Every finding on record at Elderwood at Liverpool

Based on interviews and record review during the recertification survey, the facility did not ensure that views, grievances, or recommendations voiced by residents during Resident Council group meetings were considered, acted upon, and responded to with a rationale for nine (9) of nine (9) anonymous residents present at the resident group meeting and one additional resident interviewed (Resident #17). Specifically, nine (9) anonymous residents at the resident group meeting and one additional resident interviewed (Resident #17) stated they did not receive responses to topics or concerns addressed in prior Resident Council meetings. Additionally, there was no documented evidence that the residents' voiced concerns were investigated, and rationales or responses were provided to the residents.Findings include: The facility policy Resident Council Policy, revised 12/15/2025, documented the Director of Activities was the appointed staff member to act as a liaison between the council and the administration staff for reporting problems, issues, and suggestions discussed by the residents at the council meetings. The Administrator or appropriate department head was to address problems, complaints, or issues reported at resident council meetings and submit a written response upon request.During a resident group meeting on 02/02/2026 at 11:04 AM, nine (9) anonymous residents stated the facility did not always follow up, address, or resolve their concerns. They stated missing clothing was a big issue and missing items were not replaced or returned if the resident did not have a receipt of purchase. There were also concerns with inadequate nursing and kitchen staffing not addressed with the group.During an interview on 02/05/2026 at 9:54 AM, Resident #17 stated they were missing several items of clothing. They previously brought the concern up in resident council, but nothing was done.Resident Council meeting minutes documented:-on 08/19/2025 old business included staffing concerns and staff on their cellphones. New business included missing items.-on 09/16/2025 old business included staff using cellphones in resident areas and missing items from resident rooms. New business included the President of the resident council asking when Administration was going to address their old business.-on 10/21/2025 new business included staffing concerns and staff on their phones in the dining room.-on 11/18/2025 old business included staff on their cellphones in the dining room marked as not resolved and staffing concerns marked as partially resolved. New business included an elevator does not work sign on the elevator.-on 12/16/2025 old business included the elevator does not work sign on the elevator not resolved.-on 01/20/2026 new business included a lack of nursing presence on the units, staff using their cellphones and earbuds during care, and Resident #17 missing several items of clothing. There was no documented evidence the new business or old business items were investigated, or rationales and responses were provided to the Resident Council during subsequent meetings.There was no documented Grievance/Missing Item form for Resident #17. During an interview on 02/10/2026 at 2:32 PM, the Director of Activities stated they and one other staff member were responsible for taking notes for the resident council. After the meeting, they sent out the minutes to all managers so they could address the concerns. They recently implemented a department response form that was now required to be filled out. Prior to the form, they spoke with the managers directly, discussed the issues in morning meetings, and at the bimonthly quality assurance meetings. Missing items reported in Resident Council went directly to the Director of Environmental Services. Most of the time, the Director of Environmental Services was already aware of the missing items. The issue of staff being on their phones was brought to the attention of the Administrator, the Director of Nursing, and the Unit Managers. They were unaware of anything done to address the issue in an official capacity, but it was not addressed with the Resident Council. The elevator sign was on the third floor and was placed by staff to deter confused residents from the elevator, but it only worked to upset the alert and orientated residents and confuse visitors. The issue was resolved but it took a long time for the sign not to be put back up after being taken down. During an interview on 02/10/2026 at 2:51 PM, the Director of Social Work stated if a resident stated items were missing during Resident Council there was a form that was filled out and an investigation was conducted. Usually, the Activities Director would let them know if there were any complaints of missing items. They stated they had not been made aware Resident #17 had any missing items. 10 New York Codes, Rules and Regulations 415.5(c)(6)

Based on observations, record review, and interviews during the recertification survey, the facility failed to ensure a safe, clean, comfortable, and homelike environment for one (1) of three (3) resident floors (Second floor) reviewed. Specifically, the Second floor hallway carpet was unclean with stains and dirt debris; room [ROOM NUMBER] smelled of urine; and room [ROOM NUMBER] D's bathroom had a broken light bulb. Findings include: The facility policy Building and Equipment Repairs Reporting, revised 02/02/2018, documented all personnel were informed about responsibilities for reporting malfunctioning equipment, damage to facility structure, or furniture or other items that needed repair. All new staff were educated on the procedure for reporting repairs needed and the safety and well-being of residents and staff were the responsibilities of all staff. Staff reported needed repairs via the electronic maintenance report system. Staff without access to email were to report the repairs needed to a supervisor. It was the responsibility of maintenance staff assigned to the location to monitor the requests.The facility policy Cleaning Occupied Resident Room, revised 10/12/2018, documented the room occupied by a resident was maintained in a clean, hygienic, and attractive state without disrupting resident health care, routines, or the privacy of the resident.Unclean floors:The following observations of the Second floor were made:-on 02/06/2026 at 9:16 AM the carpet outside resident rooms 231and 233 was visibly dirty. There were crumbs, dirt clumps and particles, small plastic tips and pieces of packaging on the floor.-on 02/06/2026 at 10:21 AM the carpet outside 214 had bread and/or cracker crumbs, string and visible dirt.-on 02/06/2026 at 11:05 the carpet in front of resident room [ROOM NUMBER] was had food crumbs, skin flakes, dirt and paper pieces.-on 02/06/2026 at 11:07 AM there was a medicine cup on the floor outside resident room [ROOM NUMBER], a plastic stopper along and paper on the floor between resident rooms [ROOM NUMBERS].-on 02/09/2026 at 3:19 PM the carpet between resident rooms [ROOM NUMBERS] had dirt, crumb debris and dark brownish-gray line stains. -on 02/09/2026 at 3:47 PM the carpet between resident room [ROOM NUMBER] and the housekeeping closet had visible debris, dirt, part of a plastic bag, little white pieces of paper, and an oblong brown dead bug. -on 02/09/2026 at 3:49 PM the carpet along the wall between resident rooms [ROOM NUMBERS] had visible food particles, built up dirt debris and white crumbs. During an interview on 02/10/2026 at 10:00 AM Certified Nurse Aide #35 stated housekeeping was on the floor every day and they cleaned both the residents' rooms and the hallways. It had been a while since the housekeeping staff vacuumed the carpet in the hallways. They used to vacuum every day but since the renovation occurred it no longer happened. Housekeeping walked around with a dustpan, but the broom did not do much for the overall floor. They stated the floors were dirty. During an interview on 02/10/2026 at 12:10 PM, Licensed Practical Nurse #32 stated housekeeping was on the floor every day. They stated they only vacuumed the hallways every once and a while. They stated if the floors were visibly dirty, they let housekeeping know. Nursing also had a dustpan and broom they were given to use. During an interview on 02/10/2026 at 11:13 AM the Director of Environmental Services stated the carpets in the hallway were spot cleaned several times a week and thoroughly cleaned a few times a year with carpet shampoo and extractors Resident rooms: During an observation on 02/09/2026 at 10:15 AM room [ROOM NUMBER]'s floor had white powder next to the bed, the room smelled of urine, and the bed was not made. During an interview on 02/05/2026 at 10:43 the family member of the resident in room [ROOM NUMBER] stated their only concern with the facility was how unclean the resident's room was. They stated they often had to get staff to come and clean the room as the room smelled like urine and the bed was unmade. They stated the resident urinated in the room, but they should not have to alert the staff because the room smelled, and the floor was sticky.During an interview on 02/10/2026 at 10:00 AM Certified Nurse Aide #35 stated if a resident's family complained about the cleanliness of a room, staff should let housekeeping know as well as the licensed practical nurse and the Unit Manager. They stated if it was something they could clean they would. The family of the resident in room [ROOM NUMBER] complained about the cleanliness of the room. The resident urinated in their room; however, housekeeping was supposed to be paying more attention to the room since it was becoming more common. During an interview on 02/10/2026 at 11:13 AM the Director of Environmental Services stated rooms were cleaned daily and were deep cleaned upon discharge or a room transfer. Housekeeping staff should clean the floors and bathrooms, wipe high contact areas, and look for dust. The floors should not be sticky but heavily disinfecting a floor could make them tacky. A room where a resident had a habit of urinating was readdressed when there was an issue, but it was a hit or miss.During an observation and interview on 02/06/2026 at 9:37 AM the resident in room [ROOM NUMBER] D stated their bathroom light was out and had been out for two or three days. There was no other light in the bathroom unless the door was left open. The resident stated maintenance came to check it out and told them there was no bulb to replace the light.The electronic maintenance request system report documented requests were submitted for the bathroom light not working in room [ROOM NUMBER] D on 02/05/2026 at 11:00 AM, 02/06/2026 at 8:33 AM, and 02/06/2026 at 9:58 AM.During an interview on 02/06/2026 at 9:42 AM, Unit Clerk #39 stated work orders for the facility could be entered by anyone, but they generally entered them. Maintenance usually responded quickly to the maintenance requests. They were unaware of room [ROOM NUMBER] D's bathroom light being out and stated someone else must have put the work orders in.During an interview on 02/06/2026 at 9:57 AM Maintenance Assistance #38 stated they completed maintenance requests all over the building. They stated maintenance requests were submitted via the maintenance work order system or sometimes staff stopped them in the hallway with a request. Thet stated they were not out of bathroom light bulbs. They were unaware of who told the resident they did not have light bulbs for the bathroom.During an interview on 02/06/2026 at 10:29 AM, Certified Nurse Aide #35 stated the bathroom light in room [ROOM NUMBER] D was out for about 3 days. They were informed by maintenance there was no work order, but they personally entered two different work orders for the light. They informed the Unit Manager this morning when they saw the light was not replaced. They stated not having a bathroom light was not safe.During an interview on 02/10/2026 at 11:20 AM, the Maintenance Director stated work orders come through an automated work order system. The orders came directly to the electronic tablet the maintenance workers carried so they got alerts when there was a new order. When an order was completed, the maintenance worker put a note in on what they did and mark the order as completed. They stated they checked the status of orders through a report in the system. If a bathroom light was out, it would be a high priority issue that should be resolved in 30 minutes or less. They received a report of a light being out in a resident's bathroom, but they did not recall the day or how long it took to resolve the order, but it was not long.New York Code Rules and Regulations 415.29(j)(1)

