Every finding on record at Elderwood at Hamburg

Based on interview and record review conducted during survey, the facility failed to ensure residents had the right to be free from sexual abuse for one (Resident #1) of three residents reviewed for abuse. Specifically, on 07/05/2025 Resident #2 was observed engaged in inappropriate physical contact with Resident #1. Resident #2 had wandered into Resident #1's room and was found by staff unclothed below the waist, positioned in a side lying position behind Resident #1. Resident #1's incontinence brief was displaced exposing their right buttock. Resident #1 lacked cognitive capacity to provide informed consent and exhibited emotional distress and expressed fearfulness. Using the reasonable person concept, as referenced on the Centers for Medicare and Medicaid Serviced Psychosocial Outcome Severity guide, it was determined that psychosocial harm occurred to Resident #1 that is not Immediate Jeopardy. The findings include: The facility policy and procedure titled, Abuse Prevention, Identification, Investigation, Protection and Reporting dated 04/30/2024 documented the facility would provide protection for the health, welfare and rights of each resident residing in the facility. The facility would have procedures to prevent and prohibit all types of abuse by establishing a safe environment. The facility would ensure that all residents were protected from physical and psychosocial harm during and after the investigation. Resident #1 had diagnoses including dementia, anxiety, and major depressive disorder. The Minimum Data Set (a resident assessment tool) dated 05/22/2025 documented Resident #1 was severely cognitively impaired, usually understands and was usually understood by others. The resident required a partial/moderate assist of one person for lower body dressing. There were no documented behaviors during the assessment period. The Comprehensive Care Plan revised 02/06/2025 documented Resident #1 had a history of physical aggression towards staff and residents. Interventions included for staff to monitor verbal outbursts and agitation, provide support/reassurance, and provide a safe environment. Resident #2 had diagnoses including malignant neoplasm of right kidney (cancerous tumor of the kidney), secondary malignant neoplasm of lung (cancerous tumor of the lungs), and anxiety. The Minimum Data Set, dated [DATE] documented Resident #2 was cognitively intact, understands and was understood by others. The resident required supervision from staff for dressing, transferring and ambulation. There were no documented behaviors during the assessment period. The Comprehensive Care Plan dated 03/25/2025 documented Resident #2 was at high risk for unsafe wandering and may wander into inappropriate places at times. Interventions included monitoring their whereabouts, monitoring for changes in behavior, and redirect as needed. The facility's investigation report dated 07/05/2025 at 7:30 PM, completed by Licensed Practical Nurse Supervisor #5, documented they were notified that Resident #1 was involved in an incident (victim of inappropriate sexual behavior) with Resident #2 (the aggressor). Licensed Practical Nurse Supervisor #5 documented upon their arrival to Resident #1's room, the tray table and contents on top of it were turned over onto the floor. Staff had already removed Resident #2 from Resident #1's room and had taken them to their own room. Resident #1 was lying on their left side facing the wall towards the end of the bed in the fetal position wearing a blue shirt and their soiled undergarment (brief) was pulled over towards their left buttock, exposing their right buttock. Licensed Practical Nurse Supervisor #5 documented that Resident #1 stated, you don't know what it feels like to go through something like that. Licensed Practical Nurse Supervisor #5 documented that Resident #1 was unable to describe what they meant by that statement, but the resident was very scared and had requested that Licensed Practical Nurse Supervisor #5 not leave them alone. They notified Director of Nursing #3 and Administrator #1. Director of Nursing #3 came into the facility, assessed Resident #1 and sent them out to the hospital for further evaluation. The facility's investigation file included Certified Nurse Aide #5's written witness statement dated 07/05/2025 at 7:10 PM and documented they heard Resident #1 yell, Help! They went to Resident #1's room and found Resident #2 in a spooning (cuddling) position with no pants on behind Resident #1. Certified Nurse Aide #2 documented they removed Resident #2 from the bed and redirected them to their room. Certified Nurse Aide #2 documented they told Licensed Practical Nurse #4 what happened who then notified Licensed Practical Nurse Supervisor #5. A progress note completed by Director of Nursing #3 dated 07/05/2025 at 9:13 PM documented they assessed Resident #1 after Resident #2 was found in their bed. Resident #1 had no bruising or redness to their legs and private areas, and there were no bodily fluids observed. Director of Nursing #3 documented Resident #1 was unable to provide a statement due to their advanced dementia and was sent to the hospital for further evaluation. A progress note completed by Licensed Practical Nurse #4 dated 7/05/2025 at 10:14 PM documented that Certified Nurse Aide #5 notified them that Resident #2 was found in Resident #1's bed around 7:10 PM. Resident #2 was immediately removed from the room. Licensed Practical Nurse #4 documented when they returned and reentered the room to check on Resident #1, the resident was frantic and anxious. Licensed Practical Nurse #4 documented that Resident #1 grabbed their wrist and stated, please don't leave me. The note also documented that the nursing supervisor had been made aware. Review of a hospital triage note dated 07/05/2025 at 9:30 PM documented that Resident #1 was tearful, scared and kept repeating you're going to hurt me. A telephone interview was attempted with Licensed Practical Nurse #4 on 08/24/2025 at 10:11 AM without success. During a telephone interview on 08/24/2026 at 11:42 AM, Director of Nursing #3 stated when they assessed Resident #1, they did not want to be touched. They stated they did not find any signs of sexual assault during their evaluation, made sure the resident was safe and sent them out to the hospital for further evaluation. Director of Nursing #3 stated Resident #1 was upset following the interaction and neither Resident #1 nor Resident #2 had the capacity to consent at the time of the incident. They stated Resident #2 was sent out to a different hospital for altered mental status and did not return to the facility. During a telephone interview on 08/24/2026 at 11:50 AM, Certified Nurse Aide #5 stated they had just completed their rounds and were walking down the hall when they saw Resident #2 with one knee on the bed, clenching onto Resident #1's brief trying to pull themself into Resident #1's bed. Certified Nurse Aide #5 stated they called out for help and Licensed Practical Nurse #4 arrived. They stated they had difficulty getting Resident #2 out of Resident #1's bed but eventually they were able to. Certified Nurse Aide #5 stated Resident #1 was anxious and did not want Resident #2 in their bed. Resident #2 was taken to their room where they became combative and confused. During a telephone interview on 08/24/2026 at 12:13 PM, Licensed Practical Nurse Supervisor #5 stated when Certified Nurse Aide #5 arrived at Resident #1's room, Resident #2 was lying on their left side in a spooning position with one leg resting on the tray table that was lying on the ground without any undergarments on, behind Resident #1. Resident #1's brief was moved to the side, exposing their right buttock. Licensed Practical Nurse Supervisor #5 stated Certified Nurse Aide #5 had immediately separated the residents, notified Licensed Practical Nurse #4 who notified them, and they called Director of Nursing #3 to come and assess the residents. They further stated normally Resident #1 did not want to be touched and they did not like people of other ethnicities to be around them, but the resident was requesting for them to stay. Resident #1 was afraid and did not want to be left alone, which was surprising because they were often combative with staff and refused hands on care. During a follow up telephone interview on 08/24/2026 at 1:30 PM, Director of Nursing #3 stated using the reasonable person concept, Resident #1 would not have been welcoming of the interaction with Resident #2. During a telephone interview on 08/24/2026 at 2:30 PM, Resident #1's family member stated the resident would not have been welcoming of that kind of interaction with Resident #2. They stated Resident #1 did not even sleep in the same bed as their spouse for the last twenty years of their marriage, and a strange person in their bed would have made them upset. A telephone interview was attempted with the former Medical Director #1 on 08/25/2026 at 2:59 PM without success. During a telephone interview on 08/25/2026 at 10:51 AM, Administrator #1 stated, Resident #1 had a reaction to Resident #2 going into their room and expressed that, and staff responded appropriately. Administrator #1 stated, Resident #1 reacted because they wanted Resident #2 out of their room. Resident #1 made what their determination was by the comments they said. They stated all staff have a responsibility to keep residents safe. During a telephone interview on 08/25/2026 at 11:37 AM, Medical Director #2 (current Medical Director) stated a reasonable person would not be welcoming of a disrobed person climbing into bed with them. 10 New York Codes, Rules, and Regulations 415.3(d)(1)(vii)

Based on observations, interviews, and record review conducted during survey, the facility failed to ensure that each resident received necessary behavioral health care and services to attain the highest practicable mental and psychosocial well-being for one (Resident #5) of three residents reviewed for behavioral health. Specifically, upon readmission, the resident had a history of suicidal ideations and a self-harm attempt during a prior hospital stay and the facility failed to develop an individualized behavioral health care plan incorporating specific self-harm interventions. On 08/01/2026, Resident #5 verbalized self-harm statements and immediate protective interventions were not implemented which resulted in the resident causing a self-inflicted superficial cut to their left wrist. The resident was transported to the hospital for emergency psychiatric and medical evaluation. This resulted in actual harm to Resident #5 that was not Immediate Jeopardy. The findings include: The facility policy and procedure titled, Suicide Ideations reviewed 09/20/2024 documented interventions will be developed and implemented by the interdisciplinary team when residents present with suicide ideations or who have been determined to be a risk of danger to themselves. All staff members were responsible for immediately reporting any verbal statement or physical gesture that may indicate a resident no longer wishes to live or may attempt suicide. The report will be made to the nursing supervisor, social worker, or designee. The resident will be interviewed and their history will be assessed. The following interventions will be considered when developing the plan of care for a resident who wishes self-harm: one-to-one supervision, frequent visual checks, psychological assessments, spiritual counseling, medical provider assessment, environmental assessment with consideration of the removal of items that may be used to harm self. The medical record and care plan will be updated with initial assessment. Monitoring of the resident will occur routinely and documented in the progress notes, until deemed necessary by the interdisciplinary team. Resident #5 had diagnoses including schizophrenia (a serious mental disorder that changes how a person thinks, feels and behaves), persistent mood affective disorder (a chronic long-lasting depression), and major depression disorder. The Minimum Data Set (a resident assessment tool) dated 07/08/2026 documented the resident was cognitively intact, understands and was understood by others. The Comprehensive Care Plan dated 02/13/2026 documented Resident #5 had the potential for alteration in mood/behavior related to persistent mood affect disorder, major depressive disorder, and schizophrenia. There is no documented evidence the Comprehensive Care Plan was updated after the 06/22/2026 readmission to the facility to reflect suicidal ideation, suicidal attempts or individualized interventions to prevent the re-occurrence of self-harm. The hospital Discharge summary dated [DATE] documented Resident #5 had a history of psychotic disorder (severe mental illness that causes loss of contact with reality). While in the hospital, Resident #5 was intermittently mute, not engaging, refusing psychotropic medications (medications that affect the brain and change a person's mood, thoughts, feelings or behavior), responding to internal stimuli, reporting depression, suicidal ideation with attempt to wrap call light around their neck. The Lethality Assessment (evidence-based tool used by clinicians to evaluate high risk behavioral indicators to prompt immediate safety and crisis planning) was completed and documented; Resident #5 denied any suicide intent or plan. They appeared to be a low potential risk of harm towards themselves. Review of Patient Health Questionnaire-9 (a standard nine question medical tool used to screen, diagnose and measure the severity of depression based on categories and frequency) completed on 02/13/2026, 05/13/2026, and 06/25/2026 revealed Resident #5 had stated they had little interest/pleasure in doing things, felt down, depressed or hopeless nearly every day; had trouble falling asleep, felt tired or had little energy, had poor appetite or overate, felt bad about themselves, had trouble concentrating and were moving slower. The Patient Health Questionnaires documented scores of 16 to 21 indicating moderate to severe depression. On 07/08/2026, it was documented that Resident #5 scored zero on the Patient Health Questionnaire indicating no signs of depression. Review of the nursing progress notes dated 08/01/2026:2:59 AM, Licensed Practical Nurse #1 documented Resident #5 rang the call light multiple times throughout the night to let staff know they were feeling unwell and explained they were feeling unwell mentally, felt down, depressed and unlike their usual self. Resident #5 stated they had a lot of trouble sleeping recently. Resident #5 stated they had no thoughts of hurting themselves at that time. 6:50 AM, Registered Nurse Supervisor #1 documented Licensed Practical Nurse #1 reported to them that Resident #5 wanted to speak with them and go to the hospital. At approximately 6:30 AM, the resident expressed they were feeling depressed. They spoke with the resident for a while, and the resident stated they felt better and no longer wanted to go to the emergency room. 7:26 AM (late entry), Licensed Practical Nurse #1 documented Resident #5 was requesting to be sent out to the hospital for their mental health. The resident stated their mental health was worsening and they were now having thoughts of hurting themselves/others. Registered Nurse Supervisor #1 was notified immediately. The oncoming shift nurse Registered Nurse #6 was also notified of concerns.-at 8:50 AM, Registered Nurse Supervisor #1 documented that Resident #5 was noted with a linear laceration on their left wrist, and the resident stated they had scratched themselves. One-to-one was initiated immediately and the room was checked for sharp items. The knitting bag with utensils was removed from the room. The wound was cleansed and a dressing was applied. The provider was notified and ordered the resident to be sent via ambulance to the emergency room for evaluation. The Assistant Director of Nursing and Director of Nursing were notified. The facility Investigation Summary dated 08/01/2026 completed by Director of Nursing #2 documented Resident #5 was cognitively intact, complained of feeling unwell and depressed. It was reported to the oncoming nursing supervisor who went and evaluated the resident. At approximately 8:45 AM, the resident was found by a physical therapist with a linear cut to their left wrist. Resident #5 stated they had intentionally cut themselves and they were sent to the hospital for further evaluation and treatment. Physical Therapist #1's witness statement dated 08/01/2026 documented at 8:45 AM, they approached Resident #5, who appeared lethargic and more tired than usual. The resident was in bed and asked them for a band-aid and showed them a linear horizontal cut to their wrist that did not appear to be profusely bleeding. Physical Therapist #1 documented they informed the nursing supervisor. Registered Nurse #6's witness statement dated 08/01/2026 documented that Licensed Practical Nurse #1 stated Resident #5 had complained about not feeling well and they informed Registered Nurse Supervisor #1 about their condition. Registered Nurse #1 documented the resident told them they were not feeling well, they did not want any medication, and they did not want to eat. Licensed Practical Nurse #1's witness statement dated 08/02/2026 documented that Resident #5 had rung their call light a few times during the night and stated they were not feeling well mentally. At approximately 6:30 AM, the resident rang again and stated they were feeling unwell mentally, felt worse and wanted to go to the hospital. When asked if they felt like harming themselves or others, they replied yes. Licensed Practical Nurse #1 documented at approximately 6:35 AM, they immediately went to inform Registered Nurse Supervisor #1 and told them what Resident #5 had stated; that they were currently having feelings of self-harm and hurting others. Registered Nurse Supervisor #1 stated okay, and they would be down to speak with the resident. Licensed Practical Nurse #1 documented that they finished their work and let oncoming Registered Nurse #6 know the situation before they left. Registered Nurse Supervisor #1's witness statement dated 08/03/2026 documented they were notified by Licensed Practical Nurse #1 that Resident #5 was not feeling like themselves, wanted to talk to them and wanted to go to the hospital. At approximately 6:30 AM, they went to see Resident #5, they stated they were sad, depressed, worried about their health insurance and they thought they were getting kicked out. Registered Nurse Supervisor #1 documented that they had spoken with the resident, they had stated they felt better and no longer wanted to go to the hospital. At about 8:45 AM, Physical Therapist #1 told them the resident had a mark on their left wrist that was suspicious with some blood. Registered Nurse Supervisor #1 documented they asked Resident #5 what had happened and they said it was just a scratch. Registered Nurse Supervisor #1 documented they removed a butter knife from in front of Resident #5 and had Registered Nurse #2 sit with the resident for safety. Registered Nurse #2 reported back to them that Resident #5 had tried to cut themselves with a small pair of scissors that were in their bag with crochet tools. Review of the hospital Mental Health assessment dated [DATE] documented Resident #5 had a traumatic experience, presented to the hospital for a self-inflicted laceration to the left wrist and admitted to having suicidal ideations. During the screening for suicide risk, it was documented that Resident #5 had a wish for death/sleep/not wake intermittently feeling like they were better off dead and had done something to harm self, by cutting themselves superficially. They used a small pair of scissors in their crochet kit. The resident spent two days in the comprehensive psychiatric emergency program at the hospital. During an observation and interview on 08/21/2026 at 8:46 AM, Resident #5 was well groomed and sitting up in their room watching television. There was no call light-cord on the wall, on the tray table in front of them was a breakfast tray with plastic eating utensils, and a tap bell. Resident #5 stated they did not like having a tap bell, but they understood why they were given it. They stated that they have had depression issues and really wanted to discharge to their own place, but they enjoyed some of the activities at the facility and they loved going to physical therapy. During a follow up observation and interview on 08/21/2026 at 11:40 AM, Resident #5 was sitting up in their room. They stated that earlier in the month, they were feeling really depressed and like they were in a dark place. The night shift nurse tried to help them, but they just could not get rid of how they were feeling. Resident #5 stated they used a small pair of scissors from their crochet bag and cut their wrist. Resident #5 showed their wrist and on the palm side of their left wrist was a small faint linear scar. Resident #5 stated that was where they cut themselves. They stated nobody was sitting with them when they did it. After the staff noticed it, Registered Nurse #2 came and sat with them until they went to the hospital. Resident #5 stated they were in the hospital for a long time. During an interview on 08/21/2026 at 1:27 PM, Registered Nurse #2 stated they were called by Registered Nurse Supervisor #1 on 08/01/2026 to provide one-to-one supervision for Resident #5. They stated when they entered the room, there was nobody in the room with Resident #5. The resident had a superficial cut on their wrist with a little blood. They stated they had a good rapport with Resident #5 and the resident had told them that they had cut themselves. Registered Nurse #2 stated they were aware of Resident #5's previous suicidal ideations and they did not remember if there were any interventions put in place when Resident #5 returned from the hospital in June. During an interview on 08/21/2026 at 1:48 PM, Registered Nurse Manager #3 stated that when new admissions enter the facility, either themselves or a nurse supervisor would complete the admission. They stated that part of the admission process was to read the discharge summary and discuss the resident during the 9:00 AM meeting with the interdisciplinary team. They stated specifically for Resident #5's June hospital discharge summary, it would have been up to the interdisciplinary team to determine what interventions should have been put in place. Registered Nurse Manager #3 stated they were not in the building on 08/01/2026 when Resident #5 had cut themselves. They stated that they think that the nurses who were in the building would have put the proper protocols in place when the resident stated they were going to harm themselves. However, since it was not documented, it was not known if or what protocols were put in place at that time. If the protocols were placed, Resident #5's mood might not have worsened, and they would not have been able to cut themselves. During an interview on 08/24/2026 at 10:00 AM, Physical Therapist #1 confirmed what was in their written statement. Physical Therapist #1 stated prior to entering Resident #5's room, nobody had made them aware the resident had made statements of self-harm earlier that morning. During a telephone interview on 08/24/2026 at 10:34 AM, Registered Nurse Supervisor #2 stated they read the discharge summary when Resident #5 was re-admitted to the facility in June. They stated that if they read the part of the discharge summary that documented Resident #5 had suicidal ideations with an attempt to wrap the call cord around their neck, they did not remember it. They stated that if they had read that, the hospital would have taken care of it and it was resolved, so they would not have documented it on the 24-hour report sheets or added it to the resident's care plan. They stated they did not think the resident was a risk for self-harm and it did not need to be added upon re-admission. They stated the resident had a long psychiatric history and if they were concerned, they would have talked to the provider. During an interview on 08/24/2026 at 11:33 AM, Registered Nurse #6 stated they were told by Licensed Practical Nurse #1 that Resident #5 was not feeling well. They stated they saw the resident sometime between 7:00 AM and 7:30 AM. They were aware the resident had schizophrenia but were not aware that they had a recent history of suicidal ideation or an attempt at self-harm. They stated they had not seen any cuts on the resident when they were in the room, and the resident did not voice any concerns at that time. They stated they may have relied on Registered Nurse Supervisor #1 to follow up with any concerns that Licensed Practical Nurse #1 had with the resident. Not long after they were in the room, they were called back in the room to give the resident a band-aid. Registered Nurse #6 stated the cut on the wrist looked like a superficial scratch and the blood was already dried. They provided first aid to the resident. During a telephone interview on 08/24/2026 at 12:25 PM, former Social Worker #2 stated they recalled completing Resident #5's Patient Health Questionnaire-9 forms. They stated on each form except one the resident scored as being severely depressed. They stated that Resident #5 was set up to meet with a mental health counselor every one to two weeks. If the mental health counselor had any concerns regarding the resident's depression, they would have notified the facility. They stated there was one Patient Health Questionnaire that scored as a zero indicating no depression but that may have been how Resident #5 felt at that moment in time, but their mood and behaviors should have still been monitored because of their history of depression. Social Worker #2 stated they did not quite remember if they were aware of Resident #5's suicidal ideations or attempt in the hospital in June. They stated that when the resident made comments of self-harm on 08/01/2026, the staff should have acted differently. Immediately the call cord, any sharp objects and the crochet kit with yarn should have been taken out of the room. It would have been appropriate to do 15-minute checks, one-to-one supervision, or encouraged the resident to come out of their room where they could have been visible to staff. During an interview on 08/24/2026 at 12:56 PM, Certified Nurse Aide #2 stated they were the only certified nurse aide on the unit on 08/01/2026 until 8:30 AM, so they were busy answering call lights, completing morning care and passing the breakfast trays. They stated they could not recall how Resident #5's mood was when they gave them their breakfast tray. They further stated they were never told the resident had made statements of self-harm, needed extra checks, supervision or to remove any objects from their room. During a telephone interview on 08/24/2026 at 1:27 PM, Certified Nurse Aide #4 stated they recalled Resident #5 using their call light often during the night shift on 08/01/2026. They stated that it was almost constant, and the nurse answered the light, most of the night. They stated they had gone in a couple times and the resident stated they wanted a snack so they would go and get them a snack. Certified Nurse Aide #4 stated around 6:00 AM, Licensed Practical Nurse #1 had stated that Resident #5 told them they were sad and wanted to go to the hospital because they were very depressed and having thoughts of hurting themselves. They stated that Licensed Practical Nurse #1 had reported the concern to Registered Nurse Supervisor #1 and that the supervisor had stated that was normal behavior for the resident. Certified Nurse Aide #4 stated they were unaware of any precautions that were put into place for the resident, and they were never told to remove anything from the resident's room or provide extra checks on them. During a telephone interview on 08/24/2026 at 1:45 PM, Physician Assistant #1 stated that if Resident #5 had made comments of passive suicidality (any non-lethal statements regarding having a wish to die) and self-harm, then immediately the staff should have put interventions in place such as one-on-one monitoring and a suicide lethality risk assessment should have been done. They stated if there was heightened awareness, then the resident could have been treated sooner. During a telephone interview on 08/24/2026 at 2:52 PM, Medical Doctor #1 stated they would have expected the nursing staff to include any psychological conditions including a risk for self-harm on the resident's care plan because they had made suicidal ideations and an attempt in the hospital. They stated they would have expected Registered Nurse Supervisor #1 to evaluate Resident #5 and notify the provider immediately on 08/01/2026 and not wait until the resident cut themselves. They stated Resident #5 had harmed themselves and it could have been prevented. During an interview on 08/25/2026 at 8:01 AM, Licensed Practical Nurse #1 stated Resident #5 had used their call light throughout the night. There were times when they entered the room and the resident would state they felt down or sad. Licensed Practical Nurse #1 stated they had used therapeutic nursing techniques to help the resident and each time they appeared to be happier after the interactions. They stated they had done that maybe three times before 4:00 AM. Licensed Practical Nurse #1 stated, around 6:30 AM, when they went to give the resident their medication, the resident stated they felt worse, wanted to go to the hospital and they were going to hurt themselves. Licensed Practical Nurse #1 stated they told Registered Nurse Supervisor #1 immediately and was never told to provide extra checks, one-to-one supervision, or remove any items from the room. They stated they knew the resident had a history of depression and schizophrenia but were unaware the resident had a history of suicidal ideations or an attempt of self-harm at the hospital in June. Licensed Practical Nurse #1 stated if they had known they would not have left the resident alone; they would have called for help from the room or removed the call light cord and given them a tap bell instead. They stated they would have done something different because they should have kept Resident #5 safe. During a telephone interview on 08/25/2026 at 8:56 AM, Registered Nurse Supervisor #1 stated when there was a new admission, the discharge summary was reviewed, and a basic care plan was started by the nursing supervisor. Generally, the unit manager was responsible for completing the care plan. They stated they were getting report from another nursing supervisor when they were told that Resident #5 was not feeling well, was not feeling like themselves, and wanted to go to the hospital. They stated the resident always wanted to go to the hospital, so it was nothing out of the ordinary. Registered Nurse Supervisor #1 stated they went and talked to Resident #5, and they had stated they felt better after they talked with them. They told the resident to call them if they wanted to talk more. Then about an hour and a half later, they were sitting at the nurses' desk when Physical Therapist #1 told them there was a suspicious mark on Resident #5. Registered Nurse Supervisor #1 stated they jumped out of their chair, went to the resident's room, and saw the superficial laceration from one side of the wrist to the other. They ran and got Registered Nurse #2, who they knew had a good rapport with Resident #5 to sit with them. They stated the resident had purposefully hurt themselves. They were unaware that Resident #5 had stated they felt like they wanted to harm themselves and that Licensed Practical Nurse #1 had never told them. They stated they did not recall knowing that Resident #5 had a previous suicide attempt at the hospital. If they had known that and were informed by Licensed Practical Nurse #1 that Resident #5 had thoughts of self-harm, they would have removed items from the room and started supervision earlier. They stated that it was everybody's responsibility to make sure the residents stayed safe. During an interview on 08/25/2026 at 12:27 PM, Director of Nursing #2 stated the expectation was that any recommendations from psychiatry were followed. Upon Resident #5's re-admission in June, their suicidal ideations and the attempt of self-harm at the hospital should have been added to the care plan and included specific interventions. They stated, at minimum, Resident #5's mood and behavior would have been monitored. They stated in hindsight things could have been done a little differently. At that moment on 08/01/2026, a staff member could have stayed with the resident or brought them out of their room. They stated the resident spent a long time in the hospital after 08/01/2026 incident. Director of Nursing #2 stated the typical protocol was for the nursing supervisor to do an assessment of the resident but there was no specific lethality risk form to complete. Director of Nursing #2 stated that following the incident, education was started for all nursing staff, and it was still ongoing. During an interview on 08/25/2026 at 1:30 PM, Administrator #2 stated that they would have expected past suicidal ideations and past suicide attempts were notated and diagnosed when Resident #5 was re-admitted in June. They stated that it was a significant issue and safety measures should have already been in place. Nursing was responsible for the care plan starting with the nurse manager, nursing supervisors and then the Director of Nursing. They stated the resident's suicidal ideations and past suicide attempt should have been in the care plan, to ensure staff knew how to ensure their safety. They stated the physician should have been contacted when the resident stated they had thoughts of self-harm and sent them to the hospital immediately. Some type of interventions should have been put in place to ensure Resident #5's depression did not worsen to the point where they harmed themselves. 10 New York Codes, Rules and Regulations 415.12(f)(1)

