCP and the Visual/Bedside Kardex Report (care plan used by Certified Nursing Assistant-CNA) did not include pain management. Current physician orders [REDACTED]. Review of Medication Administration Records (MAR) revealed the resident received 3 doses of [MEDICATION NAME] for pain levels ranging from 3 to 5 in (MONTH) (YEAR) and 14 doses for pain levels ranging from 2 to 7 from 11/1/18 through 11/27/18. The [MEDICATION NAME] was noted to be effective. Review of nursing progress notes from, 11/1/18 through 11/27/18, revealed that nursing frequently evaluated the resident for pain. The resident at times denied pain or discomfort and at times presented as weepy and crying which was sometimes attributed to feeling sad, down, or being in pain. Review of medical visit notes in (MONTH) (YEAR) and (MONTH) (YEAR) did not include any assessment and/or plan related to pain. Observations and interviews included the following: a. On 11/26/18 at 11:55 a.m., the resident was heard crying out. Two staff members asked her what was wrong, and she was able to tell the second staff member that she had pain in her right arm. A later review of the MAR indicated [REDACTED]. b. On 11/27/18 at 10:09 a.m., the resident appeared comfortable. When asked at that time if the pain in her right arm was better, she shook her head no. c. On 11/28/18 at 12:36 a.m., when asked if she had any pain, the resident said, yes. A family member who was present at that time added that the resident had a stroke that left her paralyzed on her right side and that some days are better than others, but she does have on-going pain in her right arm. d. When interviewed on 11/30/18 at 8:32 a.m., the CNA stated the resident can say if she is in pain but cannot tell you where her pain is due to her trouble speaking. e. In an interview on 11/30/18 at 8:53 a.m., the Licensed Practical Nurse (LPN) stated that the resident was crying quite a bit on and off that morning. When asked if she had pain, the resident told the LPN yes but because she had difficulty with getting her words out she was not able to tell the nurse where her pain was located. The LPN gave the resident some [MEDICATION NAME] which seemed to help. The LPN said she was not sure if the resident needed routine pain medication because she also gets upset when her husband leaves the room. The nurse thought sometimes her crying was related to depression and anxiety rather than pain. f. In an interview on 11/30/18 at 2:08 p.m., the Registered Nurse (RN) stated that pain assessments are done for all residents twice daily. If the CNA notices the resident has pain during care, he/she would be expected to notify the nurse, and the nurse would evaluate the resident for pain and medicate if necessary. The RN stated that she would expect a care plan related to pain in place for residents who are on routine pain medication and as needed pain medication. (10 NYCRR 415.11(c)(1))