Based on observations and interviews during the recertification survey, the facility failed to follow proper sanitation practices to prevent outbreak of illness in one (1) of one (1) main kitchen. Specifically, expired sanitizer testing strips were used to test sanitizer strength in the three-bay sink; and a cloth was used to dry dishes and silverware as they came out of the dish machine. Findings include:The facility policy Dishwashing, Drying, Proper Storage, revised 04/26/2019, documented soiled dishes, trays, glassware, and silverware would be washed and sanitized in the dish machine. The items would then be air-dried on the clean area counters of dish room and never dried with a cloth. A test of the sanitizing solution strength of the dish machine and the third compartment of the three-bay sink was conducted daily by the dietary services supervisor. Pots, pans, and large utensils used in cooking and holding food were washed and dried in the three-bay sink. The first bay contained detergent for soaking and scrubbing pans. The second bay contained water to rinse off the detergent and debris. The items were sanitized by immersion in the third bay of the sink for at least one minute in a quaternary solution. During an observation and interview on 02/06/2026 at 10:30 AM, Food Service Manager #5 demonstrated testing of the sanitizer strength in the three-bay sink. They stated they were responsible for testing the sanitizer strength three times a day using the test strips hanging near the three-bay sink. They took the test strip dispenser from where it was stored on the wall next to the sink, pulled the test strip from the dispenser, and tested the sanitizer strength in the sink. Food Service Director #6 looked at the strips and stated they expired in January of 2025. They were not aware the test strips expired. During an observation and interview on 02/06/2026 at 10:49 AM, Dietary Worker #9 was unloading dishes and silverware from the clean end of the dish machine. A white dish cloth was sitting on top of the clean silverware that had just come out on the machine. Dietary Worker #9 used the white cloth to wipe the silverware and plates. Dietary Worker #9 stated they used the cloth because the silverware and plates were wet. They demonstrated how they wiped everything off as they came out of the machine. They stated nobody taught them to do this, but they wanted to make sure the dishes were dry. During an interview on 02/09/2026 at 3:08 PM, Food Service Manager #5 stated they never checked the expiration date of the test strips and was not aware that they expired. They were not sure why the test strips would expire but thought expired test strips would not give accurate readings. During an interview on 02/09/2026 at 3:35 PM, Food Service Director #6 stated they never checked the expiration date of the test strips and was not aware that they expired. The expiration date indicated the test strips lost potency over time and once they expired would not read the sanitizer concentration correctly. They stated food service staff were trained to air dry items that were cleaned and sanitized in the dish machine. Using a cloth to dry dishes could cause cross contamination and spread germs to residents. 10 New York Codes, Rules and Regulations 415.14(h)

Based on interviews, observations, and record review during the recertification survey, the facility failed to develop and implement a baseline care plan that included the minimum healthcare information necessary to properly care for a resident within 48 hours of their admission for one (1) of one (1) resident (Resident #97) reviewed. Specifically, Resident #97 was admitted from the hospital with an arm sling recommended by a specialist and there was no physician order or care plan for the use of the arm sling. Findings include:Resident #97 had diagnoses including a right upper arm fracture, osteoporosis, and right pelvic fracture. The 12/25/2025 admission Minimum Data Set assessment documented the resident was admitted from the hospital, had moderately impaired cognition, had impairments of one arm and leg, required maximal assistance with upper body dressing, was totally dependent on transfers, and did not receive training on a splint or brace.The 12/17/20205 hospital orthopedic consult documented the right upper arm was to be non-weight bearing and a sling was to be used. The 12/19/2025 physician orders did not include the use of a right arm sling. The 12/19/2025 baseline care plan documented the resident had a closed fracture of the right arm. Interventions included medications as ordered, education for safety precautions, monitor for skin changes/swelling, orthopedic consultations as needed, physical and occupational therapy evaluations and treatments per orders. There was no documented evidence of the use of a sling.The 12/19/2025 at 3:56 PM Nurse Practitioner #10 progress note documented the resident had a sling for the right arm. The 12/19/2025 at 7:05 PM Registered Nurse #11 admission progress note documented the resident was admitted from the hospital due to a right upper arm and pelvic fracture. There was no documented evidence of a right arm sling.The 12/23/2025 at 10:23 AM Physician #12 progress note documented the resident was to be non-weight bearing to the right arm and a sling was to be used. The resident had an orthopedic follow up appointment in two weeks.During an observation and interview on 02/02/2026 at 12:20 PM, Resident #97 was lying on their bed dressed and groomed. The resident had an arm sling between their right arm and the bed sheet. The sling was not supporting the upper arm. The resident stated they got the sling during their hospital stay after they fell and fractured their right arm.During an interview on 02/09/2026 at 12:07 PM, Registered Nurse Manager #4 stated a registered nurse was responsible for initially admitting a resident. They should read the hospital discharge summary, perform the resident assessment, and review the admitting orders. The admitting orders also included equipment recommendations including a sling. The baseline care plan was also initiated. They reviewed the resident records and stated the sling was on the discharge summary but there were no admitting orders or care plan for the sling and there should have been. The purpose of including the sling in the care plan was to ensure the resident received the proper care needed. During an interview on 02/09/2026 at 12:26 PM, Certified Nurse Aide #13 stated resident specific care was documented in the care instructions that the aides reviewed prior to providing a resident care. The care instructions were populated by the care plan. They stated they were aware the resident used a right arm sling because they saw it on the resident numerous times. The resident wore the sling as they wanted and sometimes they took it off by themselves. Staff should make the nurse manager or supervisor aware if equipment was not in the care instructions and they did not remember if they told a supervisor.During an interview on 02/10/2026 at 12:13 PM, the Director of Rehabilitation stated the initial therapist was supposed to put in the care plans activities of daily living which included mobility status and any assistive devices. A sling was not considered an assistive device but should have been in the care plan. If a resident was non-weight bearing for an arm, they should be wearing the sling. If a sling was ordered from the hospital, it should be documented in the care plan, so staff were aware of its use. After reviewing the resident's chart, they stated they did not see an order or care plan for the resident to use a sling and there should have been both. 10 New York Codes, Rules and Regulations 415.11(c)