Based on observations, interviews, and record review conducted during survey, the facility failed to provide a safe, clean, comfortable, and homelike environment for one (Unit 2) of three resident units. Specifically, fecal matter (stool) and contaminated washcloths were observed on the floor within the shared resident shower room.The findings include:The facility policy and procedure titled Cleaning Guideline: Maintaining a Safe, Clean, Comfortable and Home-Like Environment, reviewed 06/03/2026, documented the facility would ensure that all residents were provided with a safe, clean, comfortable, home-like environments in accordance with regulations while promoting dignity. The facility would ensure that all environmental services, housekeeping, and maintenance practices were implemented consistently in accordance with established cleaning and maintenance guidelines. Shower rooms were to be disinfected daily, which included the walls, floors, and shower area.The facility policy and procedure titled Infection Prevention Control Program reviewed 07/02/2026, documented the facility would implement an infection control program that was consistent with infection control standards issued by the federal centers for Medicare and Medicaid Services. The program would be designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections among staff and residents. All staff had a role in keeping the facilities and equipment clean and disinfected. The facility would ensure the environment was maintained in a safe, attractive, sanitary, and clean state for residents, staff and visitors. High frequency touched surfaces would be cleaned and disinfected routinely. The Infection Preventionist would oversee the implementation of the program in collaboration with the administrator and each department head in the facility.Intermittent observations on 08/20/2026 between 9:04 AM and 10:52 AM revealed the following:-9:04 AM, Unit 2 shower room on the South Hall had wet fecal matter scattered throughout the floor and two soiled/contaminated wet washcloths.-10:21 AM, Unit 2 shower room on the South Hall remained in the same unclean condition.-10:40 AM, Unit 2 shower room on the South Hall remained in the same unclean condition. At the time of this observation Registered Nurse #4 Unit Manager stated the wet brown substance on the shower room floor, looked like a bowel movement (fecal matter). They stated certified nurse aides were responsible for cleaning up any linens or bodily fluids to the best of their ability after they gave a resident a shower; then they would notify housekeeping to disinfect the area. Registered Nurse #4 Unit Manager stated they would expect shower rooms to be cleaned up immediately following a shower. Fecal matter on a shower room floor for an unknown extended period was an infection control concern and was not homelike.10:52 AM, Unit 2 shower room on the South Hall remained in the same unclean condition. During an interview at this time Certified Nurse Aide #6 stated they had given a shower that morning to a resident in the shower room on the South side and had not noticed any fecal matter on the floor before or after the shower was given. Certified Nurse Aide #6 stated it was the certified nurse aides responsibility to clean up after a resident when they gave a shower, and further stated, you don't want to spread bacteria.During an interview on 08/20/2026 at 10:56 AM, Licensed Practical Nurse #2 stated they would expect certified nurse aides to clean the shower room, including removing linen and cleaning any bodily fluids immediately after they were finished with the resident. They stated fecal matter on a shower room floor was an infection control issue and it was not homelike.During an interview on 08/25/2026 at 11:21 AM, the Nurse Educator stated it was standard across the board that certified nurse aides were to handle the initial cleanup of any bodily fluids as soon as their resident was safely back in their room, and then housekeeping would follow with deep disinfection. They stated they would expect the certified nurse aides to leave the shower rooms the way they found it; clean. The Nurse Educator stated fecal matter on the floor of a shower room for an unknown amount of time was an infection control concern.During an interview on 08/25/2026 at 11:27 AM, Assistant Director of Nursing/Infection Preventionist stated certified nurse aides should follow the policy and procedure for cleaning up after giving a resident a shower. They would expect certified nurse aides to pick up any soiled linens, clean up any bodily fluids, including fecal matter, immediately and then let housekeeping know so they could disinfect the shower room. The Assistant Director of Nursing/Infection Preventionist stated there were infection control concerns with bowel movement being on the shower room floor for an unknown amount of time.During an interview on 08/25/2026 at 1:10 PM, Director of Nursing #2 stated if a certified nurse aide was to give a shower to a resident, their expectation would be that the aide went back and cleaned up the shower room, minimally before the next person used the shower. They stated infection control was a concern when fecal matter was left on a shower floor for an unknown amount of time and it was not homelike at all.10 New York Codes, Rules, and Regulations 415.5 (h)(2)

Based on observations, interviews, and record review conducted during survey, the facility failed to ensure that a resident received adequate supervision to prevent accidents/hazards for one (Resident #4) of three residents reviewed for accidents. Specifically, Resident #4 who was severely cognitively impaired exited the facility through a second floor pass coded stairwell door, without having to enter a passcode and was found outside the facility without injury.The findings include:The facility policy and procedure titled Elopement- Wandering- Missing Resident revised 10/08/2018, documented that all residents are assessed upon admission, annually and as needed to determine risk level for unsafe wandering/elopement. Appropriate safety measures are put into place for residents determined to be at risk or if found in an unsupervised/potentially dangerous area within the facility.Resident #4 had diagnoses including dementia with behavioral disturbances, repeated falls, and anxiety. The Minimum Data Set (a resident assessment tool) dated 03/12/2026, documented they were severely cognitively impaired.The Comprehensive Care Plan dated 12/10/2025, documented Resident #4 was a high risk for unsafe wandering and elopement; they ambulated with or without a device; they had a history of attempting to leave and expressed a desire to go home.The Kardex Report (guide used by staff to provide care) dated 04/13/2026 documented Resident #4 was a high risk for elopement and staff were to monitor their whereabouts due to unsafe wandering/risk of elopement and to redirect as needed.The Order Summary Report dated 08/25/2026 documented Resident #4 had a physician's order dated 12/10/2025 to check electronic security bracelet/anklet function and location.The incident report dated 04/13/2026 documented Resident #4 was seen by another resident, exiting the facility through the north stairwell, and alerted staff. Resident #4 followed the path towards the front of the facility at 4:05 PM and was detected by 4:07 PM, staff responded immediately and brought Resident #4 back into the facility.The progress note dated 04/13/2026 at 5:10 PM, Director of Nursing #2 documented that Resident #4 exited the facility utilizing the north stairwell that led to the path in the back of the facility and staff were notified by a visitor. Staff responded immediately and Resident #4 was escorted back into the facility without injuries. Resident #4 was noted to have increased agitation, notifications made.During an interview on 08/24/2026 at 10:14 AM, Licensed Practical Nurse #2 stated Resident #4 was ambulatory at the time of the incident, and they would continuously walk the halls of the unit. They stated the doors required a code to open them. They did not know how the resident was able to open the stairwell door without the code. They have never noticed a stairwell door not working properly, if they did, they would notify maintenance.During an observation and interview on 08/24/2025 at 8:43 AM, Maintenance Assistant #1 demonstrated the function of the north stairwell door on the second floor. They stated staff had to enter a passcode to open the door and then the door automatically closed within a few seconds. Maintenance Assistant #1 stated they did not know how Resident #4 was able to open the door without a code. Maintenance Assistant #1 stated the stairwell doors did not have wander guard alarms. The door to the outside, at the bottom of the stairs, currently had an alarm, requiring a key to deactivate it. The audible alarm on the door was demonstrated and very loud. Maintenance Assistant #1 stated the audible alarms were put in place following the elopement of Resident #4. There were no keypads on the outer doors, due to safety codes. During continued observations the grounds outside of the building had a sidewalk that stopped at the back edge of the building. Maintenance Assistant #1 stated Resident #4 must have walked through the grass to get around the building. They stated they did not recall another time when the stairwell doors malfunctioned. They stated the security functions were important to keep the residents safe.During an observation of the facility video surveillance for the camera near the 2nd floor north stairwell revealed at 4:03 PM, a resident was observed walking towards the stairwell door, pushing the bar, opening the door and walking out. The door closed behind the resident. At approximately 4:05 a staff member approached the door, attempted to open it without success, looked towards the window then ran in the opposite direction.During a telephone interview on 08/24/2026 at 11:14 AM, the Director of Maintenance stated the stairwell doors did not have wander guard alarms, only the main doors and elevators used that system. The stairwells had passcodes for security. They stated there were no reported incidents of the doors malfunctioning and they were unable to determine how the resident was able to open the door. The Director of Maintenance stated all staff had the access codes for the stairwell doors and they were used more than a 100 times a day. They stated they used to check the function of the doors weekly but were now checking them daily. They stated after the incident, they went around with the Administrator and checked all the doors. They did not find any that opened without entering the code or that did not close automatically. The Director of Maintenance stated the security of the doors was a good system and even in a power outage the generator would power them. They thought it was possible that there was a small object left in the way of the magnet (that normally pulled the door closed) which allowed the door not to latch. They stated there were no alarms in place if the door did not close within a certain time. The Director of Maintenance stated they placed audible alarms on all the outside stairwell doors following the incident. They stated the security system was important to keep the residents from getting outside by themselves.During an interview on 08/24/2026 at 11:41 AM, the Assistant Director of Nursing stated that at the time of the incident they did not hear an alarm, but observed through the boardroom window, the resident and a few staff members in the courtyard. They realized the situation was not a casual outing and the management team all went out to see what was happening. The Assistant Director of Nursing stated additional security measures, such as the alarm, would have alerted staff sooner and may have prevented the resident from getting as far as they did. They stated the event could have been much more serious.During a telephone interview on 08/24/2026 at 12:48 PM, Administrator #1 stated, following the elopement of Resident #4 they reviewed the video footage. They determined that a staff member must have gone through the door and the lock did not fully engage. There were no audible alarms on stairwell doors at the time of the elopement. They added the outside door alarms afterwards. They were never informed of the stairwell doors failing to engage before the elopement. Immediately after they brought the resident inside, maintenance cleaned all the magnets and made the door closure faster. They had maintenance increase their door audits from weekly to daily. They felt the security system was appropriate, and that was an isolated event.During an interview on 08/24/2026 at 1:10 PM, Certified Nursing Aide #1 stated they were on the 2nd floor when Resident #4 eloped. That day the resident had been agitated so they were to reapproach them later for care and allowed them to walk around. They were with another aide when they heard a family member say, the resident that walks around, is outside. They all went running to bring the resident back inside. They had never seen the door propped or noticed the lock was not working. After the elopement they heard staff talking that an aide had gone out the door at the end of their shift and the door had not fully closed. They were educated to make sure they check the doors if they walk by, and if they use a stairwell, to make sure there are no residents nearby and make sure the door fully closes behind them.During a telephone interview on 08/25/2026 at 8:24 AM, Licensed Practical Nurse #3 stated that Resident #4 was agitated the day they eloped. They overheard someone say a resident was outside, they immediately knew it was Resident #4 and they ran to bring them back inside. They could not recall if the door was locked when they tried to go out, or if they had to use the elevator, they just knew they were running. There were no audible alarms when the resident went out. They did not know if the wander guard should have alarmed in a stairwell, they knew they checked the wander guard was on the resident, and it was functioning near the elevator. Licensed Practical Nurse #3 stated there should be alarms on all doors. They stated the security measures were important to keep the residents safe.During an interview on 08/25/2026 at 10:10 AM, Director of Nursing #1 stated they had maintenance check all the doors following the elopement. There was no malfunctioning doors found. They assumed a staff member went out and did not fully close it. They stated the security system was important to keep residents safe. They did educate the staff to try to utilize elevators more often than the stairwells, and if they used the stairs, to be sure no residents were nearby, and to make sure the door closed fully behind them.During an interview on 08/25/2026 at 2:55 PM, Director of Nursing #2 stated they were unable to locate any documentation regarding recent staff education on elopement or stairwell doors.New York Code Rules and Regulations 415.12(h)(1)(2)