Based on observations, record review, and interviews during the recertification survey, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure ulcers and promote healing of pressure ulcers for one (1) of three (3) residents (Residents #16) reviewed. Specifically, Resident #16's wound care was not completed as ordered and a vascular consult was not ordered as recommended by the wound care provider. Findings include: The facility policy, Pressure Ulcer, Pressure Injury, and Other Skin Conditions: Initial Assessment, Care Planning, Ongoing Evaluation, and Management, revised 02/27/2023, documented residents with pressure ulcers, injuries, or skin conditions received timely assessments, evaluation, treatment, and services to promote healing, prevent infection, and prevent new conditions from developing. Ongoing assessments of existing pressure ulcers, injuries, and other skin conditions were to be conducted weekly by facility staff and/or a consultant who specialized in wound management. Progress, treatments, and care plan interventions were to be reviewed at that time and documented in the medical record. Wound consultant progress notes were to be scanned into the medical record.Resident #16 had diagnoses including weakness, hypertension and dementia with agitation. The 12/03/2025 Minimum Data Set documented the resident had intact cognition, was independent for most activities of daily living, was at risk of developing pressure ulcers, had a Stage 3 pressure ulcer (full thickness tissue loss), had pressure reducing devices to the bed and chair and applications of dressings to their feet.The 06/13/2025 Comprehensive Care Plan, revised 12/22/2025, documented the resident had an alteration in skin integrity related to an unstageable pressure ulcer located on the left heel. Interventions included applying the treatment per order and assessing and documenting the status of the pressure ulcer weekly. The 01/16/2026 Skin and Wound Note by Wound Consultant Nurse Practitioner #19 documented the resident was being followed for an unstageable pressure ulcer on their left heel. The wound healing had stalled. Complications to wound healing included intermittent noncompliance with their compression wraps. The staff reported the resident ambulated unassisted despite staff instruction and they had to remove the resident's heel boot to prevent falls. Nurse Practitioner #19 discussed with the staff to obtain a vascular consult due to the stalled nature of wound, if the family agreed. The treatment was changed to betadine (antiseptic) moistened gauze since peri-wound (outside) was macerated (softening due to moisture).The 01/17/2026 physician order documented to cleanse the wound on the left heel with wound cleanser, apply betadine moistened gauze and cover with a border gauze. The 01/30/2026 Skin and Wound Note by Wound Consultant Nurse Practitioner #19 documented the resident was being followed for an unstageable pressure wound on their left heel. The staff reported the resident ambulated unassisted despite staff instruction and they had to remove the resident's heel boot to prevent falls. The assessment and plan was to continue with the heel boot to the left foot when out of bed and in the wheelchair, continue the compression wraps, and to continue betadine moistened gauze treatment.There were no physician orders or any documentation in the comprehensive care plan related to the left heel boot or the compression wraps. There was no documented evidence of any follow up related to the wound consultant's recommendation of a vascular consult. Resident #16 was observed on:- 02/05/2026 at 9:35 AM walking to the room door without an assistive device. The resident then sat down in the wheelchair with slightly elevated leg rests. They did not have on heel boots or compression wraps.- 02/06/2026 at 11:15 AM sitting up in their wheelchair in their room with their feet in the slightly elevated leg rests with their heels off the back of the foot pedals. The resident had non-skid socks, but no compression wraps or a left heel boot.- 02/09/2026 3:27 PM the resident was sitting in their wheelchair with non-skid socks on with no heel boot on their left foot or compression wraps. At 3:35 PM, following their wound care being completed, they were sitting in their wheelchair and the resident asked about their compression wraps and if they needed them applied.TREATMENT OMISSIONS: The 02/2026 Treatment Administration record documented the following treatment orders: -to right heel apply skin prep wipe (skin protectant) topically every day and evening shift with a start date of 08/26/2025.-to unstageable left heal cleanse with wound cleanser, apply betadine (topical antiseptic) moistened gauze, cover with border gauze every day shift with a start date of 01/17/2026. There was no documented evidence the treatments were administered on the 02/01/2026, 02/05/2026, and 02/06/2026 day shifts. During an interview on 02/10/2026 at 10:37 AM Licensed Practical Nurse #30 stated they knew how to care for a resident by their care plan. Interventions for pressures ulcers were on a resident's care plan as well as in the Treatment Administration Record. A resident who needed a heel boot would have an order on the Medication Administration Record. Resident #16 did not have to wear heel boots, but they did have compression wraps that were supposed to be applied during day shift. Wound care ordered on their shift should be completed on that shift. If the wound care was unable to be completed, they were to inform the oncoming nurse. Sometimes when they had to split the floor between two nurses instead of three, treatments did not get done. If a wound care treatment was not documented on the Treatment Administration Record, it was not done. They were unsure if they completed the wound care treatment on Resident #16 on 2/1/2026 or 2/6/2026 but if it was not documented, they didn't do it.During an interview on 02/10/2026 at 11:48 AM Certified Nurse Aide #31 stated they knew how to care for a resident by their care plan. Any interventions for pressure ulcers were on the resident's care plan, including if heel boots needed to be applied. They checked the care plan daily. They believed Resident #16 had to wear a heel boot on their left foot while in bed and when the resident was cooperative.During an interview on 02/10/2026 at 12:10 PM Licensed Practical Nurse #32 stated interventions for a resident with a pressure ulcer were on their care plan. A resident who needed to wear heel boots would have an order. Resident #16 could use a heel boot for their pressure ulcer, but they got up at night when it was applied so it was a safety issue. If an intervention did not work, they would notify the provider. A wound care treatment ordered for their shift was to be completed on that shift and documented as completed in the Treatment Administration Record. If a treatment was not documented on the Treatment Administration Record, it meant it was not done. They stated they had completed Resident #16's wound care treatment on 02/05/2026 but there were only two nurses on the hall that day so the documentation may have been missed.During an interview on 02/10/2026 at 12:23 PM Licensed Practical Nurse Unit Manager #18 documented they updated the care plans in collaboration with the Assistant Director of Nursing #33 and the Director of Nursing. Wound rounds are done weekly with the Assistant Director of Nursing. The recommendations from the wound care provider were given to Assistant Director of Nursing #33. The Assistant Director of Nursing #33 then gave the recommendations to them, and they communicated with the provider regarding the recommendations. The recommendations for preventative equipment are put into place if it was determined safe. The provider was notified if an intervention did not work. Resident #16 was ambulatory, and a left heel boot was a safety boot while the resident was in bed. The resident did have a left heel boot, and compression wraps at one time but no longer had orders for either. They would have to clarify the recommendations and orders with the facility providers and the wound care provider since they were in the providers' notes regarding the wound treatment plan. They were unaware the wound care provider had recommended the resident to have a vascular consult, and they did not know why it had not been taken care of.During a phone interview on 02/10/2026 at 1:20 PM Nurse Practitioner #28 stated they were given the recommendations from the wound care provider by Licensed Practical Nurse Manager #18. If there were new orders or intervention recommendations, Licensed Practical Nurse Manager #18 put the orders in under their name for them to electronically sign. If a recommendation is not effective, like a heel boot, they were notified. If the wound care provider was recommending compression wraps or a left heel boot, they would need to reorder those. If the concern was safety while ambulating, the order may need to be adjusted instead of just discontinuing the order. They believe they would be notified if a wound was reclassified but they do look at the wound themselves and there may be a difference in opinion. From their opinion Resident #16 had a stage 3 pressure ulcer on their left heel but they did believe their documentation had to be consistent with the wound care provider.During a phone interview on 02/10/2026 at 1:59 PM Wound Care Nurse Practitioner #19 stated the recommendations they give to the facility got to Assistant Director of Nursing #33. They stated Resident #16 could be intermittently non-compliant. The staff stated the left heel boots didn't work but they still recommended them because they could help with the resident's wound healing. If at the time, it was not safe to put the heel boot on that day, it was fine, but it was better to have the boots recommended and used when the resident was compliant than not at all. They were unsure how often the staff put the compression wraps on the resident, but it was a recommendation they always made when the resident was compliant as the resident's legs were mostly dependent all day. They expected the facility to follow their recommendations regarding wound care and interventions. They expected the staff to continuously reassess the interventions day to day to try and get the wound to heal. 10 NYCRR 415.12(c)(1)

Based on observations, record review, and interviews, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional standards for one (1) of four (4) medication carts (1st floor North medication cart). Specifically, the 1st floor North medication cart contained an opened lidocaine (anesthetic) vial and opened insulin pens with no documented opened dates.Findings include: The facility policy Medications Administration Methods, revised 01/25/2024 documented responsible staff would pass medications according to techniques and practices in compliance with New York State rules and regulations, and current practice standards. Medication expiration dates were to be checked prior to administration. Refer to manufacturer's guidelines for medications with shortened expiration such as insulin.During a 1st floor North medication cart storage review on 02/05/2026 at 2:55 PM with Licensed Practical Nurse #3, the following was observed in the top drawer of the medication cart:- an opened vial of lidocaine 1% (anesthetic) with no opened date. - an opened Resident #185's glargine (insulin) pen with no opened date. - an opened Resident #21's Lantus (insulin) Solostar pen with no opened date. During an interview on 02/05/2026 at 3:18 PM, Licensed Practical Nurse #3 stated the nurse opening the insulin pen or vial was supposed to write the open date and their initials on it. Any nurse administering the medication should check for the expiration and open dates prior to giving the medication. They were not sure who else was responsible for checking for expired medications on a routine basis in the medication carts or rooms. They stated if an insulin pen or vial did not have an open date written on it, it was considered expired, should not be given, and discarded. Licensed Practical Nurse #3 stated they did not give those medications today.During an interview on 02/10/2026 at 12:39 PM, Registered Nurse Manager #4 stated each medication nurse should check expiration dates of all medications in the medication cart and medication room every shift. The nurse opening an insulin pen and vial should document on the medication the date they opened it. They stated insulin pens and vials were only good for 30 days after the open date and should be discarded after 30 days. The undated insulin pens and vial were considered expired as there was no way to know when they were opened. 10 New York Codes, Rules and Regulations 415.18(d)