Based on interview and record review conducted during the survey, the facility failed to ensure that each resident received adequate supervision and assistive devices to prevent accidents for two (2) (Resident's #1 and #2) of ten (10) residents reviewed for accidents. Specifically, facility staff failed to implement safety measures during resident repositioning. Residents were not provided with the assistance of two (2) staff members during bed mobility as planned and the bed locking systems were unlocked. Resident #1 fell from the bed sustaining a right elbow injury later identified as a fracture (broken bone) and Resident #2 fell from bed and sustained a fracture of their left middle finger and multiple lacerations (cut that goes through more than one (1) layer of skin caused by trauma) to their head, face and arm. This resulted in actual harm to Resident's #1 and #2 that is not Immediate Jeopardy. The findings are: The policy and procedure titled Prevention and Reporting of Accidents and Incidents for Residents dated 09/07/2023 documented that an accident was defined as an unexpected or unintentional incident, which may result in injury to a resident. This does not include adverse outcomes that were a direct consequence of treatment or care that was provided in accordance with current standards of practice. A fall was defined as an unintentional change in position coming to rest on the ground, floor or onto the next lower surface. The interdisciplinary team conducts a thorough resident assessment/evaluation to identify potential risk factors. Appropriate interventions are implemented to promote a safe environment. Interventions included, but were not limited to, adequate supervision; assistive devices; staff/resident education. The Director of Nursing Services/Nursing Supervisor will complete a resident description. The resident is approached immediately for an account of the accident/incident and if the resident was able and wishes to comment, the resident's response was recorded. The User-Service Manual for Bed Frames and Easy-Care Beds dated 2023 documented a warning: Before leaving the bed unattended, check that the Care Lock feature was in the locked position. Never leave an unlocked bed unattended and check that the Care lock feature was in the locked position before allowing the resident to enter or exit the bed. For best practices, the Care-Lock feature should be locked at all times, except when the bed was being moved. 1. Resident #1 had diagnoses that included a right below the knee amputation (surgical removal of a limb or part of an extremity), diabetes mellitus (a chronic condition characterized by high blood sugar resulting from the body's inability to produce or properly use insulin), and muscle weakness. The Minimum Data Set (a resident assessment tool) dated 08/15/2025 documented Resident #1 was cognitively intact. Resident #1 was dependent on staff for toileting and required substantial/maximal assistance for rolling left and right. The Comprehensive Care Plan dated 08/12/2025 documented Resident #1 required maximal/substantial assistance of two (2) staff members to roll left and right in bed. The Kardex Report (a guide used by staff to provide care) dated 08/15/2025 documented Resident #1 required maximal/substantial assistance of two (2) staff members to roll left and right in bed. The Accident and Incident Report completed by Licensed Practical Nurse Supervisor #1 dated 08/15/2025 documented that at 9:25 PM they were notified by Certified Nurse Aide #2 that Resident #1 was on the floor lying on their right side against the wall. Licensed Practical Nurse Supervisor #1 on the report documented that the fall was unwitnessed, and the resident description section was left blank. The provider and the family were notified. Resident #1 complained of pain to their right shoulder, right knee and x-rays were ordered. The Accident and Incident Report included statements dated 08/15/2025 completed by Certified Nurse Aide #1 and #2. Certified Nurse Aide #1's statement documented they began personal care and told Resident #1 to roll towards the wall so they could wash their backside. Resident #1 slid between the bed and wall and fell to the floor. Certified Nurse Aide #1 stayed with Resident #1 while Certified Nurse Aide #2 went to get Licensed Practical Nurse Supervisor #1. Certified Nurse Aide #2's statement documented that Certified Nurse Aide #1 told Resident #1 to roll towards the wall. The bed was not locked so when the resident rolled towards the wall the bed slid the opposite way and Resident #1 fell to the floor. Licensed Practical Nurse Supervisor #1 documented the caregivers were educated on always ensuring patient safety, double checking to make sure beds were locked while performing care. The Physicians Orders dated 08/15/2025 documented to obtain an x-ray of the right shoulder and right knee STAT (immediately) for pain related to a fall. A follow up progress note completed by Registered Nurse #3 dated 08/16/2026 documented Resident #1 had some elbow pain and further x-rays were ordered. There was no documented physicians order for an x-ray of the right elbow to be obtained. The Order Summary Report of active orders printed January 21, 2026, did not include an order for a right elbow x-ray dated 08/16/2025, however the diagnostic imaging report dated 08/16/2025 documented there were four (4) views of the right elbow obtained for pain after a fall. The findings documented a normal right elbow. The provider note completed by Physician Assistant #1 dated 08/18/2025 at 3:35 PM documented that Resident #1 was evaluated in follow up after obtaining x-ray results following a fall on 08/15/2025. Physician Assistant #1 documented Resident #1 was receiving hands on care, and the staff did not lock the bed and Resident #1 fell out of bed. The second staff member was not on the other side of the bed to prevent Resident #1 from rolling out. Resident #1 had complained of subsequent right arm pain which was controlled with Tylenol. The provider note completed by the Medical Director dated 08/19/2025 at 3:30 PM documented that staff dropped Resident #1 during hands on care on 08/15/2025 and their right elbow pain persists. On 08/17/2025 the right elbow x-ray was negative. Obtain right radius and ulna (two long bones in the forearm extending from the elbow to the wrist) x-rays if the pain persists. The Physician's Orders dated 08/27/2025 documented an order to obtain an x-ray of the right elbow. The diagnostic imaging report dated 08/27/2025 documented three (3) views of the right elbow were obtained. The findings documented a fracture involving the radial head/neck of the elbow joint (a crack in the top of the forearm bone (radius) at the elbow joint) with soft tissue swelling. The Orthopedic Consult (branch of medicine dealing with conditions affecting the bones) dated 08/29/2025 documented a diagnosis of a right nondisplaced radial head fracture (break in the bone that bone remains in place). Resident #1 was to be non-weight bearing of the right upper extremity and to wear a sling with activity. The sling could be removed for hygiene and removed two (2) to three (3) times per day to work on elbow flexion/extension (hinge point movements) to prevent stiffness. The resident was to avoid pronation (a rotational movement where the forearm turns the palm downward)/supination (the rotational movement where the forearm turns the hand palm up). The Physical Therapy Progress note completed by Physical Therapist #1 on 09/08/2025 at 3:10 PM documented that Resident #1 had actively participated in skilled therapy services with good motivation since 08/13/2025. Barriers to treatment included the resident had a non-weight bearing status to their right lower extremity related to a recent right below the knee amputation. The resident's course of therapy was further complicated by a recent right radial fracture because of rolling out of bed on the nursing unit; causing Resident #1 to maintain non-weight bearing to their right upper extremity; impacting all aspects of functional mobility. During an interview on 01/16/2025 at 10:34 AM, Resident #1 stated that on 08/15/2025 at 9:15 PM Certified Nurse Aide #1 grabbed the draw sheet (a small durable sheet placed crosswise over the bottom bed sheet, spanning from a patient's shoulders to below their buttocks used to assist in repositioning, boosting, or transferring patients) with two (2) hands from under them and forcefully rolled them towards the wall, while Certified Nurse Aide #2 stood at the foot end of the bed. Resident #1 stated their right hand hit the wall. The bed was not locked, and it rolled away from the wall causing them to fall from the bed onto the floor hitting their head. Resident #1 stated they had pain in the right shoulder and upper arm. Resident #1 stated they were care planned to have two (2) persons assist them with bed mobility, and they only used one (1). They stated it was determined on 08/27/2025 they had a right elbow fracture. Resident #1 further stated this limited their therapy progress because they could not bear weight on the right upper arm for eight (8) to nine (9) weeks. During a telephone interview on 01/20/2026 at 12:20 PM, Certified Nurse Aide #1 stated they provided care on 08/15/2025 at 9:25 PM. They rolled Resident #1 towards the wall by themselves, placing one hand on Resident #1's shoulder and their other hand on their hip. Resident #1 kept rolling and hit their right shoulder on the wall. The bed was unlocked; it moved away from the wall and Resident #1 fell out of bed to the floor. Certified Nurse Aide #2 was in the room and was standing by the foot board of bed at the time of the fall. Certified Nurse Aide #1 stated they should have waited to roll Resident #1 until Certified Nurse Aide #2 was on the other side of the bed because Resident #1 required two (2) assist for bed mobility. They stated they should have also ensured the bed was locked but they did not. During a telephone interview on 01/20/2026 at 12:31 PM, Physician Assistant #1 stated they evaluated Resident #1 on 08/18/2025. Resident #1 had fallen out of bed during care on 08/15/2025. The two (2) aides did not lock the bed and when the one (1) aide rolled Resident #1, the other aide was not on the other side. They would have expected them to lock the bed and communicate with each other. Resident #1 had complained of right shoulder and ongoing right elbow pain. The right elbow x-ray was negative on 08/16/2025. Subsequently, Resident #1 continued to complain of pain. An additional x-ray of the right elbow showed a fracture on 08/27/2025. Resident #1 had already been at a disadvantage due to a recent below the knee amputation. After the fall and fracture, they were non-weight bearing for their right upper extremity as well. This inhibited Resident #1's therapy progress. The fracture caused excess pain, less independence, physical and emotional harm. During a telephone interview on 01/20/2026 at 4:03 PM, Licensed Practical Nurse #2 stated Certified Nurse Aide #1 and Certified Nurse Aide #2 could have avoided Resident #1's fall had they provided care together and locked the brakes on the bed. During an interview on 01/21/2026 at 11:30 AM, Physical Therapist #1 stated at the time of the fall (08/15/2025) Resident #1 required maximum assistance of two (2) staff members secondary to their size, non-weight bearing to their right lower extremity and they were apprehensive (fearful). Being away from home impacted Resident #1's quality of life and the fractured elbow impacted their rehabilitation capability. The staff should have used two (2) assist for bed mobility. The fractured elbow was significant to Resident #1. Resident #1 was close to reaching their goal in using a slide board (assistive device) for transfers. Right upper extremity strengthening was compromised secondary to the fracture. Transferring with a slide board required both upper extremities, using only the left arm was difficult and therapy was limited. During a telephone interview on 01/21/2026 at 12:18 PM, the Medical Director stated Resident #1 was dropped out of bed by the staff when providing hands on care on 08/15/2025. They ordered a sling and an Orthopedic Consult. They would have expected the staff to follow the care plan. During an interview on 01/21/2026 at 12:20 PM, Registered Nurse #2 Educator stated they would have expected the bed to be secured before providing care. Certified Nurse Aide #1 should have used the appropriate assistance of two (2) for bed mobility. Certified Nurse Aide #1 should have waited for Certified Nurse Aide #2 to be in position before starting care. After the incident on 08/15/2025, an in-service on safe patient handling was completed for the nursing staff. Review of the education dated August of 2025 and staff signature pages revealed the facility educated 30 of 60 nursing staff members between the dates of 08/19/2025 -11/13/2025. During a telephone interview on 01/22/2026 at 11:07 AM, Licensed Practical Nurse Supervisor #1 stated on 08/15/2025 Certified Nurse Aide #2 informed them that Resident #1 fell out of bed during care. The bed moved away from the wall at an angle and Resident #1 was on the floor between the bed and the wall. They were informed Resident #1 was instructed to roll towards the wall, the resident pushed off the wall and fell out of the bed. Certified Nurse Aide #1 was the only one providing care at the time of the fall. Licensed Practical Nurse Supervisor #1 stated they immediately notified the provider and called the Director of Nursing and reported the care plan violation. There should have been two (2) persons for bed mobility. The fall out of bed could have been avoided. Resident #1 complained of right elbow pain on and off. On 08/27/2025 a fracture of the right elbow was discovered. During an interview on 01/22/2026 at 11:44 AM, the Director of Rehab Services stated there were two (2) aides in the room. Certified Nurse Aide #1 should not have rolled Resident #1 until Certified Nurse Aide #2 was positioned on the other side of the bed for safety purposes. Anytime they move a resident they should ensure the bed was locked to prevent the resident from moving one way and the bed from moving the other way. The fracture was harmful and impacted Resident #1's therapy due to pain and having non-weight bearing status for the duration. During an interview on 01/22/2026 11:54 AM with the Director of Nursing and the Administrator, the Director of Nursing stated that staff were expected to review the resident's plan of care prior to providing care. They stated if a resident was care planned to have two (2) staff member assist with bed mobility, they would expect staff to follow the care plan and provide safety to prevent accidents. Fractures were considered a significant injury. The Administrator stated Resident #1 was an extensive assist and turned themselves on command. Resident #1 put their hand on the wall, the bed rolled, and Resident #1 fell off the bed. Certified Nurse Aide #1 started to turn Resident #1 and Certified Nurse Aide #2 should have been on the other side to guide Resident #1. The Administrator stated they were not convinced that the fracture was caused by the fall out of bed on 08/15/2025. The fracture was nondisplaced and very subtle. The Administrator stated they believed the fracture came after the incident through performing activities of daily living and continuing therapy. 2. Resident #2 had diagnoses of chronic obstructive pulmonary disease (lung and airway disease that restricts breathing), type 2 diabetes mellitus (chronic metabolic disorder where the body cannot effectively use or produce enough insulin, leading to high blood sugar), and depression. The Minimum Data Set, dated [DATE], documented that Resident #2 was cognitively intact. Resident #2 had lower extremity impairments, required a maximum assist of two (2) with bed mobility to turn right to left, and a maximum assist of one (1) for dressing. The Comprehensive Care Plan dated 07/07/2025 documented Resident #2 required assistance with self-care and mobility and was at risk for falls. Interventions documented the resident required two (2) or more staff members to roll left and right in bed. The Kardex Report dated 05/09/2025 documented Resident #2 was dependent on two (2) or more staff to roll left and right in bed. The Accident and Incident Report completed by Licensed Practical Nurse Supervisor #1 dated 05/01/2025 documented that at 5:30 AM, Resident #2 had a witnessed fall out of bed while they received care which caused an open laceration to back of their head, a laceration to right elbow and laceration to right eyebrow. Resident #2 was transferred to the hospital for further evaluation and treatment. The attending physician and Resident #2's family were notified. The Accident and Incident Report also documented under statements by Certified Nurse Aide #3 that they were getting the resident dressed for the morning and they rolled the resident towards the wall to pull their shirt down in the back and put the sling under them. Resident #2 put their hand on the wall for support, and the bed began to move away from the wall. Certified Nurse Aide #3 documented they tried to hold on to the resident but was unable, and the resident fell between the bed and the wall. The interdisciplinary team met to discuss the resident, staff were educated on locking the beds for safety, and Certified Nurse Aide #3 was to receive corrective action for failure to follow the care plan. The After Visit Summary from the hospital dated 05/01/2025 documented Resident #2 had a fall resulting in a head injury and laceration repair to the forehead. The Progress Note completed by Registered Nurse Unit Manager #4 dated 05/01/2025 at 3:45 PM documented after Resident #2 returned from the emergency room to the facility; the resident began complaining of pain to their facial injuries and their left hand. Upon inspection, it was noted that resident's left middle finger was swollen, bruised and painful with attempted range of motion. The provider was notified, and x-ray was ordered of the residents left hand. The Progress Note completed by Licensed Practical Nurse #4 dated 05/02/2025 at 1:42 AM documented x-ray results received. Left hand with comminuted nondisplaced fracture (a severe break where a bone shatters into multiple fragments but remains in its correct anatomical alignment) of third metacarpal (middle bone). Follow up with provider and an Orthopedic Consult. During an interview on 01/21/2026 at 10:11 AM, Resident #2 stated they were unable to recall if they had a fall causing any injuries. An attempt was made via telephone to contact Certified Nurse Aide #3 on 01/22/2026 at 10:38 AM without success. The line was no longer in service. During a telephone interview on 01/22/2026 at 10:39 AM, Licensed Practical Nurse Supervisor #3 stated this was a tricky situation. They thought it was a break in the care plan but at the time the resident was a one (1) assist for dressing in bed and could not recall what the resident's assist with bed mobility was at the time. Certified Nurse Aide #3 reported to them they rolled the resident over in bed to adjust the resident's clothing and the resident fell off the bed. Resident #2 was sent to the emergency room, for a laceration on their forehead and they also had a broken finger. Licensed Practical Nurse Supervisor #3 stated they could not recall if the bed was locked at the time, but the resident was on the floor between the bed and the wall. During an interview on 01/22/2026 at 11:04 AM, the Registered Nurse #2 Educator stated they were unsure if the bed was locked when the resident fell. They believed the resident required one (1) assist for dressing and two (2) assist for bed mobility. A full in-house in-service on locking the beds and following resident care plans was completed. The facility was unable to provide documented evidence of the education provided regarding locking beds and following resident care plans. During an interview on 01/22/2026 at 11:44 AM, the Director of Rehabilitation Services stated they recalled the resident but not the incident. Resident #2's status prior to the fall was one (1) assist for dressing and two (2) assist for bed mobility. After the fall the resident was changed to have two (2) staff members assist with dressing. The Director of Rehabilitation Services stated all beds should be locked during all care for resident safety. During an interview on 01/22/2026 11:54 AM the Director of Nursing along with the Administrator present, the Director of Nursing stated the incident was a failure to follow the care plan. The resident required one (1) assist in bed for dressing and two (2) assist for bed mobility. Certified Nurse Aide #3 was pulling the resident's shirt down, rolled the resident towards the wall and the resident fell out of bed. The aide thought they were still dressing the resident when they rolled the resident over. The Administrator stated they were unsure if the bed was locked, but it would have prevented the fall. Certified Nurse Aide #3 tried to stop the resident from falling but could not. The Director of Nursing stated they checked all the bed locking devices and in-serviced the staff on locking the beds during care. Beds should be locked during care and staff should be following the residents' plan of care. A fracture was considered a serious injury. The facility was unable to provide evidence that the auditing of the bed locking devices was conducted and evidence that education was provided regarding locking of the beds during care. 10 New York Codes, Rules and Regulations 415.12(h)(2)