Based on observations and interviews during the recertification survey, the facility failed to ensure garbage and refuse was disposed of properly for one (1) of one (1) dumpster observed. Specifically, the area around the dumpster located outside near the kitchen was not maintained to prevent attraction and harborage of pests. Findings include:The facility Assistant Dining Services Manager Evening Checklist procedure form, dated 09/2002, documented food service would observe the dumpster area in the evening to check for food debris and ensure the dumpster lids were closed. During an observation on 02/06/2026 at 11:00 AM, the dumpster located outside the kitchen, had food debris, food wrappers, and used gloves around the dumpster and near the fence that surrounded the dumpster area. During an interview on 02/09/2026 at 3:08 PM, Food Service Manager #5 stated the area around the dumpster should be free of food debris and garbage to prevent rodents and for sanitation. During an interview on 02/09/2026 at 3:35 PM, Food Service Director #6 stated the area around the dumpster should be free of food debris and garbage to prevent rodents. They used the dumpsters for food waste, food packaging waste, and cardboard. They did not know who was responsible for maintaining the cleanliness of the area but stated it was either maintenance or housekeeping, and if any food service garbage needed to be cleaned up, they received a call from one of those departments. During an interview on 02/10/2026 at 10:45 AM, Housekeeping Director #7 stated they used the dumpsters for cardboard and waste. They looked around the dumpster areas for cleanliness a few times a week and whenever they were out in that area. Food service, housekeeping, and maintenance all worked together to monitor the area but not one department was primarily responsible for the area. Whoever had trash on the ground was responsible for cleaning it up. During an interview on 02/10/2026 at 10:50 AM, Maintenance Director #8 stated their department used the dumpsters for cardboard and was responsible for clearing snow around the dumpster area. No specific department was primarily responsible for monitoring the area by the dumpsters, it was a team effort between maintenance, housekeeping and dietary. During an interview on 02/10/2026 at 3:51 PM, Director of Nursing #2 stated the facility did not have a specific policy on dumpster maintenance. 10 New York Codes, Rules, and Regulations 415.14(h)

Based on observations, record review, and interviews during the recertification survey the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of four (4) residents (Resident #48) reviewed. Specifically, Resident #48 was on transmission-based precautions (contact precautions) and Registered Nurse #16 was observed not wearing appropriate personal protective equipment while administering medications or practicing hand hygiene to prevent the spread of infection.Findings include:The facility policy Transmission Based Precaution Levels, last reviewed 06/06/2024, documented standard precautions were based on the principle that all blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes could contain transmissible infectious agents. Standard precautions include a group of infection prevention practices that would apply to all residents, regardless of suspected or confirmed infection status, in the healthcare setting that would include use of gloves, gown, mask, eye protection or face shield, depending on the anticipated exposure. Contact precautions would be used for residents who were known or suspected of having a serious illness easily transmitted by direct resident contact or by contact with items in the resident's environment.Resident #48 had diagnoses including multidrug-resistant organism (bacteria that developed resistance to certain antibiotics). The 02/04/2026 Minimum Data Set (an assessment tool) documented the resident was cognitively intact, frequently incontinent or urine and stool, required supervision or touching assistance with toileting hygiene, and partial/moderate assistance with personal hygiene and bed mobility.The undated facility provided list of residents on contact precautions with active clostridioides difficile (highly contagious bacteria that causes diarrhea) included Resident #48.The 02/05/2026 physician order documented maintain clostridioides difficile (C-diff) contact precautions, resident to remain in the room and be provided services in the room.The certified nurse aide care instructions documented the resident was frequently incontinent of stool and had loose stools from 02/04/2026-02/09/2026.During an observation on 02/09/2026 at 10:17 AM, Resident #48 had a contact precaution sign posted outside their room. Registered Nurse #16 was at the resident's bedside administering eye drops, an inhaler, and other medications in applesauce while wearing gloves and a mask. At 10:19 AM, Registered Nurse #16 picked up an unused pain patch and the eye drop and inhaler boxes from the resident's bedside table while wearing the same gloves, walked out of the room and placed the unused pain patch and boxes on top of the medication cart. They removed their gloves and cleaned their hands with hand sanitizer before documenting in the electronic medical record. Registered Nurse #16 did not perform appropriate hand hygiene for clostridioides difficile.During an interview on 02/09/2026 at 10:21 AM, Registered Nurse #16 stated Resident #48 was on contact precautions for clostridioides difficile which meant staff were required to wear a gown, mask, and gloves in the room and wash their hands using soap and water to prevent the spread of infection. They did not follow the contact precautions because they did not see the sign when they went into the room. They stated they cleaned their hands with hand sanitizer after exiting the room but was going to go wash their hands with soap and water because hand sanitizer was not effective against clostridioides difficile.During an interview on 02/10/2026 at 12:23 PM, Licensed Practical Nurse Manager #18 stated when a resident was on precautions it was communicated to staff during nurse-to-nurse report. All staff received infection control education annually and they had monthly unit meetings with staff that included infection control education. Resident #48 was on contact precautions for clostridioides difficile, so staff were required to wear a gown, gloves, and mask while in the room. The medication boxes should not have been brought into the room. Because the medications and the boxes were brought into the room they should have been wiped down with cleaning wipes and air dried before going back into the medication cart. Registered Nurse #16 should not have left Resident #48's room wearing dirty gloves and they should have washed their hands with soap and water before touching anything else.During an interview on 02/10/2026 at 01:47 PM, Assistant Director of Nursing/Infection Preventionist #17 stated infection control education was ongoing all the time and staff were educated on transmission-based precautions annually and as needed. They completed weekly audits for residents on transmission-based precautions to ensure they had physician orders, care plans, precaution signage outside the room, personal protective equipment was available, and staff were wearing appropriate personal protective equipment in the resident's room. Staff were required to wear a gown, gloves, and a mask in a contact precaution room. Resident #48 was on contact precautions for clostridioides difficile. Medication boxes should not be brought in or set down inside the resident's room and the medications should have been placed inside a plastic bag before they were put back into the medication cart. Registered Nurse #16 should not have touched anything outside the room without washing their hands with soap and water because hand sanitizer was not effective at killing the bacteria and it was extremely contagious.10 New York Codes, Rules and Regulations 415.19(a)(b)

Based on record review and interviews during the recertification survey, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries for one (1) of three (3) residents (Resident #208) reviewed. Specifically, Resident #208 remained in the facility after discontinuation of Medicare Part A, and the facility did not provide a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (Centers for Medicare and Medicaid Services-10055) for Medicare Part A as required.Findings include: The instructions for the Center for Medicare and Medicaid Services Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage Center for Medicare and Medicaid Services form 10055, documented a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage form 10055 must be issued by providers to beneficiaries in situations where Medicare payment was expected to be denied. The Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage must be delivered far enough in advance that the beneficiary or the representative had time to consider the options and make an informed choice prior to services ending.Resident #208 had a Medicare Part A skilled services episode start date of 6/30/2025 with a last covered day of Part A services of 09/01/2025.The Notice of Medicare Non-Coverage for Centers for Medicare and Medicaid Services-10123 letter documented Resident #208's episode start date of 6/30/2025 and the effective end date of services was 09/01/2025. The handwritten note on the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage documented the Center for Medicare and Medicaid Services Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage Center for Medicare and Medicaid Services form 10055 was not signed by Resident #208's Power of Attorney on 10/03/2025.During an interview on 02/09/2026 at 12:15 PM, Business Office Manager #40 stated they were familiar with the Advance Beneficiary Notice of Non-coverage and knew it should have been provided to the residents at least two days prior to the start of non-coverage but it was not. They stated it took time for the family to finally decide what they were going to do regarding Resident #208's continued stay in the facility. Business Office Manager #40 stated that if the Advance Beneficiary Notice of Non-Coverage advance notice was not given to the resident or their representative, the resident would not know their financial liability and therefore could be financially liable for non-covered services received. 10 New York Code Rules and Regulations 483.10 (g) (18)

Based on observation, record review, and interview during the recertification survey conducted [DATE]-[DATE], the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in 2 of 3 food preparation and storage areas (the main kitchen and the third floor kitchenette). Specifically, the walls and ceiling in the main kitchen dish machine area were unclean, the walls behind the three bay sink were unclean and there was expired and undated food in the main kitchen dry food storage room and the third floor kitchenette. Findings include: The facility policy Kitchen, Dining and Dietary Equipment Routine Cleaning modified [DATE], documented all kitchen walls were to be cleaned monthly. The facility policy Dietary Food and Supply Orders-Storage modified [DATE], documented if a food item is partially used the item is labeled with the name and the date and covered before being put back in storage. The facility policy Food Brought into Facility from Outside Sources, Reheated Food modified [DATE]documented all food items brought in from an outside source will be properly labeled by nursing staff with the resident's identifying information including name and room number. Perishable food items will be discarded three (3) days after the label date. Nonperishable items will be discarded after the manufacturer's expiration date. During an observation in the main kitchen on [DATE] between 9:05 AM and 9:40 AM the dish machine area wall behind the clean side of the dish machine was unclean. The dish machine area ceiling tiles were not clean and the metal grid supporting the ceiling tiles were rusty. The walls behind and around the three bay sink area were unclean. The dry food storage area had a loaf of sourdough bread with a best by date of [DATE], an undated package of 6 bagels, and two undated packages of English muffins. During an observation in the main kitchen on [DATE] at 10:15 AM, the dry food storage room had one five-pound package of buttermilk pancake mix with a best by date of [DATE], three five-pound packages of devil's food cake mix with a best by date of [DATE], two five-pound packages of yellow cake mix with a best by date of [DATE], and three five-pound packages of chocolate fudge icing with a best by date of [DATE]. During an observation on [DATE] at 10:50 AM, the third floor kitchenette refrigerator had a container of ziti without a labeled opened date, and a large bag containing undated opened food items for Resident #315 including a can of salsa, a block of ,d+[DATE] used cheddar cheese, port wine cheddar cheese, pickled beets, and salad dressing. During an interview on [DATE] at 10:46 AM, the Director of Dietary Services stated they were not aware of the dirty ceiling tiles and the rusty ceiling tile grid in the main kitchen dish machine area or the unclean walls behind the clean side of the dish machine and the three bay sink area. They stated the walls in the main kitchen should have been cleaned weekly by whoever was assigned the task, and supervisors were responsible for ensuring this was completed. There was no documentation this had be completed. The Director of Dietary Services stated they were not aware of the expired food items found in the main kitchen and the expired sour dough bread should have been discarded within three days by a kitchen supervisor. The packages of the bagels and English muffins had been taken from larger boxes that had been dated but these dates were not carried over to the smaller packages. They stated that they were responsible for checking the expiration dates of food products in the dry food storage room, were checking this quarterly, and were not aware of the expired products. They were not aware of the undated resident items in the third floor kitchenette and all staff had previously been told to date all food products that were brought in from the outside of the facility once they were opened. They stated it was important to ensure the cleanliness of the main kitchen was maintained and food was not expired for the safety of the residents. 10NYCRR 415.14(h)

Based on observation, record review, and interviews during the recertification survey conducted 2/21/2024 - 2/27/2024, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #82) reviewed and for the facility's Legionella (a bacteria that can cause Legionnaires' disease) water management program. Specifically, staff did not wear required personal protective equipment or take off personal protective equipment appropriately when caring for Resident #82 who was on transmission-based precautions. Additionally, the facility's annual Legionella assessment was not completed in 2022 and the annual review of the Legionella program was not completed in 2021 and 2022. Findings included: The facility policy Infection Prevention Control Program modified 2/5/2018 documented the facility would establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and included: - Standard and transmission-based precautions to be followed to prevent spread of infections. - Staff should wash their hands before and after coming into contact with residents or handling of possessions. - Residents with a communicable disease would be placed on transmission-based precautions status to protect other residents from cross-contamination. - The Infection Preventionist would educate residents, responsible parties, and visitors on transmission-based precautions as necessary. - Department staff would be informed of the facility infection prevention plan and would be trained and expected to follow proper infection prevention practices. PERSONAL PROTECTIVE EQUIPMENT Resident #82 had diagnoses including Parkinson's disease (a progressive neurological disorder) and respiratory syncytial virus (a contagious respiratory virus). The 1/31/2024 Minimum Data Set assessment documented the resident had intact cognition. A 2/21/2024 laboratory test documented the resident tested positive for respiratory syncytial virus. A 2/21/2024 physician order documented precautions: respiratory syncytial virus isolation (contact and droplet) being maintained every shift. Resident to remain in room and all services provided in room every shift for respiratory syncytial virus. A 2/21/2024 at 10:28 AM physician assistant #14 progress note documented the resident had an acute visit for positive respiratory syncytial virus and continue contact precautions. The care instructions active as of 2/23/2024 did not include contact and droplet precautions. During an observation on 2/21/2024 at 1:48 PM Resident #82's room had a sign on the door documenting, Stop - please check with nurse prior to entering the room. A plastic bin with drawers was outside of the resident's room and contained personal protective equipment including face masks and yellow isolation gowns. During an observation on 2/26/2024 at 11:29 AM activities aide #15 started to deliver mail to Resident #82's room, saw the Stop - please check with nurse prior to entering the room sign, asked licensed practical nurse #8 what personal protective equipment they were supposed to wear when entering the resident's room and the nurse told them to wear a surgical mask, goggles, gown, and gloves. Activities aide #15 put on the required personal protective equipment and entered the resident's room. At 11:33 AM the resident was holding activities aide #15's gloved hand, thanking them for the mail. Activities aide #15 exited the resident's room wearing the personal protective equipment and walked down the hallway, using their gloved hands to push up their goggles. At 11:36 AM they removed their gown and gloves, discarded them in the trash can attached to the medication cart, then sanitized their hands. Wearing the same goggles and surgical mask they continued to pass out mail to four other resident rooms. During an observation on 2/26/2024 at 11:38 AM licensed practical nurse #8, was wearing a surgical mask and put on a gown, gloves, and goggles, and entered Resident #82's room to administer medications. Before exiting the room licensed practical nurse #8 removed their gown and gloves, then placed their goggles on top of the personal protective equipment bin outside of the resident's room without sanitizing them and performed hand hygiene using the alcohol-based hand rub from the medication cart. They did not discard and change their surgical mask. During an interview on 2/26/2024 at 11:41 AM activities aide #15 stated they had infection control training during their orientation and did not recall the training telling them where to dispose of soiled personal protective equipment. They had wanted to remove their soiled personal protective equipment in the shower room trash can, but the medication cart was in the way. They did not want to move the medication cart, so they disposed of their soiled personal protective equipment in the medication cart trash can. They did not recall being told to change their surgical mask after exiting a transmission-based precautions room or sanitizing their goggles. They were not aware they had touched their goggles with their bare hand in the hall. If personal protective equipment was not worn or removed appropriately, they could spread germs to other residents. During an observation on 2/26/2024 at 11:59 AM certified nurse aide #16 was put on a gown and gloves. They were already wearing a surgical mask. They did not put on goggles. They entered Resident #82's room and assisted them with transferring from their bed to the chair for lunch. At 12:04 PM they discarded their gown and gloves prior to exiting the room, they did not perform hand hygiene, and continued to wear the same surgical mask. During an interview on 2/26/2024 at 12:05 PM certified nurse aide #16 stated they had infection control training during orientation and knew that personal protective equipment should be put on before entering a transmission-based precautions room and discarded before exiting the room and wash their hands if needed. They had only assisted Resident #82 with positioning in their chair for lunch and not hands-on care, so they did not need to wash their hands. They changed their surgical mask on occasion. On the back of the signage on Resident #82's door it documented the resident was on droplet precautions which included a gown, gloves, mask, and eye protection. They did not realize they should have worn eye protection while in Resident #82's room. If personal protective equipment was not worn appropriately and infection control practices were not followed correctly, they could get sick or make others sick. During an interview on 2/27/2024 at 8:33 AM the Director of Nursing stated the facility required all residents, staff, and visitors to wear face masks. A respiratory illness required a resident to be placed on contact and droplet precautions. The personal protective equipment would be a gown, gloves, mask, and eye protection. Personal protective equipment should be put on before entering a transmission-based precautions room and removed before exiting the room. Hand hygiene should be performed before exiting the room and there was also hand sanitizer available in the hallways. Staff should wear a surgical mask over an N95 mask in a droplet precautions room and remove the surgical mask before exiting the room. They should not be wearing a surgical mask from a transmission-based precaution room into other residents' rooms. Face shields were disposable, but goggles should be washed with soap and water or with sanitizing wipes that were kept on the medication cart. LEGIONELLA ASSESSMENT AND PROGRAM: There was no documented evidence that the annual review of the Legionella program was completed in 2021 and 2022 or that the facility's annual Legionella assessment was completed in 2022. During an interview on 2/23/2024 at 8:55 AM, the Maintenance Director stated while reviewing the maintenance books they became aware the annual assessment was not completed/documented in 2022, and the annual program review was not completed/documented in 2021 and 2022. They were aware of the Legionella regulations, and it was important for the safety of the residents that the facility completed all the requirements. During an interview on 2/23/2024 at 3:28 PM, the Administrator stated they were not aware of the annual Legionella assessment and assumed that all requirements were being completed by the maintenance department. The Legionella program was reviewed in 2022 but there was no documentation it could be verified. During an interview on 2/27/2024 at 8:33 AM the Director of Nursing stated they had a policy for Legionella and worked as a team with the maintenance department. They were not aware the facility's annual Legionella assessment was not completed in 2022 and the annual review of the Legionella program was not completed in 2021 and 2022. 10 NYCRR 415.19(a)(b)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00312902 and NY00317893) surveys conducted 2/21/2024-2 /27/2024, the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 1 resident (Resident #67) reviewed. Specifically, licensed practical nurse #12 administered a wound treatment to Resident #67's foot that was not consistent with the physician ordered treatment. Findings include: The facility policy, Pressure Ulcer, Pressure Injury, Other Skin Conditions: Initial Assessment, Care Planning, Ongoing Evaluation and Management revised 2/2023 documented upon the identification of a new skin condition (on admission or thereafter), an assessment will be completed. Findings will be recorded in the medical record, the care plan will be reviewed and/or revised, the medical provider will be notified, appropriate treatments implemented, and applicable notifications made. Resident #67 had diagnoses including atherosclerotic (plaque buildup) of arteries of the right foot and midfoot, non-pressure chronic ulcer of the right heel and midfoot, and peripheral vascular disease (poor circulation). The 11/30/2023 Minimum Data Set assessment documented the resident had moderately impaired cognition, did not have non-pressure related skin conditions, and required application of dressings to their feet. The comprehensive care plan revised 1/2023 documented the resident had an alteration to skin integrity: a chronic wound to the right foot. Interventions included apply treatments as per medical orders; assess and document status of wound/skin sites weekly and as needed; consult wound care as per medical order; monitor site(s) for signs and symptoms of infection (redness, drainage, tenderness, and warmth); see nutrition on care plan; see skin integrity on care plan; update medical on resident/patient status as needed. The 2/14/2023 physician order documented Betadine solution 10% (povidone-iodine, an antiseptic) to the right foot every day shift for wound healing; soak for 5 minutes in 50 cubic centimeters of Betadine added to basin of water, dry and secure with dry dressing; change daily. A 2/19/2023 nurse practitioner #22 Skin and Wound note documented the resident had a wound to the right dorsal (top) foot that was chronic in nature. Treatment recommendations included Betadine soak with 50 cubic centimeters betadine added to basin, secure with dry dressing and change daily. During a wound care observation and on 2/23/2024 at 11:01 AM with licensed practical nurse #12, they gathered dressing supplies for Resident #67's right foot, put on gloves and removed the soiled pink foam dressing dated 2/22/2024. They cleansed the wound with 2 normal saline vials and dried the wound with gauze. They opened a skin protectant pad and wiped around the edges of the resident's wound. They applied a 1/2 inch by 1/2 inch antimicrobial dressing (a dressing to prevent bacteria) and placed a 2 inch by 2 inch pink foam dressing over the entire area. The February 2024 treatment administration record documented povidone-iodine 10% solution apply to right foot wound topically every day shift for wound healing; povidine-iodine soak daily for 5 minutes (50 cubic centimeters of povodine-iodine solution added to basin of water, dry, and secure with dry dressing change daily). The treatment was signed as being completed by licensed practical nurse Supervisor #13 on 2/22/2024 and by licensed practical nurse #12 on 2/23/2024. During an interview on 2/23/2024 at 11:03 AM, licensed practical nurse #12 stated the dressing they removed was not an antimicrobial dressing, but it had been previously ordered as well as a medicated honey type treatment. They stated they also applied the medicated honey treatment to the resident's wound because it worked well and thought it would not hurt. Licensed practical nurse #12 stated they did not apply the iodine-based treatment because they did not find the product in the storage room and would have to order it. They stated it was important to follow the physician's orders so the resident's wounds would heal. During an interview on 2/23/2024 at 11:18 AM, licensed practical nurse Supervisor #13 stated ordered supplies such as iodine-based solutions took 8-16 hours from the time they were ordered and were delivered by the central supply department. They stated if there were no iodine-based swabs for Resident #67's foot treatment the nurse should have filled a medicine cup with the iodine-based solution and soaked the gauze in it. Licensed practical nurse Supervisor #13 stated they had iodine-based swabs and took one out of a green bin at the nurses' station. During an interview on 12/23/2024 at 12:00 PM, registered nurse Unit Manager #6 stated treatments should be followed as per the physician orders. They had iodine-based swabs in the facility, and they would expect the resident's treatment be completed as ordered. They stated if treatment orders were not followed as ordered the physician would not know if the treatment worked and the wound could worsen. During an interview on 2/27/2024 at 9:19 AM the Director of Nursing stated when the medical provider wrote an order, nursing was responsible to implement the order timely and could not change the order or treatment without consulting the provider. The Director of Nursing stated they expected nursing to call the provider if the supplies were not available and should not substitute an older treatment as the resident could have a negative outcome or their wound could worsen. During an interview on 2/27/2024 at 9:36 AM, physician #4 stated when an order was written, the pharmacy double checked the order and nursing implemented it. An iodine-based solution was a common treatment used to clean and dry up the wound. The facility always had it in stock. Physician #4 stated nursing should not use an alternative treatment without consulting the medical provider. Using an alternative treatment could result in the resident's wound worsening. Physician #4 stated the antimicrobial dressing treated infections and the medicated honey prevented infections and should not have been used. 10NYCRR 415.12 48632