Based on observation, interview, and record review conducted during the survey, the facility did not ensure that services were provided to meet professional standards of quality care for one (1) (Resident #3) of six (6) residents reviewed. Specifically, Resident #3 did not receive all their evening medications as ordered by the medical provider, the nursing supervisor and medical provider were not notified of the omissions, and the Licensed Practical Nurse documented the medications were administered. The finding is: The policy titled Medications Administration Methods dated 01/25/2024, documented medication administration must be documented on the Medication Administration Record/Electronic Medication Administration Record immediately before going on to the next resident. The nurse will indicate if the medication was withheld or refused. Reasons are recorded on the Medication Administration Record/Electronic Medication Administration Record. The policy documented all problems related to medication are noted and later reported to unit manager/supervisor. The policy titled Notification of Resident Changes dated 03/29/2018, documented the facility would immediately inform the resident and consult with the resident's physician if a need to alter treatment significantly. The facility's Licensed Practical Nurse Team leader job description revised January 2026 documented essential job functions would consist of administering medications and treatments to assigned residents as ordered by physician and utilizing the five (5) rights as applicable. The job description documented the licensed practical nurse will perform timely and accurate documentation according to the service excellence standards and goals established for the position. The licensed practical nurse will contact the medical doctor/nurse practitioner/physician assistant for orders or updates according to the resident response to treatment plan and/or situation. Resident #3 had diagnoses that included anxiety disorder, major depression disorder, and schizophrenia. The Minimum Data Set (a resident assessment tool) dated 10/03/2025 documented Resident #3 was cognitively intact, understood and understands. The comprehensive care plan dated 01/30/2024, documented Resident #3 was independent with decision making and had potential for bleeding due to the resident being on anticoagulant therapy related to history of pulmonary embolism (blood clot in the lungs) and transient ischemic attack (temporary blockage of blood flow to the brain) with interventions to administer medications as ordered and monitor for side effects. Resident #3 was used psychotropic medications due to depression, anxiety and tardive dyskinesia (a movement disorder caused by a long-term use of antipsychotics) and fibromyalgia (disorder with widespread muscle pain). Interventions included administering medications as medical doctor/nurse practitioner ordered, monitor effectiveness and update medical doctor/nurse practitioner on residents' status as needed. Review of the iQIES (Internet Quality Improvement and Evaluation System) complaint/incident investigation report, facility reported incident #2664370, dated 11/10/2025, the Director of Nursing documented that Resident #3 reported that on 11/07/2025 Licensed Practical Nurse #3 did not administer their bedtime medications because the pharmacy had not delivered them yet. The Director of Nursing documented that Resident #3 was claiming their tardive dyskinesia is acting up because they did not get their medications. Review of a statement dated 11/08/2025, provided as part of the facility's investigation, Licensed Practical Nurse #6 documented that they obtained a verbal statement from Licensed Practical Nurse #3 who stated that Resident #3's evening medications on 11/07/2025 were not available, but they did administer the narcotics and stock medications. Licensed Practical Nurse #3 stated they later became aware the Resident #3's next week supply of medication was available and assumed the next nurse (Licensed Practical Nurse #4) would administer them. Review of an electronic mail conversation message thread dated 11/10/2025 and 11/11/2025, provided by the facility as part of their investigation, the Assistant Director of Nursing responded to the Administrator request to interview Licensed Practical Nurse #4 regarding Resident #3's evening medications not being administered. The Assistant Director of Nursing documented Licensed Practical Nurse #4 stated they were never notified by Licensed Practical Nurse #3 that Resident #3's evening medications were not administered. Licensed Practical Nurse #4 stated that Licensed Practical Nurse #3 found the medication in the medication room in the cycle tote. Review of an undated statement, provided by the facility as part of their investigation, Licensed Practical Nurse #5 documented Resident #3 told them they did not receive their evening medications the previous night. Licensed Practical Nurse #5 documented there were no evening medications in the drawer on Friday day shift and there were no evening medications missing from future medication packs. Review of a statement dated 11/11/2025 at noon, the Director of Nursing documented they performed a telephone interview with Licensed Practical Nurse #3 regarding Resident #3's evening medication pass. It was documented that Licensed Practical Nurse #3 stated Licensed Practical Nurse #4 showed them where Resident #3's medications were in the medication room when they came into work (at shift change). It was documented that Licensed Practical Nurse #3 stated they had already counted out and thought Licensed Practical Nurse #4 would give the medications since they knew Resident #3 had not had them yet. When Licensed Practical Nurse #3 was asked why the medications were signed as administered, they replied I was tired and did not even think about it. Review of the electronic Medication Administration Record dated 11/01/2025-11/30/2025 revealed the following medications were to be administered to Resident #3 at bedtime on 11/07/2025:Buspirone 10mg (antianxiety)Caplyta 21 mg (antidepressant)Eliquis 5mg (blood thinner)Floranex one tab (probiotic)Lipitor 40mg (cholesterol)Lyrica 75mg (narcotic analgesic)Oxycodone 10mg (narcotic analgesic)Polyethylene glycol 17 mg (laxative)Senna S one tab (laxative)Simethicone one tab (antiflatulent)Topiramate 25 mg (migraine prevention)Valbenazine 80mg (medication to lessen tardive dyskinesia symptoms)Zyrtec 10mg (congestion)Licensed Practical Nurse #3 signed the above medications as administered on 11/07/2025. Review of the facility's house stock formulary dated 12/2024 revealed Floranex, Polyethylene glycol, Senna S and Simethicone were listed as facility stock medications. Review of the Progress Notes dated 11/07/2025-11/30/2025 revealed no documented evidence that Resident #3's bedtime medications on 11/07/2025 were unavailable and that the nursing supervisor or medical provider were notified for new orders. On 11/08/2025 at 10:49 AM, the Director of Nursing documented they saw Resident #3 for complaints of increased tardive dyskinesia symptoms. They documented no increased facial movement or exacerbation of tardive dyskinesia was observed. During an observation and interview on 01/21/2026 at 2:18 PM, Resident #3 stated there was an evening sometime in November when the nurse did not administer all their evening medications. Resident #3 stated they do not remember why the nurse did not give them all their medications, but the staff member no longer worked for the facility. Resident #3 stated they were upset they did not get their medications and wondered if the incident would happen again. Resident #3 stated they have not had a problem with medication administration since then. Telephone interviews were attempted on 01/20/2026 at 3:43 PM and 5:19 PM, on 01/21/2026 at 2:21 PM, and on 01/22/2026 at 2:39 PM with Licensed Practical Nurse #3 without success. During a telephone interview on 01/20/2026 at 3:45 PM, Licensed Practical Nurse #4 stated on 11/07/2025 they relieved Licensed Practical Nurse #3 at 11:00 PM. Licensed Practical Nurse #4 stated they entered the medication room for the narcotic key exchange with Licensed Practical Nurse #3 and they noticed the seven (7) day supply of medication pill packs (medications from pharmacy sorted by date and time for administration and placed into sealed packets) were still in the medication room and had not been placed into the medication cart for the new week that started the next day. Licensed Practical Nurse #4 stated that when they remarked that no one put the pill packs into the medication cart, Licensed Practical Nurse #3 response was that they did not know what the pill packs were. Licensed Practical Nurse #4 stated Licensed Practical Nurse #3 never informed them that Resident #3's evening medications were unavailable and never asked them to administer Resident #3's evening medications from the following day's evening supply. Licensed Practical Nurse #4 stated they were asked to give a statement about the situation on 11/08/2025 and that was when they found out that not all of Resident #3's evening medications were given. Licensed Practical Nurse #4 stated all of Resident #3's evening medications on 11/07/2025 were signed as administered by Licensed Practical Nurse #3. Licensed Practical Nurse #4 stated the importance of administering medications as prescribed was because the medical provider prescribed them for something that was going on with the resident and it was the nurse's duty to administer them. During a telephone interview on 01/21/2026 at 12:31 PM, the Medical Doctor #1 stated they do not recall being notified that Resident #3 was omitted some of their evening medications in November 2025. They stated that if Resident #3's medications were unavailable they would have expected to be notified for new orders and the situation be documented in the electronic medical record. Medical Doctor #1 stated they would not expect medications to be documented as given if they were not administered. Medical Doctor #1 stated they were familiar with Resident #3, and they did not believe the resident was having any medical issues in November including any increase in their tardive dyskinesia symptoms. During a telephone interview on 01/21/2026 at 2:54 PM, the Pharmacy Consultant stated they were unsure if they were notified in November 2025 that Resident #3 had some of their evening medications omitted. They stated the facility's pharmacy provided the facility a 7-day supply of pill packs on a weekly basis. The Pharmacy Consultant stated their expectation for any unavailable medications was that staff notify the medical provider for any new orders. They stated that staff members should not sign off that medications were given if they were not administered because that staff member was not following proper policy and procedure and the facility could not determine if the medications were given or not. During an interview on 01/21/2026 at 3:41 PM, Registered Nurse #4, Unit Manager, stated Resident #3 reported a nurse did not administrator all their evening medications a few months ago and the facility did an investigation. Registered Nurse #4 stated Resident #3 stated because of their omitted medications their tardive dyskinesia symptoms were worse. Registered Nurse #4 stated they did not observe any increased symptoms in Resident #3. Registered Nurse #4 stated if the medications were unavailable, Licensed Practical Nurse #3 should have notified the nursing supervisor. They stated they do not believe Licensed Practical Nurse #3 notified the supervisor, the pharmacy or the medical provider and if they did, then it should have been documented in the electronic medical record. Registered Nurse #4 stated Licensed Practical Nurse #3 should not have documented Resident #3's evening medications as given because that would be false documentation. During a telephone interview on 01/22/2026 at 11:07 AM, Licensed Practical Nurse #1, Nursing Supervisor, stated they were the building supervisor working 11/07/25 into 11/08/25 on the 6:00 PM- 7:00 AM shift. Licensed Practical Nurse #1 stated Licensed Practical Nurse #3 did not notify them that Resident #3's evening medications were unavailable. Licensed Practical Nurse #1 stated Licensed Practical Nurse #3 should have notified them immediately and they would have attempted to remove any medications they could from the emergency medication supply, contacted the pharmacy for an extra delivery and notified the medical provider for any new orders. During an interview on 01/22/2026 at 2:58 PM, the Director of Nursing stated they were notified that Licensed Practical Nurse #3 did not administer all of Resident #3's evening medications on 11/07/2025. The Director of Nursing stated Licensed Practical Nurse #3 documented all of Resident #3 evening medications were administered on 11/07/025 when they were not. They stated when Licensed Practical Nurse #3 was interviewed they admitted they only administered Resident #3's narcotics and stock medications because the other evening medications were not in the medication cart. The Director of Nursing stated Licensed Practical Nurse #3 never told the nursing supervisor and therefore the pharmacy was not contacted for an extra delivery nor was a medical provider notified. The Director of Nursing stated professional standards were not followed and Licensed Practical Nurse #3 was no longer employed at the facility. During an interview on 01/22/2026 at 3:11 PM, the Administrator stated they were aware Resident #3 did not receive all their evening medications in November 2025. The Administrator stated Licensed Practical Nurse #3 believed they did not have Resident #3's medications available to administer and Licensed Practical Nurse #3 never notified the nursing supervisor. The Administrator stated that Licensed Practical Nurse #3 was made aware by Licensed Practical Nurse #4 that there was a new weekly supply of medications in the medication room. They stated Licensed Practical Nurse #3 made an assumption that Licensed Practical Nurse #4 would administer Resident #3's evening medications but the two nurses did not have clear communication on who was administering Resident #3's medication. The Administrator stated the Licensed Practical Nurse #3 also documented all of Resident #3's evening medications as administered. The Administrator stated Licensed Practical Nurse #3 received their final disciplinary action through this issue and was no longer employee by the facility. They stated professional standards were not met in this incident. 10NYCRR 415.11(c)(3)(i)

Based on observation, interview, and record review conducted during an Abbreviated survey (Complaint #2596250), the facility did not ensure that all alleged abuse violations were reported immediately but not later than 2-hours after the allegation was made to the Administrator of the facility and to the State Survey Agency for one (1) (Residents #1) of three (3) residents reviewed. Specifically, staff failed to report an allegation of physical abuse to the Administrator immediately which resulted in delayed reporting to the New York State Department of Health within the required time frames.The finding is:The policy titled Abuse Prevention, Identification, Protection and Reporting of Victims last revised on 4/30/2024 documented all facility staff were required to immediately report to the Administrator, Director of Nursing or designee when there was an observed act or suspicion of abuse, mistreatment or neglect. The facility Administrator or designee will report all alleged violations to, state agencies immediately, but no later than two (2) hours after the alleged abuse, mistreatment, and as required agencies (law enforcement, adult protective services, licensing authorities, state nurse aide registries when applicable) with in specified timeframes. All staff will be trained in identifying abuse. Resident #1 had diagnoses which included dementia, depression, and hypertension. The Minimum Data Set (a resident assessment tool) dated 06/20/2025 documented Resident #1 was severely, cognitively impaired, was rarely/never understood and rarely/never understands.The comprehensive care plan revised on 07/11/2025 documented that Resident #1 had severe cognition, required assistance with activities of daily living, and had limited physical mobility. Review of the New York State Department of Health Complaint Tracking System Complaint/Incident Investigation Report revealed the date/time of the alleged incident was 8/9/2025 at 7:32 AM. The date/time the Administrator was first made aware of the incident was 8/20/2025 at 2:00 PM. It was submitted by the facility to the New York State Department of Health on 8/20/2025 at 3:17 PM.The facility accident/incident dated 8/20/2025 at 2:00 PM documented a potential altercation between a staff member and resident occurred at some point last week in the afternoon between (lunch and 3:00 PM). Licensed Practical Nurse #1 was told that an employee slapped Resident #1 in the back of their head. The alleged abuse occurred on 8/9/2025 at 7:32 AM based on review of the facility's camera footage.During an observation on 8/27/2025 at 9:42 AM, Resident #1 was seated in their wheelchair across from the third-floor nurse's station. They were alert and oriented to self only and were unable to be interviewed. During an interview on 8/27/2025 at 9:50 AM, Certified Nurse Aide #1 stated they witnessed Certified Nurse Aide #2 slap Resident #1 on top of the head when they were sleeping in their wheelchair sometime within the last few weeks between 11:30 AM and 1:00 PM. Certified Nurse Aide #1 stated they reported incident to Licensed Practical Nurse #1 on 8/20/2025. Certified Nurse Aide #1 stated they knew they should have reported the slap immediately, but they were afraid of retaliation from Certified Nurse Aide #2. Review of the facility's camera footage in the presence of the Director of Nursing and Certified Nurse Aide #1 of the alleged incident dated 8/9/2025 at 7:32 AM as reported to the Department of Health on 8/20/2025 revealed Certified Nurse Aide #2 slightly tap Resident #1 in the back and on top of the head. During an interview on 8/27/2025 at 1:15 PM, the Director of Nursing stated that Certified Nurse Aide #1 should have reported the suspected abuse immediately on 8/9/2025 to the nurse. The incident was reported eleven days later. During an interview on 8/27/2025 at 2:10 PM, Registered Nurse Unit Manager #2 stated abuse allegations had to be reported within a two-hour time frame from the occurrence. Certified Nurse Aide #1 should have reported the abuse to the Supervisor on 8/9/2025. Waiting over one week was too long. During a telephone interview on 8/27/2025 at 2:16 PM, Certified Nurse Aide #2 denied slapping Resident #1 in the back of their head and stated slapping a resident would be physical abuse. During a telephone interview on 8/28/2025 at 10:28 AM, Licensed Practical Nurse #1 stated Certified Nurse Aide #1 reported to them on 8/20/2025 at 2:00 PM that they had witnessed Certified Nurse Aide #2 slap Resident #1 in the back of the head, and that Certified Nurse Aide #1 was uncertain of the day and time that it had occurred. Licensed Practical Nurse #1 stated they reported the allegation of abuse immediately to the Director of Nursing on 8/20/2025. During a telephone interview on 8/28/2025 at 1:15 PM, the Administrator stated Certified Nurse Aide #1 should have reported the suspected abuse immediately on 8/9/2025 after witnessing Certified Nurse Aide #2 slap Resident #1. The delay in reporting was unacceptable. 10 NYCRR 415.4 (b)(2)

Based on observation, interview, and record review conducted during the Standard survey completed on 6/4/25, the facility did not ensure that pain management was provided to residents who require such services, consistent with standards of practices, the comprehensive person-centered care plan, and the resident's goals and preferences for one (1) (Resident #9) of one (1) resident reviewed for pain management. Specifically, there was a delay in addressing Resident #9's continued hip pain when non-opioid oral and topical analgesics (pain medications) were ineffective. The finding is: The policy titled Pain Management, dated 3/17/25, documented the to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences would be evaluated upon admission, readmission, through periodic assessments, and as needed. The interdisciplinary team was responsible for developing a pain management regimen. If the resident's pain was not controlled by the current treatment regimen, the practitioner should be notified. The policy titled Medical Provider Notification Guidelines, dated 2/13/20, documented the facility utilized guidelines as to when to notify the medical providers of urgent or non-urgent resident concerns. Routine notification or non-immediate notification (notification to provider same day of the finding) would be indicated for but not limited to positive cultures, abnormal radiology results, and acute issues needing to be addressed before the next facility visit. Resident #9 had diagnoses including dementia without behavioral disturbances, anxiety, and osteoarthritis (swelling and tenderness in joints that occurs when flexible tissue at the ends of bones wears down causing pain and stiffness). The Minimum Data Set (a resident assessment tool) dated 4/10/25 documented Resident #9 was moderately cognitively impaired, usually understands, was usually understood, and received scheduled pain medication regimen for frequent moderate pain that rarely interfered with day-to-day activities. The comprehensive care plan dated 3/14/23 documented Resident #9 had pain or had the potential of an alteration in their comfort with interventions to report non-verbal or verbal signs and symptoms of pain promptly to the nurse, assess characteristics of pain as needed, complete pain evaluation assessment per policy, reassess and adjust plan to optimize pain relief as needed, and teach resident to request analgesics/non pharmacological methods before pain becomes severe. The Kardex (guide used by staff providing care) dated 6/3/25 documented Resident #9 was independent for ambulation, bed mobility, dressing, and toileting hygiene. Review of 24-hour Report sheets dated 5/29/25 to 6/2/25 revealed on 6/1/25 Resident #9 complained of pain unrelieved by Tylenol and during the evening (3:00 PM - 11:00 PM) shift, requested a stronger analgesic. Review of untitled documents located in a binder, identified by Licensed Practical Nurse #3 Unit Manager as the medical provider communication book, dated 5/29/25 to 6/2/25 revealed Resident #9 was written in the communication book on 6/2/25 for complaints of right hip pain and was requesting something stronger than Tylenol. There was no documented evidence that Resident #9's complaint of unrelieved hip pain was placed in the communication book prior to 6/2/25. Review of Medication Review Report dated 6/3/25 documented Resident #9 had orders dated 5/30/25 for Acetaminophen Tablets 650 mg (milligrams) (Tylenol, non-opioid analgesic) by mouth three (3) times a day for pain and every 4 (four) hours as needed, and Aspercreme Lidocaine patch 4% (topical analgesic) to their low back one time a day. During an observation and interview on 5/29/25 at 10:28 AM, Resident #9 was transferring from their wheelchair to bed, holding their right hip. They stated they were awake all night because of the pain in their right hip and had received Tylenol that took the edge off. Licensed Practical Nurse #5 entered the room at 10:31 AM and stated they had Tylenol for the resident. Resident #9 started to rub their hip and stated oh, it hurts so bad. Review of nursing progress note dated 5/29/25 at 11:34 PM, Licensed Practical Nurse #4 documented Resident #9 was alert and able to make needs known, was given Tylenol for complaints of right hip pain, which was effective, and requested an x-ray. Resident #9 denied any fall or injury. During an observation on 5/30/25 at 9:14 AM, the Activities Director brought Resident #9 their breakfast tray and Resident #9 grabbed their hip, said their right hip hurt and had been hurting for a while. Review of nursing progress note dated 5/30/25 at 3:10 PM, Licensed practical Nurse #5 documented Resident #9 complained of right hip pain that was severe and unrelieved by Tylenol. Licensed Practical Nurse #3 Unit Manager was made aware and placed call to Physician Assistant #1 requesting an x-ray of the right hip. Review of nursing progress note dated 6/1/25 at 11:07 PM, Licensed Practical Nurse #4 documented Resident #9 complained of right hip pain, as needed Tylenol was given with little effect. Resident #9's family was in visiting and requested a stronger analgesic than Tylenol because Resident #9's pain was disruptive. During follow up observations and interviews on 6/2/25 at 9:56 AM and 6/2/25 at 10:39AM, Resident #9 was lying in bed, they grabbed at and rubbed their right hip. Resident #9 stated their right hip was still very painful. Review of nursing progress note dated 6/2/25 at 2:22 PM, Licensed Practical Nurse #4 documented Resident #9 in tears again today over pain in hip and wants something more helpful than Tylenol and a lidocaine patch. Review of nursing progress note dated 6/2/25 at 4:00 PM, Licensed Practical Nurse #3 Unit Manager documented Resident #9's Health Care Proxy was in the facility and asked if Resident #9 could have a stronger analgesic than Tylenol for when that did not work, and a note was left in the book for the provider. During an interview on 6/3/25 at 9:11 AM, Certified Nurse Aide #9 stated Resident #9 had complained of right hip pain to them two days prior. They stated they told Licensed Practical Nurse #5 about Resident #9's complaints and were unsure of what happened after that. During an observation and interview on 6/3/25 at 9:17 AM, Resident #9 stated they were still in pain and Tylenol was not effective. They stated they thought the head nurse was going to come and speak with them about something stronger. During an interview on 6/3/25 at 9:24 AM, Licensed Practical Nurse #5 stated Resident #9 had been complaining of right hip pain for a couple days and complained more when visitors were present, had an x-ray that was negative and received Tylenol and a pain relief patch for pain management. Licensed Practical Nurse #9 stated they updated Licensed Practical Nurse #3 Unit Manager on 6/2/25 that Resident #9's pain was unrelieved by Tylenol and wanted something stronger. Licensed Practical Nurse #3 Unit Manager wrote in the doctor book to address this when they were in the facility next. During an interview on 6/3/25 at 9:44 AM, Licensed Practical Nurse #3 Unit Manager stated Resident #9 had complained of right hip pain and had an x-ray on 5/30/25 that was negative. They stated on 6/2/25 they were made aware the Tylenol was no longer relieving Resident #9's pain, and they wrote in the doctors' book that Resident #9 and their family requested something stronger than Tylenol for the pain. They stated they did not feel it was emergent and could be addressed the next day. Licensed Practical Nurse #3 Unit Manager stated they were unaware that Resident #9 was crying in pain on 6/2/25, Licensed Practical Nurse #5 should have verbally told them, and they would have called the provider to get an order sooner. During an interview on 6/3/25 at 10:04 AM, the Director of Nursing stated there were no requests for any residents to be seen in the doctors' book from Unit 2 (the unit Resident #9 resided on) for 5/29/25, 5/30/25, 5/31/25, and 6/1/25. During a telephone interview on 6/3/25 at 10:41 AM, Licensed Practical Nurse #4 stated Resident #9 had complained of right hip pain and received scheduled and as needed Tylenol but that was ineffective in managing their pain. They stated they wrote on the 24-hour report sheet that Resident #9 was requesting a stronger analgesic and updated the nursing supervisor but could not recall who the supervisor was. During a telephone interview on 6/3/25 at 11:24 AM, Resident #9's Health Care Proxy stated Resident #9 had issues with pain in their hip and back in the past that was relieved with Tramadol (opioid analgesic used to relieve moderate to severe pain) when Tylenol didn't work. They stated they visited on 6/2/25 and requested a stronger analgesic for Resident #9. During an interview on 6/3/25 at 1:36 PM, Licensed Practical Nurse #3 Unit Manager stated they were unaware of the facility's pain assessment policy but if a resident complained of new or worsening pain they would go down and physically assess them right away. They stated they went down to assess Resident #9 on 6/2/25 but they were asleep and when they woke up did not have any pain at that time. The resident complained of increased pain later that day and asked for something for breakthrough pain so they added Resident #9 to the list to be seen by the medical provider the next day. Review of nursing progress note dated 6/3/25 at 4:49 PM, Licensed Practical Nurse #5 documented Resident #9 was still complaining of right hip pain, Tylenol and pain relief patch were ineffective. During a telephone interview on 6/4/25 at 7:50 AM, Physician Assistant #1 stated they would have expected staff to notify them on 6/1/25 that Resident #9 was having pain unrelieved by their scheduled and as needed pain medication. They stated they were not made aware that Resident #9 was crying and in tears from pain and would have expected to be updated right away; it was important to get pain taken care of before it became too severe. Physician Assistant #1 stated they received a call on 6/3/25 that Resident #9's family was requesting Tramadol for their increased pain because it had worked for them in the past. During an interview on 6/4/25 at 9:32 AM, Licensed Practical Nurse #3 Unit Manager stated they had not reviewed the 24-hour report sheets from previous days and were unaware Resident #9 complained of right hip pain unrelieved by Tylenol on 6/1/25. During an interview on 6/4/25 at 9:38 AM, the Director of Nursing stated the provider should have been updated on 6/1/25, as soon as Resident #9 stated they had pain unrelieved by Tylenol. They stated it was important to update the provider right away when someone had unrelieved pain because no one should live with pain. They stated a pain assessment should have been completed as soon as Resident #9 complained of increased pain. 10NYCRR 415.12