Based on observation, record review, and interviews during the recertification survey conducted 2/21/2024-2/27/2024, the facility did not ensure that pain management was provided to residents who required such services consistent with professional standards of practice for 1 of 1 resident (Resident #143) reviewed. Specifically, Resident #143's physician ordered pain patch was not administered and was documented as administered by licensed practical nurse #3. Findings include: The facility policy Medication Administration revised 1/25/2024 documented licensed practical nurses and registered nurses were responsible for passing medications according to techniques and procedures that met current practice standards and were in compliance with New York State codes, rules, and regulations and other applicable state and federal laws. The nurse must watch each resident take and swallow the medication. The nurse will document the date, time, and their initials on the electronic medical record before starting another resident's medication administration. The facility policy Pain Management revised 2/3/2023 documented the facility would 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. Resident #143 was admitted to the facility with diagnoses including hemiplegia (paralysis on one side) and hemiparesis (weakness or paralysis of one side) of the right side following a cerebrovascular accident (stroke). The 1/2/2024 Minimum Data Set assessment documented the resident was cognitively intact, received scheduled pain medication, and the resident did not have pain in the last 5 days. The comprehensive care plan did not include a focus of pain with interventions. The 11/21/2023 physician order documented lidocaine patch 4% (pain patch) apply to lower back topically one time a day for pain. Remove after 12 hours as per schedule. During an interview on 2/21/2024 at 11:21 AM, Resident #143 stated they were supposed to have a pain patch placed every day and it was never applied. They stated it was not on and they were in pain. There was no pain patch observed on the resident. During an interview on 2/22/2024 at 8:45 AM, Resident #143 was in the dining room after breakfast and stated their pain patch was not applied and they were in pain. There was no pain patch observed on the resident. The February 2024 medication administration record documented lidocaine patch 4% for pain, apply to lower back topically one time a day at 6:00 AM and remove at 8:00 PM. The lidocaine patch was documented as administered by licensed practical nurse # 3 at 6:00 AM on 2/21/2024, 2/22/2024, and 2/23/2024; and removed by licensed practical nurse #19 on 2/21/2024, by licensed practical nurse #20 on 2/22/2024, and by licensed practical nurse #21 on 2/23/2024 at 8:00 PM. During an interview on 2/23/2024 at 10:54 AM, licensed practical nurse #3 stated pain patches were used to control pain and allowed residents to participate in daily activities more comfortably. They stated Resident #143 had an order for a pain patch and they did not apply it on 2/21/2024 and 2/22/2022 because they were busy, and on 2/23/2024 because the resident was in physical therapy. They stated they documented they administered the pain patch when they did not, and this was not the standard of practice. If the resident did have the pain patch placed as ordered, they could have pain that was not addressed, and it could impact their daily function and their ability to participate in physical therapy. During an interview on 2/26/24 at 11:27 AM, registered nurse Unit Manager # 6 stated they expected nurses to follow all physician orders regarding resident care. Medications were administered according to physician orders and should be signed only after administration. If a resident refused or was not in their room, there was an area on the electronic medication administration record to document. If the resident's pain patch was not administered the resident could be in pain. During an interview on 2/26/2024 at 1:36 PM physician # 4 stated they ordered oral and topical medications to control pain and improve function. If a pain patch was ordered for a resident, they expected it to be administered. If a medication was signed as administered, it meant it was administered. If the pain patch was not administered but was signed for, the resident could have increased pain and decreased function. During an interview on 2/26/2024 at 3:53 PM the Director of Nursing stated they expected all medications were to be administered as ordered and signed after administration. They looked in the electronic medical record and stated Resident #143 received their pain patch daily from 2/21/2024- 2/23/2024, it was administered by licensed practical nurse #3, and was not held or refused. they stated if the medication was not administered, it should not be signed off as administered. If the resident did not receive the pain patch, they could have increased pain and decreased ability to participate in physical therapy. During a follow up telephone interview on 2/27/2024 at 9:55 AM licensed practical nurse # 3 stated the pain patches were in the medication room, which was down the hall, not in the medication cart where most other medications were located. They stated they did not get the pain patches from the medication room as it interrupted their medication pass. It was inconvenient to lock the medication cart and go all the way to the medication room and back. They signed all medications when they administered them in the morning, including the pain patch, thinking they would come back later and apply the patch. They got busy and forgot to come back and apply the patch. 10NYCRR 415.12