Based on observation, interview, and record review conducted during the Standard survey completed on 6/4/25, the facility did not ensure that residents who had an indwelling foley catheter (tube inserted into the bladder to drain urine) received appropriate care and services to manage catheters for two (Resident #45 and Resident #96) of two residents reviewed. Specifically, infection control practices were not maintained (#45, #96) and staff did not utilize enhanced barrier precautions (interventions designed to reduce transmission of multi-drug-resistant organisms including gown and glove use during high contact resident care activities) when providing direct hands-on care (#45). The findings are: The policy and procedure titled Catheter; Daily Care (Indwelling) dated 11/23/22 documented position of the catheter bags should be below the level of bladder. Collection bags and tubing should not touch the floor. Barriers like dignity bags or basins may be necessary due to individual position needs. The policy and procedure titled Catheter, Emptying/Changing of Urinary Drainage Bag dated 9/18/20 documented, residents with indwelling catheters will have regular catheter care including emptying/changing of drainage bag for the purpose of preventing urinary tract infections and maintain catheter patency. Staff to place barrier pad on floor below resident; place graduate cylinder on top of barrier pad; and allow all urine to drain into graduate cylinder. Ensure catheter tubing and bag does not touch the cylinder or floor; cleanse end of catheter tubing with an alcohol wipe and reconnect catheter tubing to collection bag. The policy and procedure titled Transmission Based Precautions Levels dated 6/6/24 documented that Enhanced Barrier Precautions involve gown and glove use during high contact resident care activities for residents known to be colonized or infected with a multidrug-resistant organism as well as those at increased risk of multidrug-resistant organism acquisition (example: residents with wounds or indwelling medical devices). Enhanced barrier precautions can be applied to residents with any of the following: wounds or indwelling medical devices regardless of multidrug-resistant organism colonization status. Examples of indwelling medical devices include central line, urinary catheter (tube inserted into the bladder to drain urine), feeding tube and tracheostomy/ventilator. 1. Resident #45 had diagnoses of congestive heart failure, dementia with mild behavioral disturbance, and chronic kidney disease. The Minimum Data Set (a resident assessment tool) dated 5/28/25 documented Resident #45 was severely cognitively impaired and could not understand others and could not be understood by others. Resident #40 had no impairment to upper and lower extremities, used a wheelchair and required supervision or touching assistance for toileting. The undated comprehensive care plan report documented Resident #45 had an alteration in bladder/bowel elimination related to functional incontinence, urinary retention, aging process, history of urinary tract infections and impaired mobility. Interventions included, but not limited to, monitor for signs and symptoms of urinary tract infections, pain, burning, blood-tinged urine, cloudiness, no output, change in behavior and deepening of urine color. The Kardex (guide used by staff to provide care) dated 6/4/25 for documented enhanced barrier precautions were in place for a Resident #45 related to the use of an indwelling foley urinary catheter. Staff were to monitor the indwelling catheter's urine input and output, record every shift and to notify supervisor of any irregularities in the urine characteristics. Observation on 5/30/25 at 9:24 AM Resident #45 was in their room lying in bed with their urinary catheter bag full of dark gold urine and the catheter tubing and catheter bag were lying directly on the floor. Observation on 5/30/25 at 9:46 AM Resident #45 was lying in bed while housekeeping mopped the floor. The housekeeper picked up the resident's catheter bag by the tubing, mopped under the catheter bag and placed the catheter bag back on the damp floor. Observation on 5/30/24 at 11:05 AM Resident #45 urinary catheter bag and tubing was lying directly on the floor and a portion of the catheter bag was under one of the tray table wheels. Observation on 6/02/25 at 3:04 PM Resident #45 sat in a recliner in the common area with their pant leg rolled up above their right knee. The resident's catheter leg bag was visible and noted to be half full of tea colored urine. Observation on 6/2/25 at 3:17 PM revealed Resident #45 was taken to their room by Certified Nurse Aide #1. There was an Enhanced Barrier Precaution sign posted on the door indicting personal protective equipment was required. This included but not limited to gloves and a gown for transferring, assisting with toileting and urinary catheter care. Certified Nurse Aide #1 transferred Resident #45 to the toilet, the resident had a bowel movement and then was transferred back into their wheelchair. Certified Nurse Aide #1 was not wearing a protective gown. Certified Nursing Aide #1 then washed their hands, applied clean gloves, placed a cylinder on the floor with no protective barrier and proceeded to drain the resident's catheter collection bag without ensuring the spigot did not come in contact with the sides of the cylinder. Certified Nursing Aide #1 wiped the spigot with a with a wipe, (not an alcohol wipe) and placed back into the holder. During an interview on 6/2/25 at 3:37 PM, Certified Nursing Aide #1 stated Resident #45 was on enhanced barrier precautions, and they should have put on personal protective equipment prior to providing care. They stated they should have put on a gown in addition to their gloves during care because this would reduce the risk of cross contamination. They stated they did not place a barrier on the floor before draining the catheter bag and they should have to prevent any urine from spilling on the floor. They stated they also should have provided peri care after the resident had a bowel movement to decrease the risk of infection. During an interview on 6/2/25 at 3:40 PM, Registered Nurse Unit 3 Manager #1 stated Resident #45 had just finished Bactrim (antibiotic) on 5/27/25 for a urinary tract infection. Resident #45 was a high risk for urinary tract infections, and Certified Nursing Aide #1 should have read the Transmission Based Infection notice placed on the outside of the resident's door prior to entering the room. They expected the aides to wear a gown and clean gloves while providing care for Resident #45. They stated Certified Nursing Aide #1 should have done peri care after the resident had a bowel movement to prevent any feces from going into the catheter tubing. They stated they expected Certified Nursing Aide #1 to place a barrier on the floor before they emptied the catheter bag to help decrease the risk of cross contamination. During an interview on 6/3/25 at 11:41 AM, the Director of Nursing stated staff were to wear clean gloves and a gown at the minimum but should wear goggles if a high risk of splashing any bodily fluid could occur. They stated they would have expected Certified Nursing Aide #1 to have read the transmission-based precautions sign placed outside the resident's door before entering the resident's room and providing care. They stated they would expect them to place a barrier on the floor prior to draining the urine from the catheter bag and to provide peri care after a bowel movement to avoid cross contamination. They stated the spigot should be wiped with an alcohol wipe before draining, should not touch the sides of the cylinder, and should be wiped again with a new alcohol wipe after drained. They stated this was important to decrease the risk of infection. During an interview on 06/03/25 at 12:40 PM, Registered Nurse Educator, stated it was important to provide peri care after a resident had a bowel movement when they had a foley catheter and they would have expected Certified Nursing Aide #1 to have done that prior to draining Resident #45 catheter bag. This was important to keep the peri area clean to help prevent the risk of an infection. They stated they would have expected Certified Nursing Aide #1 to wear a gown, clean gloves, and goggles while care was provided for Resident #45. They stated they expected them to place a protective barrier under the cylinder before they emptied the catheter bag for infection control reasons. During an interview on 6/3/25 at 12:48 PM, the Assistant Director of Nursing/Infection Control stated all certified nursing aides were trained on emptying catheter bags and maintaining proper infection control measures. The expectation would be for staff to do what they were taught and trained in for providing care to any of the residents. Staff could reference the back of their name badge where they had a guide to refer to when a resident was on transmission-based precautions and what personal protective equipment should be worn while providing care. They stated the transmission-based precaution signs were always visibly placed on the outside of the resident's room and they would expect the staff to read what type of personal protective equipment should be worn before they even enter the room. 2. Resident #96 had diagnoses that included obstructive and reflex uropathy (obstruction in the urinary tract), urinary retention and dementia. The Minimum Data Set (a resident assessment tool) dated 4/11/25 documented Resident #96 had severe cognitive impairment, required substantial/ maximal assistance with toileting and had an indwelling urinary catheter. The comprehensive care plan revised on 12/2/24 documented Resident #96 had an alteration in bladder and bowel elimination was at risk for urinary tract infections and had an indwelling foley catheter. Interventions included to monitor/document for signs and symptoms of urinary tract infection, record output every shift, urinary leg bag placed on in morning and removed for bedtime, catheter bag to be applied at bedtime until morning. The Kardex dated 6/4/25, documented Resident #96 had an indwelling foley catheter, staff to record output every shift. Urinary leg bag to be placed on in the mornings and urinary catheter bag to be on at bedtime. The provider note dated 5/8/25, signed by Physician Assistant #1 documented Resident #96 had a history of urinary tract infections. The Order Listing Report dated 4/1/25 - 6/30/25 documented orders for urinary catheter to gravity related to obstructive uropathy every shift, apply leg bag while out of bed, and apply drainage bag while in bed every shift. Observation on 5/29/25 at 3:43 PM, Resident #96 was lying in bed with the bed lowered to the floor. The catheter drainage bag was clipped to the side of the bed frame and the bottom of the catheter drainage bag was lying directly on the floor without a barrier. Observations on 6/2/25 at 12:21 PM and 1:13 PM Resident #96 was sitting in their wheelchair in the TV lounge with 6-8 inches of the catheter tubing lying directly on the floor under wheelchair. Urine in the catheter tubing was cloudy yellow. Observation on 6/2/25 at 4:37 PM, Resident #96 was observed to be self-propelling in their wheelchair in the TV lounge with 6-8 inches of the catheter tubing dragging directly on the floor. Observation on 6/3/25 at 8:30 AM, Resident #96 was sitting up in bed and their foley catheter drainage bag was lying flat on the floor under bed without a barrier. At 8:40 AM staff entered Resident #96's room, assisted to open items on their breakfast tray and left the room, and the catheter drainage bag remained on the floor. Observation of catheter care on 6/3/25 at 9:15 AM, Certified Nurse Aide #2 and Certified Nurse Aide #10 entered Resident #96's room, washed their hands, gathered supplied and applied gown and gloves. Certified Nurse Aide #10 picked up Resident #96's catheter drainage bag off the floor from under their bed and attached it to the side of the bed frame. Certified Nurse Aide #10 applied a barrier on the floor and obtained a graduate cylinder from bathroom and placed on top of barrier. Without wiping off the spigot of the drainage bag, Certified Nurse Aide #10 placed the spigot into the graduate cylinder to empty the catheter drainage bag, closed it and then placed it back into the drainage bag without cleaning the end of the spigot. During an interview on 6/3/25 at 9:45 AM, Certified Nurse Aide #10 stated Resident #96 catheter drainage bag was lying on the floor when they first entered their room, they stated catheter bags should not be on the floor so they hooked to the side of the bed for infection control purposes. They were unsure how long the catheter bag was on the floor. Certified Nurse Aide #10 stated they had emptied Resident #96's catheter bag and forgot to wipe off the spigot prior to and after draining. They stated it was important to prevent germs from entering the catheter bag. During an interview on 6/3/25 at 9:50 AM, Certified Nurse Aide #2 stated they did not see Resident #96's catheter bag lying on floor when entering their room. They stated catheter drainage bag and tubing should never be touching the floor, drainage bags should be hooked on the side of the bed off the floor. During an interview in 6/3/25 at 11:20 AM, Licensed Practical Nurse #6 stated catheter drainage bags and tubing should never be on the floor due to risk for contamination and infection. They stated drainage bags should be positioned below the level of the balder and on a nonmoving part of the bed. Licensed Practical Nurse #6 stated Resident #96 should have a leg bag on when out of bed unless refused, they stated Resident #96 was able to self-propel in their wheelchair and could run the tubing over if it was on the floor. During an interview on 6/3/25 at 11:37 AM, Registered Nurse Manager #1 stated the certified nurse aides were responsible to check position of the foley catheter drainage bag and tubing and should monitor and document output every shift. They stated catheter drainage bags and tubing should never be on the floor for infection control purposes, it was possible for bacteria to travel up to the resident and place them at risk for urinary tract infections. Registered Nurse Manager #1 stated staff should have cleaned the spigot on the catheter bag prior to and after emptying to prevent bacteria from getting inside the catheter bag. They stated Resident #96 had a history of urinary tract infections and their foley catheter was recently re-inserted due to urinary retention. During an interview on 6/4/25 at 10:01 AM, the Director of Nursing stated all staff were responsible to monitor the placement of catheter bags and tubing, they expected nursing staff to maintain infection control while providing catheter care. They stated catheter drainage bags and tubing should not be on the floor, and the spigot of the catheter drainage bag should be wiped with an alcohol pad before and after draining to prevent bacteria from entering. 10 NYCRR 415.12 (d)(1)

Based on observation, interview, and record review conducted during a Standard survey completed on 6/4/25, the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for one (Resident #90) of five residents reviewed. Specifically, Resident #90 was not provided with timely incontinence care after they requested to be changed for AM care. The finding is: The policy titled Perineal, Incontinence Care dated 5/3/18 documented perineal care will be provided with morning and HS care (hour of sleep), and when residents are incontinent or cannot provide such care for themselves. Perineal care will be given to cleanse the genital area, to prevent infection and to eliminate odors. Nursing Assistants will perform perineal care for residents. The policy titled ADL (activities of daily living) Assistance and Supervision dated 1/8/18 documented the unit manager/designee will ensure that a plan of care for receiving activities of daily living assistance is incorporated into the daily nursing care for each resident if needed. The unit manager/designee monitors the activities of daily living assistance provided for residents throughout the shift and gives appropriate guidance and assistance to the nursing staff. The policy documented the team leader provides a daily report to the nursing assistants regarding the activities of daily living assistance status of each assigned resident as needed and monitor the activities of daily living assistance provided for residents throughout the shift. The team leader gives appropriate guidance and assistance to nursing assistant. The policy documented nursing assistants provided activities of daily living assistance to assigned residents and assists other nursing assistants in giving activities of daily living care as needed. Resident #90 had diagnoses including rheumatoid arthritis, morbid obesity and diabetes mellitus type II. The Minimum Data Set (a resident assessment tool) dated 4/25/25 documented Resident #90 was cognitively intact, was understood, and understands. The assessment tool documented Resident #90 was always incontinent of bowel and bladder and was dependent on staff for toileting hygiene. The comprehensive care plan revised 5/15/25, documented Resident #90 had a deficit in activities of daily living due to related medical diagnosis and interventions included they were total dependence for toileting hygiene and maximal assist of two persons for bathing. The care plan documented Resident #90 had an alteration in bladder/bowel elimination and inventions included they were always incontinent of bowel and bladder and were to have incontinent care every 2-4 hours and as needed. The care plan documented Resident #90 had the potential for alteration in their daily customary routine due to a new environment and their rise time preference was 7:00-10:00 AM. The Kardex (guide used for staff providing care) dated 6/3/25 documented Resident #90 was total dependent on staff for toileting hygiene and a maximal assist of two persons for bathing. The Kardex documented Resident #90 was to be provided incontinent care every 2-4 hours and as needed and was always incontinent of bladder and bowel. During an interview on 5/30/25 at 9:03 AM, Resident #90 stated staff did not provide them incontinent care when they asked to be changed. Resident #90 stated staff turned off their light and told them they needed to get a second person. Resident #90 stated there were times they had to wait four hours and at times were not provided incontinent care/morning care until lunch time. A continuous observation of Resident #90 on 6/3/25 from 9:54 AM-11:54 AM revealed the following: -at 9:54 AM, Resident #90 was in bed in a hospital gown. The resident stated they had not seen their certified nurse aide yet that morning and was not sure who was assigned to their care. They stated that they were incontinent of stool at present and 5:30 AM was the last time they were provided incontinent care by the night shift. -at 10:36 AM, Resident #90 remained in bed, in the same hospital gown and had an odor of stool. Resident #90 stated they told Licensed Practical Nurse #6 that they needed incontinent care and was also ready to for AM care. Resident #90 stated still no staff had been in their room to provide care. -at 10:40 AM, Licensed Practical Nurse #6 was observed standing at their medication cart near Resident #90's room. They stated, about 10 minutes ago Resident #90 told them they needed incontinent care and would like to be washed and changed for the morning. Licensed Practical Nurse #6 stated they informed Certified Nurse Aide #11 and Certified Nurse Aide #10. They stated that Resident #90 was incontinent of bowel and bladder and should receive incontinent care every 2-4 hours. Licensed Practical Nurse #6 stated they would have expected AM care to be completed by now and incontinent care be provided to a resident within 10-15 minutes of them asking. -at 11:54 AM, Resident #90 remained in bed wearing a hospital gown without any care provided. During an observation of AM care on 6/3/25 at 11:55 AM, Certified Nurse Aide #11 and Certified Nurse Aide #10 gathered their supplies for care, Resident #90 stated again that they had not had incontinent care since 5:30 AM that morning. Resident #90 stated they felt dirty and itchy and had to wait for care like this every day. Certified Nurse Aide #11 provided AM care with rolling assistance from Certified Nurse Aide #10, washing Resident #90's face, neck, chest, arms, perineal (area between the anus and genitalia) area and back. When the two staff members provided perineal care to Resident #90, it was observed that the resident was incontinent of a moderate amount of semi formed stool with foul odor in their brief. During an interview on 6/3/25 at 3:04 PM, Certified Nurse Aide #10 stated Licensed Practical Nurse #6 made them aware around 11:00 AM that Resident #90 requested to be changed. Certified Nurse Aide #10 stated they agreed to help Certified Nurse Aide #11 with the care after Certified Nurse Aide #11 completed a shower on a different resident. Certified Nurse Aide #10 stated that Resident #90 was incontinent and incontinent care should be given every 2-3 hours. Certified Nurse Aide #10 stated they did not provide any care to Resident #90 on 6/3/25 until 11:55 AM and Resident #90 was not given care in an appropriate time frame. They stated residents should only have to wait a maximum of 10 minutes after asking for care to be given. During an interview on 6/3/25 at 3:26 PM, Certified Nurse Aide #11 stated they had arrived to work 8:00 AM and unit 2 was not their regular unit. They stated when they arrived on the unit, Registered Nurse #1 Unit Manager, instructed them to focus on the residents that needed to be out of bed for breakfast, the residents that needed to get out of bed for therapy and the scheduled showers. Certified Nurse Aide #11 stated they did not have time to read all care guides for their assigned residents and was unaware that Resident #90 was incontinent. They stated between 10:00 AM -10:30 AM, Licensed Practical Nurse #6 informed them that Resident #90 needed care. Certified Nurse Aide #11 stated the first time they provided care for Resident #90 was at 11:55 AM and they would not consider that timely incontinent care. Certified Nurse Aide #11 stated all incontinent residents should be provided incontinent care after breakfast and after lunch. Certified Nurse Aide #11 stated if they were aware Resident #90 did not receive any incontinent care since 5:30 AM they would have prioritized their care prior to giving other residents showers. During an interview on 6/4/25 at 11:03 AM, Registered Nurse #1, Unit Manager, stated their expectation was all residents should have AM care completed by 11:30 AM. Registered Nurse #1 stated their expectation for timely incontinent care would be every 2-4 hours and within 10-15 minutes of a resident requesting to be changed. They stated that Resident #90 was incontinent, and their care plan indicated that the resident be provided incontinent care every 2-4 hours and as needed. Registered Nurse #1 stated Certified Nurse Aide #11 was assigned to Resident #90 and they gave report to Certified Nurse Aide #11 on who needed to be up for breakfast and showed them the shower list. Registered Nurse #1 stated they did not recall giving report to Certified Nurse Aide #11 on which residents were incontinent. They stated Resident #90 not receiving incontinent/AM care from 5:30 AM until 11:55 AM was not timely and incontinent care should have been prioritized over showers. Registered Nurse #1 stated that untimely care could lead to increased risk of infection, skin issues, emotional turmoil to the resident and a dignity issue. During an interview on 6/4/25 at 12:07 PM, the Director of Nursing stated that Resident #90 was incontinent, and they expected staff to provide incontinent care every three to hours and as needed. They stated they expected that care be provided less than 20 minutes from when a resident requested care. They stated it was important to provide timely care because it could affect a resident's dignity, skin and comfort. 10NYCRR 415.12(a)(3)