Based on observation and interview during the recertification survey conducted 2/21/2024 - 2/27/2024, the facility did not ensure each resident received and the facility provided food and drink that was palatable, flavorful, and at an appetizing temperature for 2 of 2 meals reviewed (2/22/2023 and 2/23/2023 lunch meals). Specifically, food was not flavorful and was not served at palatable and appetizing temperatures. Findings include: The facility policy Food Temperature Requirements and Holding Time modified 6/28/2019 documented: - If a food/beverage item does not meet the temperature goals specified, corrective action will be taken, and a second temperature will be obtained and documented. Food/beverage items will not be included in meal service until proper temperatures have been achieved. - Steam table thermostats will be turned on 30 minutes prior to meal service and set to maintain hot food between 140 degrees Fahrenheit and 160 degrees Fahrenheit. - Cold food items should be held in an appropriate container or bin to maintain the Temperature below 41 degrees Fahrenheit. During an interview on 2/21/2024 at 11:14 AM, Resident #143 stated that the food was not hot and had no flavor. During an interview on 2/21/2024 at 10:56 AM, Resident #112 stated the food could be cold. During an observation in the first floor dining room on 2/22/2024 at 12:05 PM, a chocolate milk shake, and a ginger ale were placed on the table for Resident #143. At 12:25 PM the lunch meal was delivered to Resident #143. A replacement tray was ordered for Resident #143 and their original tray was reviewed for temperatures. At 12:27 PM, the chocolate milk shake was 51 degrees Fahrenheit and not a palatable temperature. During an observation on 2/22/2024 at 12:39 PM, after all residents had been served their meals and the steam table was still on, a test tray was requested. The tray included hot food items that were being held in the first floor kitchenette steam table and cold items that were on the counter if residents wanted extra food. At 12:40 PM, the food temperatures were measured. The rice pudding was 68 degrees Fahrenheit, and the broccoli was 118 degrees Fahrenheit. The rice pudding and the broccoli were not held at palatable temperatures. During an interview on 2/23/2024 at 10:54 AM, licensed practical nurse #3 stated that Resident #112 complained the food was cold, the toast was not always hot, and when hot food items were not hot, they would microwave them. Licensed practical nurse #3 stated they did not know the food item temperatures after being heated up as there were no thermometers available. During an on observation on 2/23/2024 at 12:28 PM, a second floor lunch tray arrived at Resident #112's room. A replacement tray was requested, and the original tray was tested for temperatures. At 12:29 PM the lettuce salad was 65 degrees Fahrenheit, and the garlic toast was 100 degrees Fahrenheit. The lettuce salad and garlic toast were not held at palatable temperatures. During an interview on 2/23/2024 at 3:58 PM, the Director of Dietary Services stated that hot food items should be served at 120 degrees Fahrenheit or hotter, and cold food items should be served at 40 degrees Fahrenheit or lower. They stated the chocolate milk shake and the rice pudding both contained milk and it was not acceptable for the chocolate shake to be served at 51 degrees Fahrenheit and the rice pudding to be served at 68 degrees Fahrenheit. The lettuce salad served at 65 Fahrenheit was not at an appetizing temperature. They stated that it was not appetizing for the broccoli to be served at 118 degrees Fahrenheit, the garlic toast served at 100 degrees Fahrenheit, and the lettuce salad served at 65 Fahrenheit. They stated test trays were done twice a week. They took the test tray when it was delivered to a specific resident hallway and measured the temperatures of the hot and cold food items. There had been unacceptable food temperatures on previous test trays, and they had mentioned this during weekly meetings or quality assurance meetings. They stated they talked to the food service staff about the process of delivering food. The resident unit kitchenette steam tables were reviewed weekly and as needed. They stated that it was important for residents to be served food at palatable and safe temperatures. 10NYCRR 415.14(d)(2) 37516 48446

Based on observation, record review, and interview during the recertification survey conducted 2/21/2024-2/27/2024, the facility did not maintain an effective pest control program so that the facility was free of pests in the main kitchen. Specifically, the main kitchen had fruit flies. Findings include: The third party pest control vendor service reports from 8/8/2023 to 2/13/2024, did not include documented evidence of fruit flies in the facility. During observations on 2/21/2024 at 9:05 AM, and on 2/23/24 at 11:30 AM, there were fruit flies in the dish machine area and over 20 fruit flies in the rest of the kitchen. During an interview on 2/26/2024 at 9:39 AM, the Director of Maintenance stated that the pest control vendor did a site visit on 2/23/24 which was the vendors second biweekly visit for the month. They stated the pest control vendor had identified that the main kitchen dish machine area floor drain had debris in it and chemicals were poured down this drain. They stated fruit flies were reported in the kitchen via a work order on 11/28/2023, and a vendor came onsite the next day. After reviewing the bi-weekly pest control vendor reports the Director of Maintenance stated fruit flies were not identified on any of the bi-weekly vendor inspections from 8/8/2023 to 2/13/2024. They stated that it was important for the facility to properly treat and eliminate fruit flies and other pests so they would not bother residents and staff. During an interview on 2/26/2024 at 10:30 AM, the Director of Dietary Services stated they had reported via a work order on 11/28/2023 about fruit flies in the main kitchen. They stated a pest control vendor came the next day and poured a solution down all the kitchen drains. They stated the fruit flies had gotten better since then. 10NYCRR 415.29(j)(5)