Based on observation, record review, and interview conducted during the Standard survey completed on 6/5/25, the facility did not ensure residents had the right to choose activities, schedules, and health care consistent with their interests, assessments, and plan of care for one (1) (Resident #36) of five (5) residents reviewed for choices. Specifically, Resident #36 was not provided showers twice a week per their preference. The findings are: The policy and procedure titled Bath, Tub/Shower dated 8/7/2021 documented a shower or tub bath will be given once a week and/or as deemed necessary to all residents or per the resident's preference. The policy and procedure titled Resident Rights effective 2/24/2022 documented the facility shall ensure that all residents are afforded their right to a dignified existence, self-determination, respect, full recognition of their individuality, consideration and privacy in treatment and care for personal needs. The facility shall protect and promote the rights of each resident and shall encourage and assist each resident in the fullest possible exercise of these rights as set forth. The facility shall also consult with residents in establishing and implementing facility policies regarding residents' rights and responsibilities. 1. Resident #36 had diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness of one side of the body) of right dominant side, major depressive disorder and anxiety disorder. The Minimum Data Set (a resident assessment tool) dated 5/22/25, documented Resident #36 was understood and understands and was severely cognitively impaired. The Minimum Data Set documented, Resident #36 required partial/moderate assistance (helper does less than half of the effort) for showering and there were no refusals of care. The Annual Minimum Data Set, dated [DATE] documented it was very important for Resident #36 to choose between a tub bath, shower, bed bath, or sponge bath. Review of the (current) comprehensive care plan revised on 11/30/2021 documented Resident #36 had a potential for alteration in their daily customary routing related to long term care placement. An intervention included bathing preference and frequency: No male aide for showers only. Review of the Kardex (a guide used by staff to provide care) dated 6/3/25 documented bathing schedule: shower Friday 7:00 AM - 3:00 PM shift. Review of Skilled Nursing Facility Admission/readmission forms dated 9/30/2016, 1/9/2017, and 1/10/2017 documented Resident #36 was alert and oriented to person, place and time, and they were not confused. The forms documented Resident #36 preferred a shower twice a week. Review of the Skilled Nursing Facility Admission/readmission form dated 3/4/2017 documented Resident #36 was readmitted to the facility, was oriented to person and presented with confusion. The form documented Resident #36's preference was a shower per schedule. The Unit 2 Shower Schedule dated 1/25/25 documented Resident #36 was scheduled to have a shower on Friday on the 7:00 AM - 3:00 PM shift. Review of the Progress Notes dated 4/1/25 through 6/3/25 revealed there was no documented evidence Resident #36 had received or refused their showers. Review of the Documentation Survey Report dated 5/1/25 - 5/31/25, Certified Nurse Aide #6 documented Resident #36 received a sponge bath. During an interview on 5/29/25 at 11:20 AM, Resident #36's Responsible Party stated there was a time when Resident #36 received two (2) showers a week but then the pandemic hit, and they were told that because of staffing only one shower a week could be scheduled. They stated they had asked various staff members through different meetings if Resident #36 could have an additional shower a week because Resident #36 tends to become very hot and sweaty. The answer was always the same; only one shower a week could be scheduled because of there was not enough staff. During an observation and interview on 5/30/25 at 10:03 AM, Resident #36 was fully dressed and sitting in their wheelchair just inside their room with a visitor. The visitor stated, Resident #36 has not received their shower yet today. During an observation and interview on 5/30/25 at 3:46 PM, Resident #36 was in their room and stated they never received a shower during the day shift. They stated their family member who was visiting stated that it was probably going to be done either before or after lunch. Resident #36 stated all they ever will give us here was one shower a week, if that, but they would love an additional shower during the week. During a telephone interview on 6/3/25 at 8:13 AM, Resident #36's Responsible Party stated Resident #36 never received a shower on 5/30/25. They stated a sponge bath was not the same as a shower and Resident #36's preference was always to have a shower. During an interview on 6/3/25 at 10:03 AM, Certified Nurse Aide #4 stated all the resident's preferences were on the care plan; including what type of activities the resident liked, when the resident liked to wake up or go to bed, and if they preferred showers or bed baths. They stated at the facility residents received only one shower a week. Certified Nurse Aide #4 stated that the residents should be allowed to have as many showers as they would like. They stated they worked last week on 5/30/25 but they were not Resident #36's assigned aide. They stated the assigned aide should have provided Resident #36 with a shower and not a bed bath because it was Resident #36's preference. During an interview on 6/3/25 at 10:35 AM, Certified Nurse Aide #5 stated they reviewed the Kardex at the beginning of the shift and throughout it to check a resident's preferences and how to take care of them. They stated residents at the facility usually received a shower once a week. The Kardex would state if a resident was to receive a shower or a bed bath and which day of the week the resident received their shower. There was also a shower list at the nurse's station. They stated the shower days for residents usually change when they change rooms or from one unit to another. They stated Resident #36's Kardex indicated they should receive a shower on Fridays during the 7-3 (day) shift. They stated there was a difference between showers and bed baths because it just seems like a shower gets everyone cleaner. They stated resident #36 should always receive a shower and never a bed bath because that was what they wanted. During a telephone interview on 6/3/25 at 11:13 AM, Certified Nurse Aide #6 stated they were assigned Resident #36 on 5/30/25 but they did not get into the facility until a couple hours after the shift started. They stated when they got to the unit, Resident #36 was already up and dressed for the day and they assumed that Resident #36 already had a shower. They stated they did not ask any of the Certified Nurse Aides working on the unit if Resident #36 received a shower or who had gotten them up for the day. Certified Nurse Aide #6 stated that they documented that a sponge bath was given on 5/30/25 because it was essentially the same thing as morning care. They stated that they figured someone would have told them what needed to be completed with the residents on their assignment. Certified Nurse Aide #6 stated that they should have reviewed the Kardex for Resident #36's preferences. They stated all residents had the right to choose between a shower and bed bath and how often they received a shower because that was their right. During an interview on 6/3/25 at 1:06 PM, Licensed Practical Nurse #1 stated residents usually received a shower once a week and the Certified Nurse Aides were responsible for completing the showers. They stated the Certified Nurse Aides would let them know if a resident was refusing their shower and would want a bed bath instead and then that would be documented in the nursing progress notes. They stated the residents' preference for showers would be listed in the Kardex. Licensed Practical Nurse #1 stated residents have the right to choose if they wanted a shower or bed bath and if they wanted more than one shower a week. They stated someone else at the facility determines that. During an interview on 6/3/25 at 1:41 PM, Licensed Practical Nurse #2 Unit Manager stated residents on the unit were showered once or twice a week whenever they preferred. They stated residents who do not want showers were given a good bed bath. Their preference would be listed in the care plan and there was a shower list in the back of the assignment book at the nurse's station. They stated a resident was asked their preferences related to showers when they were admitted to the facility. If the resident who admitted to the facility was confused, then the nurse doing the admission would have to speak to the resident's family to determine what their preferences were. Licensed Practical Nurse #2 Unit Manager stated it was documented by Certified Nurse Aide #6 that Resident #36 received a sponge bath but according to Resident #36's Kardex their preference was a shower. They stated that it was never brought to their attention by anyone that Resident #36 received a sponge bath instead of a shower and it was not documented in the nursing progress notes if Resident #36 refused their shower. Resident #36 should have been given a shower because that was what they would have wanted and if they wanted two showers a week that should have been accommodated because that was their preference During a telephone interview on 6/3/25 at 3:05 PM, Registered Nurse #3 stated they were responsible for completing new admission forms. When a resident admitted to the facility and was confused, they would attempt to ask them their shower preferences, but it they could not answer the question they might ask the family, or they would just follow the schedule set by the room number without following up. They stated, typically they would just follow the set schedule. Registered Nurse #3 stated if a resident admitted to the facility and was confused, they should have followed up with a responsible party. During an interview on 6/4/25 at 8:41 AM, Licensed Practical Nurse #3 stated on 5/30/25 there was confusion over which Certified Nurse Aide was responsible for Resident #36 in the morning. They were unsure who had gotten them up and ready for the day and was not told that Resident #36 did not receive their shower. Licensed Practical Nurse #3 stated they believed Resident #36 preferred to have a shower and was scheduled to have showers every Tuesday and Friday. They stated Resident #36 had the right to receive a shower twice a week because that was their preference. During an interview on 6/4/25 at 10:20 AM, the Director of Nursing stated their expectation was to accommodate a resident's preference as best they could, and the preferences should be reviewed quarterly with the care plan reviews. Staffing was never an excuse to not accommodate a resident's preference. They stated they expected the Unit Manager of the unit to follow up with the residents regarding their preferences and document in the nursing progress notes. 10NYCRR 415.5 (b) (1,3)

Based on observation, interview, and record review conducted during the Recertification Survey completed on 10/3/23, the facility did not ensure it is free of a medication error rate of five percent or greater for one (Resident #115) of 8 residents observed during medication administration. There were two errors for 27 observed medication opportunities resulting in a medication error rate of 7.41 % (percent). Specifically, medications were not administered to Resident #115 in accordance with the physician's order. The finding is: The policy and procedure titled Medication Administration Methods last modified 7/12/2022, documented the Medication Nurse must follow the five rights of administration (Right Drug, Right Dose, Right Time, Right Resident, Right Route). Medication may be administered one hour before or after the routine scheduled time, unless otherwise indicated. All problems related to medication administration are noted and later reported to Unit Manager/Supervisor. Resident #115 had diagnoses including hypokalemia (low potassium levels in the blood), history of falls, and cerebral infarction (stroke). The Minimum Data Set (MDS, a resident assessment tool) dated 7/9/23, documented the resident had severe cognitive impairment. The comprehensive care plan (CCP) dated 6/22/23 documented alteration in cardiac status related to hypokalemia, cerebral infarction. Interventions documented administer medications per Physician/ Nurse Practitioner (MD/NP) order. Review of the facility Order Summary Report dated 10/2/23 revealed the following active medications: a. Klor-Con M20 (medication used to treat or prevent low amounts of potassium in the blood) Tablet Extended Release (ER) 20 mEq (milliequivalent) (Potassium Chloride Crys ER), give 2 tablets by mouth (po) three times a day for potassium supplement. b. Senna-S (medication used to relieve occasional constipation) Tablet 8.6-50 mg (milligrams) (Sennosides-Docusate Sodium), give 2 tablets po every morning and at bedtime for constipation. Review of the Medication Administration Record (MAR) dated September 2023 documented Klor-Con M20 Tablet ER 20 mEq, 2 tablets po had administration times of 7:00 AM- 9:00 AM, 12:00 PM-2:00 PM and 7:00 PM-9:00 PM and Senna-S tablet 8.6-50 mg, 2 tablets po at 7:00 AM-9:00 AM and 7:00 PM-9:00 PM. During an observation of medication pass on 9/27/23 at 11:50 AM, Licensed Practical Nurse (LPN) #8 stated Resident #115 was in the shower and was then available to give medications to. LPN #8 administered multiple medications (6) to Resident #115 including, but not limited to, Klor-Con tablets dissolved in plastic medication cup with water and over the counter (OTC) geri-kot (senna- medication to treat constipation) 8.6 mg, 2 tablets. LPN #8 did not dispense or administer morning doses of Klor-Con or Senna-S as ordered by the physician however documented that they had. Review of facility progress note dated 9/28/23 at 9:44 AM by Registered Nurse (RN) #4 Unit Manager (UM) documented a late entry: Provider made aware resident (#115) received am medications on 9/27/23 at approximately: 11:30 AM. Review of the Medication Admin Audit Report dated 10/3/23, documented Klor-Con M20 tablet ER 20 MEQ, 2 tablets scheduled for 9/27/23 7:00 AM was administered on 9/27/23 at 11:55 AM by LPN #8 and there is no documented evidence that the scheduled 12:00 PM-2:00 PM dose of Klor-Con was administered as ordered. During an interview on 9/27/23 at 11:21 AM, LPN #8 stated they had 30 residents to administer medications to that morning and they had 4 residents remaining. LPN #8 stated all morning medications should be done by 10:00-10:30 AM, they have an hour leeway before and after scheduled administration time. During a follow up interview on 10/3/23 at 8:58 AM, LPN #8 stated they typically write a list of the medications administered late for the UM so they can get an order to cover them being administered outside the parameters. LPN #8 stated they did not administer the 12:00 PM-2:00 PM scheduled dose of Klor-Con on 9/27/23 because it was too close to the morning dose given at 11:50 AM. LPN #8 stated they thought they reported administering Resident #115 medications late to the unit manager and was waiting to hear if it was ok to give the 12:00 PM-2:00 PM dose of Klor-Con. Additionally, LPN #8 stated they assumed they had given the correct Senna, because the other senna is unable to be crushed. LPN #8 stated they shouldn't have given the senna and should have gotten an order clarification. During an interview on 10/3/23 at 10:14 AM, RN #4 UM stated they expected medications to be administered as ordered on time and to be notified of issues so they could follow up with a medical provider. RN #4 UM stated LPN #8 gave them a list of residents who didn't receive their medications on time on 9/27/23. RN #4 UM stated they documented in the medical record that the provider was notified of medications being administered late but was not aware of the omitted dose of the Klor-Con on 9/27/23 at 12:00 PM-2:00 PM. RN #4 UM stated this was a medication error because a dose of Klor-Con was omitted, and a provider wasn't notified. Additionally, RN #4 UM stated LPN #8 should have double checked the label on the bottle of senna, because senna-s has docusate (Colace-laxative/ stool softener) in it. During an interview on 10/3/23 at 10:31 AM, Director of Nursing (DON) stated they expected the nurses to verify and identify that the proper medication is administered as prescribed. Additionally, DON stated it is not standard practice to omit medications and that the medical provider should have been notified. During an interview on 10/3/23 at 10:53 AM, Physician Assistant (PA) #1 stated they would expect some type of communication to be notified of late administration, omission of medications, or anything out of policy. 10 NYCRR: 415.12(m)(1)

Based on observation, interview, and record review conducted during the Standard survey completed on 10/03/23 the facility did not ensure that residents were free from physical restraints for the purposes of discipline or convenience, and that are not required to treat the resident's medical symptoms for one (Resident #83) of three residents reviewed. Specifically, Resident #83 was observed with a seat belt restraint, that was not ordered by the physician. The finding is: The policy & procedure (P&P) titled Physical Restraints Policy dated 5/24/2018 documented that a physical restraint will be defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, and which restricts freedom of movement or normal access to one's body. The P&P documented that physical restraints will only be used after all reasonable less restrictive alternatives have been considered and rejected for reasons related to the resident's well-being, and medical causes are ruled out. The use of a physical restraint under non-emergency conditions, would always require a physician's order and an individual nursing plan of care to insure the proper care of the resident with a restraint. The P&P titled Restraints - Self Release Belts dated 7/24/2018 documented that self-release belts will be utilized for residents with medical symptoms warranting application for time periods and conditions as ordered by the Attending Physician. Place belt (attached to chair) around resident's waist over clothing and secure Velcro or clip. The State Operations Manual issued 10/21/22 defined a physical restraint as any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body and cannot be removed easily by the resident and restricts the resident's freedom of movement or normal access to their body. Examples of the facility practices that mean the definition of physical restraint include but not limited to using devices in conjunction with a chair, such as belts, that the resident cannot remove and prevents the resident from rising. 1. Resident #83 had diagnoses which included dementia with agitation, repeated falls, and adjustment disorder (an unhealthy response to a change in a person's life) with mixed disturbance of emotions and conduct. The Minimum Data Set (MDS- a resident assessment tool) dated 9/19/23 documented Resident #83 was moderately cognitively impaired, understood and usually understands. The MDS documented the resident required an extensive assist for transfers, wandered daily, and had a history of falls. In addition, the MDS revealed no evidence that a physical restraint was used. The comprehensive care plan (CCP) revised 8/29/23, documented Resident #83 had episodes of wandering and was at risk for falls related to self-transfers. There CCP did not document the use of a seat belt restraint. The facility Matrix (a tool used to identify pertinent care areas for residents in a skilled nursing facility) dated 9/27/23 documented that no restraints were used in the facility. The physician's Order Summary Report for Resident #83 dated from 3/1/23 to 9/30/23 revealed there was no physician's order for the use of a self-release belt or any type of physical restraint. The SNF Physical Restraint/Device Decision Tree Evaluation V2 with the effective dates of 3/30/23, 4/15/23, 8/23/23, and 9/19/23 revealed there were no physical devices or equipment which may potentially restrict Resident #83's movement used. Review of the facility's accident and injury (A&I) reports from 4/15/23 through 9/12/23 revealed Resident #83 had twenty-three falls. Review of the progress notes from 7/1/23-9/29/23 revealed that Resident #83 had sustained multiple falls related to self-transfers. During an observation on 9/27/23 at 9:31 AM on Unit 3, Resident #83 was in their wheelchair in the 3rd floor dining room. A black seatbelt restraint clip was visible and hanging off the left handle of the wheelchair. Review of a 9/27/23 dated work order revealed the Rehab Aide #1 notified Maintenance at 10:00 AM, to please add reminder belt to wheelchair. During an observation on 9/28/23 at 10:10 AM on Unit 3, Resident #83 was in their wheelchair with a black seatbelt restraint across their waist and was secured and buckled. During an observation and interview on 9/28/23 at 11:09 AM on Unit 3, Resident #83 was in their wheelchair, self-propelling down the north hall. The seatbelt was secured and buckled across their waist. Each side of the black restraint belt had gromets that were bolted to the sides of the wheelchair. Resident #83 could not release the seatbelt buckle and stated, I know it starts over here and ends over there. While pointing to both ends of the belt. Resident #83 was unable to release the belt buckle. Review of a 9/28/23 dated work order revealed Social Worker #1 submitted a work order at 12:22 PM to Maintenance and requested to remove belt from wheelchair asap. During an observation on 9/29/23 at 8:56 AM on Unit 3, Resident #83 was in their wheelchair. The seatbelt was no longer on Resident #83's wheelchair. During an interview on 9/29/23 at 10:04 AM, Certified Nursing Assistant (CNA) #2 stated that Resident #83 had the seat belt on their chair for at least a month. During an interview on 9/29/23 at 10:08 AM, CNA #1 stated they saw Resident #83 in their wheelchair with the seatbelt buckled on 9/28/23. During an interview on 9/29/23 at 10:11 AM, Licensed Practical Nurse (LPN) #7 stated they noticed the seatbelt on 9/28/23. Resident #83 had a seat belt and there was no physician's order. Resident #83 was cognitively unable to follow commands, therefore should not have had a seatbelt. The seatbelt was a restraint. LPN #7 stated Resident #83 had a history of falls and did not know how long the seatbelt was used. LPN #7 stated the restraint was not on the care plan and had notified Registered Nurse (RN) #2 to have it removed. During a telephone interview on 9/29/23 at 10:37 AM, CNA #3 stated that Resident #83 had the seatbelt on their chair since at least 8/29/23 due to falls and self-transfers. Resident #83 was incapable of removing the seatbelt. During an interview on 9/29/23 at 12:46 PM, RN #2 Unit Manager (UM) stated they were unaware of the seatbelt. The facility did not use seatbelts unless the resident could self-release it on command because that would be considered a restraint. RN #2 (UM) stated Resident #83 would be unable to self-release the seatbelt. Restraints required Interdisciplinary Team (IDT) review and a physician's order. RN#2 stated there was no order for the restraint. RN #2 stated Resident #83 should not have had the seatbelt. During an interview on 9/29/23 at 12:56 PM, Rehab Aide #1 stated that on 9/27/23 they were instructed by the Occupational Therapist (OT) #1 to submit a work order to have the seatbelt removed. The Rehab Aide mistakenly requested Maintenance to apply a reminder belt to Resident #83's wheelchair and should have requested the seat belt be removed. During an interview on 9/29/23 at 1:07 PM, OT #1 stated they noticed the seatbelt on Resident #83's wheelchair a few weeks ago. They notified the rehab aide # 1 to put in a work order and have the belt removed. Resident # 83 should not have had a seatbelt and it was placed on the wheelchair in error. The OT stated Resident #83 was unable to release the seatbelt due to their cognition, making the seatbelt a restraint. During an interview on 9/29/23 at 2:19 PM, Maintenance worker #1 stated that they did not know how the seat belt got put onto Resident #83's wheelchair. When they received the work order (9/27/23) to add the belt to the chair, they noticed that the seatbelt was already on the wheelchair. During an interview on 9/29/23 at 2:22 PM, the Social Worker #1 stated they noticed the seatbelt on Resident #83's wheelchair on 9/15/23 and left a voicemail for therapy, questioning why it was there. Review of an email dated 9/15/23 at 8:31 AM revealed Physical Therapist (PT), Assistant Director of Rehab, responded to the SW's voicemail via email that they would look into this today. During an interview on 9/29/23 at 2:51 PM, The Director of Rehab stated they were unaware of who put the seatbelt on, when the seatbelt was put on, and why the seatbelt was put on Resident #83's wheelchair. Seat belts were used as a reminder for residents to sit down when attempting to stand. They also stated that Resident #83 should not have had a seatbelt because they would not be able to self-release it. The seat belt for Resident #83 was a restraint. During an interview on 10/2/23 at 10:18 AM, the PT Assistant Director of Rehab stated that they did not know how long Resident #83 had the seatbelt on their wheelchair. They stated that when they received the voicemail about the seatbelt that they requested OT to evaluate Resident #83 to see if the seatbelt was appropriate. They stated that the resident did not pass the evaluation, so they requested to have the seatbelt removed. During an interview on 10/2/23 at 3:06 PM, CNA #4 stated the seatbelt was used because Resident #83 self-transfers, falls and had been used for a month. CNA #4 stated the seatbelt was not on Resident #83's care plan. During an interview on 10/3/23 at 10:06 AM, RN #3, Nurse Educator, stated CNAs were taught that the facility did not use restraints due to entrapment (a state of being caught or stuck). Residents must be able to self-release the seatbelt, otherwise it would be a restraint. Restraints were documented on the care plan. RN #3 stated CNAs were to interact with residents and implement activities which reduced behaviors as an alternative means to utilizing restraints. During an interview on 10/3/23 at 10:47 AM, The Director of Nursing (DON) stated they did not know how long or why the seatbelt was on Resident #83's wheelchair. Seatbelts were not indicated for frequent falls. The IDT determined the need for a seatbelt. The seatbelt would be reviewed with the physician. The physician would write an order and the seatbelt would be implemented on the care plan. The DON stated falls were discussed at morning report. A seat belt for Resident #83 was never discussed, did not have a physician's order, and was not on the care plan. The seatbelt on Resident #83's wheelchair was a restraint and should not have been used. During an interview on 10/3/23 at 11:03 AM, the Administrator stated that they were unaware of the seatbelt on Resident #83's wheelchair. OT identified the seatbelt two weeks ago. The seatbelt should have been removed but fell through the cracks and was used in error. During an interview on 10/3/23 at 11:18 AM, The Physician's Assistant (PA) stated they didn't recall writing a physician's order for a seatbelt restraint for Resident #83. A seatbelt would be the last choice of intervention to deal with frequent falls. The PA also stated that for a resident to qualify for a seatbelt they would have to be able to self-release it. They stated that Resident #83 was at risk for falls but that they were not really on their radar for someone that would require a seatbelt. 10 NYCRR 415.4 (a)(2)(iii)

Based on observation, interview and record review conducted during the Standard survey completed 10/3/23, the facility did not protect, promote, and treat each resident with respect and dignity and care for residents in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, four (Resident #8, #63, #71 and #80) of seven residents reviewed for dignity with dining were observed being fed by staff (Registered Nurse (RN) #2, Occupational Therapist, Registered (OTR), and Licensed Practical Nurse (LPN) #6) who were standing while providing meal assistance on multiple occasions. The findings are but not limited to the following: The policy and procedure titled Feeding Guidelines dated 3/12 documented, sit at residents' eye level while providing assistance with meals. 1.) Resident #8 has diagnoses including dementia, Alzheimer's disease, and diabetes mellitus. The Minimum Data Set (MDS - an assessment tool) dated 8/24/23 documented Resident #8 was understood and understands and required limited assistance of one person for eating. Review of the untitled Kardex (a resident care guide) as of date 10/2/23 revealed Resident #8 was supervision with set up help only for eating. During an observation on 9/27/23 at 12:08 PM to 12:18 PM, Resident #8 was seated in their wheelchair in the 3rd floor dining room. RN # 2, Unit Manager (UM) leaned on the top of table with their left hand, hovered over Resident #8. RN #2 assisted Resident #8 with their right hand. During an interview on 10/2/23 at 3:14PM, RN #2 stated normally they sit at eye level and engage in conversation with Resident #8. RN #2 stated the dining room was busy on 9/27/23 and they had to circulate. Standing was inappropriate. RN #2 stated they should have sat down. 2.) Resident #71 has diagnoses including schizophrenia, dementia, and dysphagia (difficulty swallowing). The MDS dated [DATE] documented Resident #71 was rarely/never understood and rarely/never understands and required extensive assistance of one person for eating. Review of the Visual/Bedside Kardex Report with as of date 10/2/23 documented Resident #71 required extensive assistance/ one person physical assist for eating. During an observation on 10/2/23 from 12:13 PM to 12:30 PM, the OTR stood while they assisted Resident #71 with their lunch. During an interview on 10/2/23 at 12:31PM, the OTR stated Resident #71 was too tall and wouldn't be able to reach Resident #71's mouth. No chairs were available, standing was undignified and should have located a chair from another room. 3.) Resident #63 has diagnoses including dementia, hemiplegia (paralysis on one side of the body), and metabolic encephalopathy (disease of the brain and spinal cord). The MDS dated [DATE] documented Resident #63 was always understood, always understands, and had moderate cognitive impairment. Resident #63 required extensive assistance of one staff member for eating. The comprehensive care plan revised 9/14/23 documented Resident #63 required extensive assistance of one staff member for eating. Review of the Visual/Bedside Kardex Report dated 10/3/23 revealed Resident #63 required extensive assistance of one staff member for eating. During an observation on 9/29/23 from 9:57 AM to 10:05 AM, in the residents' television lounge, LPN #6 was standing next to Resident #63 who was in a Geri chair (a specialized reclining chair with wheels) assisting them by alternating yogurt and a drink while standing over them. During an observation on 10/2/23 at 8:58 AM, LPN #6 was in Resident #63's room assisting them during breakfast. Resident #63's bed was in low position with the head of the bed elevated. Resident #63 was sitting up in bed with a slight lean to the right. LPN #6 was on the left side of the bed, standing over Resident #63's while assisting them with their breakfast. During an interview on 10/2/23 at 10:03 AM, LPN #6 stated Resident #63 does not eat much during meals; they would only drink their boost and take bites. LPN #6 stated they offered yogurt between meals because Resident #63 enjoyed yogurt and they wanted to encourage Resident #63 to eat as much as possible. LPN #6 stated they should have sat while assisting Resident #63 to eat. LPN #6 stated it was easier to stand while assisting Resident #63 to eat in bed because Resident #63 was leaning to the side LPN #6 stated they should have been at eye level with Resident #63, both times, to make the resident more comfortable. During an interview on 10/2/23 at 1:48 PM, the Dietitian stated it was policy for staff to sit while assisting any resident to eat. The Dietitian stated staff should be seated at eye level because it was a dignity thing. During an interview on 10/3/23 at 8:22 AM, RN #4 stated staff should be seated at the same level as residents when they are assisting them to eat because it shows respect, gives the residents dignity, and provides a more personal interaction. During an interview on 10/3/23 at 10:11 AM, RN #3, Nurse Educator stated staff should be focused at eye level and engaged with conversation with the resident. Leaning on the table, standing, and hovering over someone was undignified. During an interview on 10/3/23 at 10:48AM, the Director of Nurses, DON stated sitting at eye level provided a sense of dignity. Staff were expected to make every attempt to sit while assisting with meals. 10 NYCRR 415.5(a)

Based on observation, interview, and record review conducted during complaint investigations (Complaint #NY00322837) during the Standard survey completed on 10/3/23, the facility did not ensure that a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming, personal hygiene for one (Resident #47) of two residents reviewed. Specifically, the CNA (Certified Nurse Aide) lacked proper hand hygiene and glove changes during bowel incontinence care (Resident #47) and before touching items in the environment. The finding is: The policy and procedure (P&P) titled Perineal, Incontinent Care last modified 5/3/2018 documented perineal care will be provided when residents are incontinent or cannot provide such care for themselves. Assist resident onto bedpan, toilet, or commode chair or perform procedure directly in bed. In cleansing perineal areas of female resident, always cleanse from front perineal areas to rectum to prevent contamination of orifices. Discard gloves and wash hands thoroughly. Required for infection control. 1. Resident #47 had diagnoses including unspecified dementia, hemiplegia (paralysis on one side of body) and hemiparesis (weakness of one side of body) following cerebral vascular accident (CVA-stroke). The Minimum Data Set (MDS - a resident assessment tool) dated 8/10/23, documented Resident #47 had moderate cognitive impairment. In addition, Resident #47 was always incontinent of bowel and bladder; required extensive assist of two staff members for transfers and toilet use. The comprehensive care plan (CCP) revised on 5/15/23 documented that Resident #47 had a deficit in ADL (Activities of Daily Living). The resident required extensive assistance with the use of a mechanical lift (Sit to Stand), two-person physical assist for transfers, initiated 10/13/21 and toileting hygiene the resident required total dependence of one-person, initiated 9/2/21. Review of complaint intake detail report received 8/23/23 at 11:42 AM, revealed the complaintant reported that Resident #47 was helpless and relied on staff for all hygiene. During an observation of incontinent care on 10/2/23 at 1:19 PM to 1:33 PM, with CNA's #7 and #8, Resident #47 was lifted by the mechanical lift to a standing position in front of wheelchair in the middle of their room. While wearing clean gloves, CNA #7 removed a soiled brief of urine and bowel from Resident #47 and placed it on a barrier at bottom of a bed. CNA #7 then used prepped washcloths with soap and water from a clean barrier on tray table to provide incontinent care while Resident #47 stood in lift. After cleaning Resident #47's genital area, CNA #7 proceeded behind the resident to cleanse their buttocks and rectal area. While cleansing rectal area, Resident #47 was observed to be moving their bowels, as CNA #7 continued wiping rectal area, several more times, with presence of soft brown stool. CNA #7's gloved hands touched the stool soiled washcloth. CNA #8 asked Resident #47 if they would like to sit on the toilet. Resident #47 responded they didn't think so. After continued wiping of rectum with washcloths to remove the stool, CNA #7 while wearing the same gloves to provide incontinent care, touched the mechanical lift and operated the controller of the lift. While still standing on mechanical lift, Resident #47 was transferred into their bathroom and placed on toilet. CNA #8 assisted with guidance of resident into the bathroom and placement onto toilet. CNA #7 doffed (took off) gloves at this time and donned (put on) new gloves without sanitizing or washing their hands. Upon completion of Resident #47 moving their bowels while sitting on the toilet, Resident #47 was brought to a standing position via the mechanical lift. CNA #7 wiped Resident #47 back to front with the presence of stool on the washcloth. After completion of care and prior to doffing (removing) the contaminated gloves; CNA #7 handled a clean towel to dry Resident #47, assisted CNA #8 with applying a clean brief, pulling up clothing and maneuvering the mechanical lift out of bathroom and placing Resident #47 back into their wheelchair. CNA #7 doffed gloves and donned new gloves to gather soiled linen prior to leaving the room to dispose the linens in the soiled work room. CNA #7 doffed their gloved hand after disposing soiled linen, garbage and washed their hands with soap and water. During an interview on 10/2/23 at 1:33 PM, CNA #7 stated they did not change their gloves or wash their hands after gloves came into contact with stool during incontinent care. Additionally, CNA #7 stated they were supposed to wipe front to back when providing peri-care and that Resident #47 had stool in their genital area area while completing peri-care after toileting. CNA #7 stated by not removing their gloves prior to touching clean items they would have contaminated the whole area, everything they touched. During an interview on 10/2/23 at 1:40 PM, CNA #8 stated, CNA #7 should have changed their gloves after cleansing Resident #47 of stool because their gloves were contaminated, and they did not. Additionally, CNA #8 stated CNA #7 should have removed gloves prior to touching anything clean. During an interview on 10/2/23 at 1:44 PM, Licensed Practical Nurse (LPN) #8 stated hands should be washed before care, washed after soiled gloves were removed, and directly after care was provided. LPN #8 stated they would expect staff to remove gloves that were contaminated prior to touching anything clean to prevent cross contamination. LPN #8 stated residents should always be cleaned front to back during incontinent/peri-care to prevent infection. Additionally, LPN #8 stated they would expect staff to change residents in their bed or be transferred onto the toilet, unless their plan of care stated something different. During an interview on 10/2/23 at 1:54 PM, Registered Nurse (RN) #4 Unit Manager (UM) stated incontinent care should be performed in a private area and per residents' preference. RN #4 UM stated they expected nursing staff to remove gloves and wash hands between different tasks with incontinent care for infection control practices. During an interview on 10/2/23 at 2:02 PM, the Director of Nursing (DON) stated they expected incontinent care to be performed with a front to back motion, so nothing was introduced from the back to the front. DON stated this was an infection risk if a resident was cleansed back to front. Additionally, DON stated they expected gloves to be changed when visibly soiled and hands sanitized before touching anything clean. 10NYCRR 415.12(a)(3)

Based on observation, interview, and record review conducted during a Complaint investigation (Complaint #NY00320987) during the Standard survey completed on 10/3/23, the facility did not ensure the resident environment was free of accident hazards as possible for two (Residents #60 & #94) of three residents reviewed for falls. Specifically, staff did not follow each resident's care plan which resulted in falls. The findings are: The policy and procedure (P&P) titled ADL (Activities of Daily Living) Assistance and Supervision last modified 1/4/2018, documented the Unit Manager/designee monitors the ADL assistance/supervision provided for residents throughout the shift and gives appropriate guidance and assistance to nursing staff. The Personal Care Profile/Kardex and Care Plan are the documents to be referenced for the type of ADL assistance/supervision needed by a resident. The Nursing Assistant provides ADL assistance/supervision to assigned residents and assists other Nursing Assistants in giving ADL care as needed. The P&P titled Care Planning (IDT-Interdisciplinary Team) last modified 1/22/19, documented the IDT will develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial wellbeing. The Kardex will be utilized by the IDT as a guide to provide care to the resident. 1. Resident #60 had diagnoses including rheumatoid arthritis (chronic inflammatory disorder), spinal stenosis (narrowing of the spinal space) and obesity. The Minimum Data Set (MDS- a resident assessment tool) dated 7/11/23 documented the resident was cognitively intact, understands and was understood. The MDS also documented Resident #60 required total dependence of two assist with transfers and extensive assist of two staff members with bed mobility and toileting. The Comprehensive Care Plan (CCP) initiated on 11/14/17 documented Resident #60 had an ADL function/mobility deficit related to their medical diagnosis. Interventions, initiated on 1/21/23, included that the resident required extensive two-person assistance for rolling side to side in bed and two-person assistance using a mechanical lift (Hoyer) with a green sling for transfers. The Kardex (a guide used by staff to provide care) dated 7/28/23 documented Resident #60 required extensive two-person assistance for rolling side to side in bed and two-person assistance using a mechanical lift (Hoyer) with a green sling for transfers. The incident report dated 7/5/23 at 10:45 AM, completed by Registered Nurse (RN) #5 documented Certified Nursing Assistant (CNA) #5 used a sit to stand lift with a yellow sling to transfer Resident #60 into their wheelchair. The resident was care planned for a full body mechanical lift. CNA #5 stated the resident was unable to stand and slipped down out of the lift and to the floor. No injuries were noted at that time. A note dated 7/6/23 completed by the Director of Nursing (DON), documented that CNA #5 did not follow the care plan. The incident report dated 7/28/23 at 7:15 AM, completed by Licensed Practical Nurse (LPN) #9 supervisor documented Resident #60 fell on the floor during care. Certified Nursing Assistant (CNA) #1 had Resident #60 turn onto their left side with the bed in a high position while providing care. The Incident Investigation dated 8/3/23, completed by the DON documented type of incident as a care plan violation, CNA #1 was preparing to provide personal care to Resident #60. CNA #1 attempted to remove the brief from Resident #60 even though they knew Resident #60 was a two assist. In the process Resident #60 grabbed the curtain to pull themselves over and fell out of the bed onto the floor. During an interview on 10/2/23 at 9:21 AM, CNA #1 stated Resident #60 was incontinent of bowel and requested to be changed. CNA #1 stated there were no other nursing staff on the unit at that time and Resident #60 needed help. CNA #1 stated Resident #60 was a two assist for rolling in bed and won't attempt to take care of Resident #60 again by themselves. During a telephone interview on 10/2/23 at 9:58 AM, LPN #9 Supervisor stated that Resident #60 was care planned to have two aides at the time they fell out of bed. LPN #9 stated the incident could have been avoided if staffing wasn't so poor at that time. During a telephone interview on 10/2/23 at 4:13 PM, CNA #5 stated they did not check Resident #60's Kardex prior to providing care and that they were literally directed by another staff member, not sure who, to transfer Resident #60 with the sit to stand lift. CNA #5 stated they remembered Resident #60 had fallen, and that their statement given on 7/5/23 sounded familiar. During an interview on 10/2/23 at 4:23 PM, the DON stated they expected anyone who interacts with residents to follow their care plans for resident safety. The DON stated Resident #60's falls could have been prevented if their care plans were followed. 2. Resident #94 had diagnoses including dementia, repeated falls, and osteoporosis (a disease that weakens your bones). The MDS dated [DATE] documented the resident was severely cognitively impaired, usually understands and was understood. The MDS documented Resident #94 required total assistance of two staff members for transfers. The CCP initiated on 12/1/22 documented Resident #94 had an ADL function/mobility deficit related to their medical diagnosis. Interventions, initiated on 3/8/23, included the resident required a mechanical lift (Hoyer) and two-person physical assist, with a green trim sling for transfers. The incident report for a witnessed fall dated 4/1/23 at 11:35 AM, completed by LPN #10, documented they were called to Resident #94's room by an aide, Resident #94 was sitting on the floor in the bathroom. Resident #94 slid out of the sit to stand (mechanical lift). Review of a Progress Note dated 4/1/23 at 12:15 PM, LPN #10 documented Resident #94 was being placed on the toilet with the sit to stand lift when they let go of the handles and slid out of the sling. The Notice of Disciplinary Action dated 4/14/23 documented that on 4/1/23 CNA #6 transferred Resident #94, who was care planned as a two person assist without assistance. The document contained the Administrator and CNA #6's signatures. During an interview on 10/2/23 at 5:20 PM, Administrator stated they expected each person rendering care to review the care plan and provide care according to the resident's care plan. 10 NYCRR 415.12(h)(2)

Based on observation, interview, record review conducted during a Standard Survey completed on 10/3/23, the facility did ensure the Nurse Staffing information and data requirements were posted daily and the data was maintained for 18 months. Specifically, the facility did not keep the staffing data for 18 months and the facility did not update and post the daily Nurse Staffing information on 9/30/23, 10/1/23 and 10/2/23. The finding is: The policy and procedure(P&P) titled, Posting of Daily Resident Care Staffing (BIPA) dated 4/12/2018, it documented that Skilled Nursing Facilities (SNFs), and Nursing Facilities (NFs) staffing will be posted at the beginning of each shift the facility specific shift schedule for a 24-hour period licensed and unlicensed personnel who provide direct care to residents. Further review of the P&P documented that the facility must keep records of the posted nurse staffing information for 18 months. During an observation on 10/2/23 at 8:00 AM, the posted nurse staffing information sheet titled, Report of Nursing Staff Directly Responsible for Resident Care had the date of 9/29/23. During an additional observation on 10/2/23 at 9:30 AM, the posted Report of Nursing Staff Directly Responsible for Resident Care had the date of 9/29/23. During an interview on 10/2/23 at 11:35 AM, the Administrator stated that they don't keep copies of the BIPA as they have it in their time management system. The Administrator stated that they could produce the nurse staffing information, but they would not have 18 months' worth. The Administrator stated the Report of Nursing Staff Directly Responsible for Resident Care sheet gets discarded and they would not have copies of it. The Administrator stated the posted nurse staffing information was probably not posted over the weekend. The Administrator stated the Nursing Supervisor was responsible to post the nurse staffing information. During an interview on 10/3/23 at 8:38 AM, the Registered Nurse (RN) Nursing Supervisor (RNS) #1 stated that it was the Nursing Supervisor's responsibility to post the nurse staffing information daily, but the facility does not staff a Nursing Supervisor every day. RNS #1 stated only certain staff members have access to information and the system. They stated that Unit Managers do not have access to this information. RNS #1 stated there were no Nursing Supervisors working this past weekend. 10NYCRR 415.13

Based on observation, interview, and record review conducted during an Abbreviated survey (NY 591) completed from 8/31/22 through 9/1/22, the facility did not maintain an environment as free of accident hazard as possible for 4 (Residents #1, 2, 3, and 4) of 4 residents reviewed. Specifically, staff used incorrect mechanical lift slings during transfers (Resident #1). In addition, (Residents #2, 3, and 4) had the incorrect mechanical lift sling in place per their plan of care. The findings include but are not limited to: Review of the facility policy and procedure (P&P) titled Safe Patient Handling Program dated 1/16/20, revealed the facility was committed to maintaining a safe and comfortable environment to protect our employees, residents, and assets. As part of this commitment and to comply with regulatory requirements, our facility has implemented a Safe Patient Handling Program for transferring, mechanical lifting and repositioning of our residents ( referred to herewith in as resident movement). The basic objectives of this program were defined: To increase the quality of care for our residents and to perform a safe and comfortable resident movement for our residents. The licensed therapist or trained registered nurse will determine appropriate sling size, based upon manufacturer's recommendations and individualized resident needs and documented on the applicable resident care plan and profile of care. Prior to transfer, the nursing assistant will refer to the resident care plan or profile of care for appropriate sling size. Review of the facility P&P titled Care Planning (IDT) modified 1/22/19, revealed the comprehensive care plan will include services that are to be furnished to attain or maintain the residents highest practicable physical, mental and psychosocial wellbeing. 1. Resident #1 was admitted to the facility with diagnoses which included muscle weakness, hypertension-[CONDITION(S)], and chronic pain syndrome. The Minimum Data Set (MDS-a resident assessment tool) dated 6/23/22 documented intact cognition, was understood and understands, and that Resident #1 was totally dependent on staff for transfers. The Therapy Progress Note dated 12/2/21, written by the Assistant Director of Rehab, documented Resident #1 was screened for sling size due to resident complaints. The resident was previously recommended for yellow sling with assessment determining that resident was more appropriate for green sling. Review of the Electronic Medical Record (EMR) weight documentation revealed Resident #1's most recent weight was 193.7 pounds (lbs) on 7/14/22. Review of the sling manufacturer size guide titled Sling Color and Size Guide revealed the following: -Adults who weighed between 77-132 lbs required a small sling (red) -Adults who weighed between 121-165 lbs required a medium sling (yellow) -Adults who weighed between 154-264 lbs required a large sling (green) The Bedside Kardex Report (guide used by staff to direct care) as of 8/30/22 documented Resident #1 transferred with total dependence via mechanical lift (Hoyer) with two-person physical assist, and used the ceiling lift with a green sling. The Comprehensive Care Plan revised 12/2/21, documented the resident transferred with total dependence via mechanical lift (Hoyer) with two-person physical assist and used the ceiling lift with a green sling. During an observation on 8/31/22 at 10:42 AM, Certified Nurse Aide (CNA) #1 and CNA #2 positioned a yellow mechanical lift sling under Resident #1. CNA #1 and #2 transferred Resident #1 from the bed to the shower chair using the ceiling lift (mechanical lift) using the yellow sling. During further observation at 11:40 AM, CNA #1 and #2 transferred Resident #1 from the shower chair to the bed with the ceiling lift and used the same yellow sling that was wet. At 11:46 AM, CNA #1 and #2 transferred Resident #1 from the bed to the wheelchair with the ceiling lift and used a dry yellow sling that was present in Resident #1's room. The sling was noted to be tight around the resident legs causing their legs to be squeezed together. During an interview on 8/31/22 at 11:49 AM, CNA #1 stated sling sizes were determined by residents weight. Therapy assessed residents for sling size and updated the Kardex. CNAs checked the Kardex daily prior to care. CNA #1 stated they did not check the Kardex and was unaware Resident #1 was care planned for a green colored sling. Aides were used to the residents' routines and checked the Kardex when they were off for a few days. CNA #1 stated they had never used a green sling for Resident #1. During an interview on 8/31/22 at 11:52 AM, CNA #2 stated sling sizes were documented on the Kardex. The Kardex was checked daily in the morning or prior to giving care. CNA #2 stated Resident #1 was not their assigned resident therefore they did not review the Kardex despite assisting with the transfer and should have used a green sling. During an interview on 8/31/22 at 1:45 PM, the Assistant Director of Rehab stated they assessed Resident #1 on 12/2/21 due to a referral from the nursing staff. Resident #1 was uncomfortable while transferring using the yellow sling because it was too small. The plan of care was revised on 12/2/21 for use of the ceiling lift with the green sling. The green sling was more appropriate for Resident #1's weight and body type. The Assistant Director of Rehab stated CNA #1 and #2 should have transferred Resident #1 using the green sling for safety reasons and could cause injury. 2. Resident #2 was admitted to the facility with diagnoses which included muscle weakness, dementia, and depression. The Minimum Data Set (MDS-a resident assessment tool) dated 7/29/22 documented severe cognitive impairment, was usually understood and usually understands. The MDS further documented Resident #2 was totally dependent on staff for transfers. The Visual/Bedside Kardex Report dated as of 9/1/22 documented Resident #2 transferred with total dependence via mechanical lift (Hoyer) with two-person physical assist using a green sling. The CCP revised on 7/20/22 documented the resident transferred with total dependence, via mechanical lift (Hoyer) with two-person physical assist using a green sling. During an observation on 9/1/22 at 11:32AM, Resident #2 was at the nurses station in the geri recliner chair and positioned on a red sling. On 9/1/22 at 11:35 AM, CNA #3 observed the resident and stated Resident #2 was positioned in the geri recliner on a red mechanical lift sling and should have used a green sling per the Kardex. CNA # 3 stated they used whatever color sling was in Resident #2's room. CNA #3 stated they did not check the Kardex. 3. Resident #3 was admitted to the facility with diagnoses which included muscle weakness, dementia, and anxiety. The Minimum Data Set (MDS-a resident assessment tool) dated 8/5/22 documented moderate cognitive impairment, was understood and understands. The MDS further documented Resident #1 was totally dependent on staff for transfers. The Visual/Bedside Kardex Report dated as of 9/1/22 documented Resident #3 transferred with total dependence, via mechanical lift (Hoyer) with two-person physical assist using a green sling. The CCP revised on 5/19/22 documented the resident transferred with total dependence, via mechanical lift (Hoyer) with two-person physical assist using a green sling. During an observation on 9/1/22 at 11:35 AM, Resident #3 was in the Unit 3 common area lounge positioned on top of a red mechanical lift sling in a high back wheelchair. During an interview on 9/1/22 at 12:40 PM, CNA #4 observed the resident and stated Resident #3 was positioned on top of a red sling. CNA #4 stated per the Kardex I should have used a green sling. CNA #4 stated they should get into the habit of reviewing the Kardex prior to giving care and there was just no time. In addition, CNA #4 stated they were taught they could go up a size if needed. During an interview on 9/1/22 at 12:45 PM, Registered Nurse (RN) #1 Nursing Supervisor stated CNAs were supposed to review resident Kardex's every morning prior to starting care. Using the wrong sling could cause a resident to potentially slip out of the sling causing someone to get hurt. During an interview on 9/1/22 at 1:27 PM, the Director of Rehab stated Physical Therapists determined when residents required a mechanical lift for transfers. The guidelines were based on a resident's weight, body-torso shape, and comfort. CNAs were expected to use the color of sling documented on the Kardex per therapy recommendations for safety. Skin tears could occur and a resident may be uncomfortable. The Director of Rehab stated staff must have grabbed any sling and were rushed to get the residents up in the morning. During an interview on 9/1/22 at 3:29 PM, in the presence of the Interim Director of Nursing (DON), the Administrator stated CNAs were expected to review Kardex's at the beginning of each shift and use the appropriate sling per the therapist recommendations. When wrong-colored slings were used, staff were not following the safe patient handling program. The Administrator stated their goal was safe patient handling, and using the wrong slings was not safe. 415.12 (h)(1)

Based on observation, interview, and record review conducted during a Standard survey completed on 10/13/21, the facility did not ensure that a resident who was unable to carry out activities of daily living receives the necessary services to maintain good grooming, and personal hygiene for one (Resident #54) of four residents reviewed for activities of daily living (ADLS). Specifically, Resident #54 was unshaven and had dark brown/ black debris beneath all their fingernails. The finding is: The facility policy and procedure (P&P) titled Hand and Nail Care dated 1/25/19 documented that residents will receive nail care for cleanliness and to prevent infection. Appropriately trained nursing assistants will provide nail care for all residents except those with diabetes mellitus or severe [CONDITION(S)]. The facility P&P titled A.M. Care dated 4/10/2018 documented that morning (A.M.) care will be provided for all residents in preparation for breakfast and the daily routine. The procedure included to provide nail care if indicated and assist with grooming needs, brush, comb hair, shave or clip facial hair if applicable. The facility P&P titled Hygiene and Grooming dated 7/24/18 documented that nursing staff will ensure that residents are clean and appropriately groomed at all times. Residents will be provided with care to maintain or improve abilities to perform hygiene and grooming tasks as needed. Grooming Regimen included nails are cleaned and trimmed as part of the bath/shower routine and whenever needed. The facility P&P titled Shaving a Male Resident dated 5/8/18 documented that the nursing assistant will shave the face of a male resident if the resident is unable to do the procedure safely by himself. The procedure will be carried out daily or as needed. 1. Resident #54 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 8/19/21 documented Resident #54 was cognitively severely cognitively impaired, did not reject care, and required extensive assistance of one person for personal hygiene. Review of the undated Comprehensive Care Plan (identified as current) documented Resident #54 had an ADL deficit related to medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Visual/Bedside Kardex Report (a guide staff use to provide care) dated 10/13/21 documented Resident #54 required supervision/set up help for personal hygiene. Review of the Progress Notes dated 10/8/21 through 10/13/21 revealed there was no documented evidence Resident #54 refused ADL care. During intermittent observations on 10/6/21 at 3:39 PM, 10/7/21 at 1:39 PM, 10/8/21 at 9:59 AM, 11:08 AM at 2:55 PM, 10/12/21 at 8:07 AM, 11:09 AM, and 12:33 PM revealed Resident #54 remained unshaven and had dark brown/black debris beneath all their fingernails. During an interview on 10/7/21 at 9:22 AM, Resident #54's Heath Care Proxy Agent stated in the past they have had to speak with facility staff regarding the resident's fingernails because they were long and dirty. During a morning care observation on 10/13/21 at 8:25 AM Resident #54 was unshaven and had dark brown/black debris beneath all their fingernails. Certified Nursing Assistant (CNA) #1 did not offer Resident #54 to be shaved, and/or to have their fingernails cleaned/trimmed. During an interview on 10/13/21 at 8:38 AM at the completion of AM care, CNA #1 stated that morning care was completed and morning care for a resident consisted of washing, dressing, toileting and brushing teeth. CNA #1 stated they were familiar with Resident #54 and Resident #54 was to be shaved and provided with fingernail care on shower days and when needed. At 8:40 AM, CNA #1 observed Resident #54 and stated that during morning care Resident #54 should have been shaved and provided with nail care. During an interview on 10/13/21 at 8:43 AM, Registered Nurse (RN) #1 Unit Manager stated the CNA staff should be shaving and providing nail care as needed as part of the resident's morning care. At the time of the interview RN #1 observed Resident #54 and stated the resident should have been shaved and provided with nail care during morning care. RN #1 stated the CNAs do not specifically sign for shaving or fingernail care because it was expected to be completed during ADL care. During an interview on 10/13/21 at 12:02 PM, the Director of Nursing (DON) stated they expected residents to be shaved with morning care and nail care to be provided on shower days and as needed. The DON stated, Team Leaders and unit Managers should be looking at the residents every day to ensure they have received all ADL care which included shaving and fingernail care. 415.12 (a)(3)

Based on observation, interview, and record review conducted during the Standard survey completed on 10/13/21, the facility did not ensure that each resident receives and the facility provides food prepared by methods that conserve nutritive value, flavor and appearance and food that is palatable. Specifically, one (kitchen) of one kitchen reviewed for pureed food preparation had issues involving pureed food items that were not palatable or appetizing. The finding is: The policy and procedure (P&P) titled Level 1 Diet (pureed) dated 11/09 documented this diet meets recommended dietary allowances for all residents consists of pureed, homogenous (smooth) and cohesive (adhered together) foods. Foods should be pudding-like and no coarse textures. The recipe titled Pureed Green Beans dated 2/11/19 documented Ingredients - green beans and water. Prepare green beans by portioning out green beans servings for purees. Add green beans into the food processor and then add water as needed, one cup at a time. Blend until smooth or desired consistency is achieved. Review of the recipe entitled Pureed Noodles dated 10/8/21 Ingredients- pasta noodles and water. Prepare noodles by portioning out noodles servings for purees. Add noodles into the food processor and then add water as needed, one cup at a time. Blend until smooth or desired consistency is achieved. During an observation on 10/08/21 at 11:10 AM in the presence of Dietary Services (DDS) the Cook scooped approximately 6-7 large spoon full of green beans from the steam table into the food processor. The Cook proceeded to the sink and added water directly from the faucet into the blender without measuring, covering the green beans. The green beans were blended for approximately 40 seconds and were poured into a square pan. The green beans were watery when poured into the pan. The Cook added approximately one cup the thickener into the green beans in the pan directly from the container (without measuring). The Cook whisked the beans for approximately 20 seconds and proceed to add approximately another cup of thickener to the beans directly from the container and whisked again for a few seconds. The green beans were tempted, covered in foil and placed on the steam table. After cleaning the food processor, washing their hands and putting on clean gloves, the Cook spooned seven large scoops of egg noodles from the steam table into the food processor. The Cook proceeded to the sink and added water directly from the faucet without measuring covering the egg noodles. The Cook blended the egg noodles for approximately 40 seconds and poured the egg noodles into a square pan. The egg noodles were watery when poured into the pan. The Cook added approximately one cup of thickener into the egg noodles in the pan from directly from the container without measuring. The Cook whisked the egg noodles for approximately 30 seconds. The egg noodles were tempted, covered them with tin foil and placed the egg noodles on the steam table. After all the trays were served at 12:45 PM, a test tray was conducted off the serving line with the DDS. The results were as followed: - Green beans had very little taste and were very pasty - Egg noodles had no taste and were very pasty During an interview on 10/08/21 at 12:32 PM, the DDS stated in the presence of the Diet Tech (DT) the the Speech Therapist gives direction on how to make the pureed consistency, they like it like pudding texture. The recipes do not call for thickener and the green beans were watery when they came out of the food processor. The cook should have added water gradually like the recipes calls for. When the DDS tasted the pureed green beans and egg noodles, they stated the food tasted weak in flavor and was pasty. The DT did not taste the pureed food, and nodded in agreement to the DDS statements. During an interview on 10/08/21 at 12:40 PM, the Cook stated they were never educated on how to puree food and was unaware of there were any recipes to follow. The pureed texture should be pudding consistency. The Cook stated they add water to the top of the food in the food processor before blending. The Cook stated the green beans and egg noodles were watery and was unsure how much thickener was added but had to add more to get it to the proper consistency. After reviewing the recipes provided by the DDS for the pureed green beans and egg noodles, the Cook stated the recipes did not call for thickener. During an interview on 10/08/21 at 1:10 PM, the Speech Language Pathologist (SLP) stated they would expect the pureed food to be like a mashed potato/pudding consistency and they were unsure how the pureed food was prepared or if thickener was used. During an interview on 10/08/21 at 1:17 PM, the Registered Dietitian (RD) stated we do not normally use thickener in our pureed food. If the end product was too thin, the cook should have added more of the product, so you're not taking away from the nutritional valve of the food. Water should be added in small amounts and a small amount of thicker was ok at times. Excessive thickener and water take away the nutritional value of the food. The RD stated they would expect the consistency of the pureed food to be smooth, no lumps and doesn't run off the spoon. During an interview on 10/08/21 at 2:10 PM, Resident #60 (who received a pureed meal) stated the green beans and egg noodles were not good. 415.14(d)(1)(2)