Based on record review and interview during the abbreviated survey (NY00304302), the facility failed to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation of an alleged violation was in progress and failed to report the incident in accordance with State law for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1 alleged a staff member sexually assaulted them and the staff member was not removed from having access to Resident #1 or other residents prior to completion of the facility's investigation. Additionally, the facility did not report the allegation to the New York State Department of Health (NYS DOH) within 2 hours of the allegation as required. Findings include: The facility policy Abuse Prevention, Identification, Investigation, Protection, and Reporting modified 4/17/19 documented: -All staff were obligated to report to the Administrator and State Department of Health all incidents or suspicion of physical abuse, mistreatment, or neglect of residents. - Residents would be protected at all times from harm or retribution during the investigative process. The Administrator and/or the Director of Nursing (DON) would determine the employment status of the staff involved. Resident #1 had diagnoses including congestive heart failure (CHF), history of falling, and cognitive communication deficit. The 9/14/22 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, exhibited no behavioral symptoms, and required extensive assistance for all activities of daily living (ADLs) except eating, which the resident required set-up assistance. The comprehensive care plan (CCP) initiated 6/21/22 documented the resident had potential for alteration in mood and behavior due to adult failure to thrive and moderate depression. Interventions included: document mood and behavior changes; monitor environmental stimuli and adjust as needed; and provide support and reassurance. There was no documented CCP related to any behavioral issues of statements of victimization or making false accusations toward staff. The 10/21/22 at 9:37 PM nursing progress note entered by registered nurse supervisor (RNS) #8 documented licensed practical nurse (LPN) #3 notified RNS #8 that Resident #1 stated certified nursing assistant (CNA) #1 tried to rape them while getting the resident ready for bed. The RNS instructed LPN #3 to start an incident report and get statements from CNA #1 and the resident, and check to see if the resident was on the list to not have male caregivers. The 10/21/22 at 9:54 PM nursing progress note entered by LPN #3 documented they spoke to Resident #1 about the incident with the CNA. The resident stated CNA #1 tried to get into the resident's bed and hurt the resident. LPN #3 asked the resident how the CNA was trying to hurt them, and the resident would not say anything further. The resident stated they requested that CNAs of the opposite sex and of a different race to not provide care for them. The 10/21/22 at 10:32 PM nursing progress note entered by RNS #8 documented per LPN #3, the resident accused CNA #1 of raping them. The resident was not upset at the time and had already gone to sleep. The family was notified. There were no further nursing progress notes on 10/21/22 related to the accusation by Resident #1 of sexual assault. The Investigation Summary completed 11/3/22 by the Director of Nursing (DON) documented: - On 10/21/22 at 8:30 PM, Resident #1 alleged a CNA of the opposite sex (CNA #1) tried to rape them. - CNA #1 entered the room when the resident tried to self-transfer to bed, and pulled the bed covers back to allow the resident into bed. - The resident stated they did not want CNA #1's help and the CNA left the room. - Resident #1 walked to the doorway and called for help, and CNA #2 responded and assisted the resident to bed. - Resident #1 stated they did not want a caregiver of the opposite sex and of another race. - CNA #1's 10/21/22 statement documented Resident #1 accused the CNA of trying to rape them. The CNA only went into the room and pulled the covers back on the bed and the resident stated they did not want the CNA's help. CNA #1 did not provide any care prior to the allegation. - CNA #2's 10/21/22 statement documented the resident walked to the hallway and started yelling help me and stated CNA #1 raped them and tried to get into bed with them. CNA #2 added this did not happen as CNA #1 was in the next room. - RNS #8's undated statement documented on 10/21/22. LPN #3 notified the RNS at approximately 9 PM the resident made an accusation against a CNA. RNS #8 went to the floor at approximately 9:45 PM and spoke to CNA #2, who stated the resident accused CNA #1 of attempted rape. CNA #2 reported they told Resident #1 that CNA #1 was just trying to help them. The RNS saw the resident asleep and left the room. The RNS obtained CNA #1's statement. LPN #3 had no knowledge of the incident as they were on a break at the time and the issue was reported to them upon returning from their break. The RNS called the resident's family member (healthcare proxy) who advised them the resident told stories of the past and the accusation was likely due to confused memories. The relative did not wish for any further action. - On 10/24/22, additional statements were obtained from the resident by the DON and social worker (SW) #13. The resident did not recall the incident and reiterated they did not want a caregiver of the opposite sex or a different race. -On 10/24/22, the Director of Social Services contacted the resident's representative for background information. - On 10/24/22, SW #8 obtained statements from other residents on the same unit to address any possible concerns with caregivers. No concerns were identified. - The investigation conclusion completed 11/3/22 by the DON documented there was no evidence to substantiate the allegation and the incident was reported to NYS DOH on 10/24/22. There was no documented evidence CNA #1 was removed from direct access to residents while the incident was investigated. The facility's staffing schedules documented CNA #1 was assigned as follows: - on 10/21/22, 2 PM-10 PM on Resident #1's unit and 10 PM-2 AM on another unit; - on 10/22/22, 10 AM-10 PM on Resident #1's unit; - on 10/23/22, 6 AM- 2 PM on Resident #1's unit; and - on 10/24/22, 4 PM- 10 PM on Resident #1's unit. CNA #1's timesheet documented: - on 10/21/22, clock in at 2:09 PM, and clock out at 2:04 AM; - on 10/22/22, clock in at 10:12 AM, and clock out at 10:09 PM; - on 10/23/22, clock in at 6:14 AM, and clock out at 2:18 PM; and - on 10/24/22, clock in at 3:53 PM, and clock out at 10:25 PM. During an interview with CNA #2 on 11/21/22 at 2:35 PM, they stated on 10/21/22, they heard Resident #1 screaming for help and stating they had been raped. Resident #1 motioned toward CNA #1 who was across the hall in another room. CNA #2 asked Resident #1 again what they meant, and the resident replied a CNA of opposite gender and of another race came in and raped the resident. CNA #2 calmed the resident, assisted them to bed and completed the resident's evening care. The CNA reported the information to the LPN who was working, and they could not recall who it was. CNA #2 provided a statement regarding the allegation. The CNA did not see Resident #1 prior to their allegation. CNA #1 continued to work with CNA #2 that evening, until the end of their shift at 10 PM. CNA #1 was contacted via certified mail on 11/22/22. On 11/25/22, CNA #1 responded they were out of the country. Attempts to reach the CNA by telephone were unsuccessful. During a telephone interview with RNS #8 on 11/28/22 at 2:35 PM, they stated LPN #3 reported to them that Resident #1 accused CNA #1 of rape. When the RNS went to the resident's unit, they spoke to CNAs #1 and 2 and did not talk to the resident, as the resident was sleeping. The RNS did not think it was a valid allegation based on what the CNAs reported and did not realize it was a reportable incident. The RNS stated they did not think it was true based on the time frame reported, which was minutes, and because of what the resident's representative stated regarding the resident's possible delusions. The RNS did not make a final determination on the investigation and did not remove CNA #1 from resident care or from the unit. CNA #1 worked the next shift (10 PM 6 AM) on another floor. The RNS stated on 10/24/22, they were advised by the DON they should have reported the allegation to the Administrator or DON immediately and the accused CNA should have been removed from resident care pending the outcome of the investigation. The RNS stated they knew this protocol from their experience and did not think it applied because the RNS did not think the allegation was true. The RNS stated they now knew it was not up to them to determine if the allegation was true or not. The Administrator or the DON would complete the investigation and make that determination. During a telephone interview on 11/29/22 at 1:35 PM, the Administrator stated the facility policy when a resident alleged abuse included a supervisor was to respond, ensure the safety of the resident, assess the resident for signs of injury, notify the physician, and the Administrator or the DON. Further steps should be taken depending on the issue, such as care plan revision, removal of the accused employee, or other safety measures as needed. When Resident #1 alleged CNA #1 sexually abused them, RNS #8 should have immediately notified the Administrator or the DON for guidance. Typically, an accused staff member was to be suspended pending a determination of the investigation. RNS #8 began the investigation, but the final determination had not been made. Although the resident was asleep when RNS #8 went to see them, they should have woken the resident for an assessment. When family representatives provided input, it did not negate the RNS from completing the assessment at that time or from taking other steps to protect Resident #1 and other residents during the investigation. CNA #1 should have been removed from resident care until the investigation was completed. The Administer and DON were not made aware of the allegation until 10/24/22, at which time a determination was made. The allegation also should have been reported to NYS DOH immediately on 10/21/22 and was not. The protocol was for the responding supervisor to notify the Administrator or DON, who had the capability to submit the report to NYS DOH. During an electronic communication with CNA #1 on 12/3/22 at 1:43 PM, they stated after Resident #1 made the accusation, the CNA provided a written statement to the nursing supervisor. CNA #1 was uncertain when they provided the statement, although it was prior to the end of their shift on 10/21/22. CNA #1 stated they continued to care for other residents after the allegation by Resident #1. The CNA could not recall what the supervisor said to them and was not removed from the unit that evening. 10NYCRR 415.4 (b)(2)(3)

Based on record review and interview during the abbreviated survey (NY 684) conducted on 11/24/21, the facility failed to ensure allegations of neglect were thoroughly investigated and failed to report the incident in accordance with State law for 2 of 7 residents (Residents #3 and 5). Specifically, - certified nurse aide (CNA) #24 did not follow the comprehensive care plan (CCP) for Resident #5 when transferring the resident. The resident was injured and the facility's investigation did not identify the CCP violation and the incident was not reported to the New York State Department of Health (NYS DOH) as required. - Two days later, CNA #24 did not follow the CCP when transferring Resident #3. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: The 7/24/18 Transfer and Lifting Techniques policy documents: Residents will be transferred and lifted by appropriately trained nurses, nursing assistants, and therapy staff using proper techniques following the recommendations of a licensed physical therapist (PT) -Check the care plan/profile to determine the level of staff assistance and transferring method. -When transferring from wheelchair to bed, raise and position foot pedals to not interfere with transfer or remove entirely. The 4/17/19 Abuse Prevention, Identification, Investigation, Protection, and Reporting policy documents: -All staff are obligated to report to the Administrator and State Department of Health all incidents or suspicion of physical abuse, mistreatment, or neglect of residents. - All incidents of alleged and/or substantiated abuse or neglect will be investigated by the facility. - The investigation shall include: review of the resident's medical record; demonstration of care delivery if involving care techniques and/or assessment of care technique provided by staff; 1) Resident #5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/16/21 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, transferred with extensive assistance of one person, and utilized a walker and a wheelchair. The comprehensive care plan (CCP) documented: - on 7/20/20, the resident was at risk for impaired skin integrity related to impaired mobility, impaired cognition, and thin fragile skin. Interventions included: tubi-grips (devices that provide tissue support) to the upper and lower extremities at all times for protection of fragile skin, high risk of skin tears. - On 1/14/21, the resident had a deficit in activities of daily living (ADL) function/mobility related to medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/1/21 Kardex Report (care instructions) documented the resident utilized a scoot chair, transferred with limited assistance of one person, with a front wheeled walker, and foot pedals from the scoot chair were to be removed prior to transfers to avoid injury. The 5/2/21 Incident Report completed by registered nurse Supervisor (RNS) #27 documented: - At 5:40 PM, the resident was sitting on the bed with certified nurse aide (CNA) #24 on the floor next to them. CNA #24 was holding a paper towel against the right outer calf area, which was bleeding. The resident stated CNA #24 dropped them. Two skin tears were noted on the right outer calf, cleansed and dressed. The resident had some discomfort, Tylenol was given, and the medical provider was notified. - CNA #24's statement included with the Incident Report documented they transferred the resident from the chair to bed and noticed blood coming from the left leg, notified the nurse, and had not provided any care yet. - The Incident Report did not document whether the resident used their walker for the transfer, if the wheelchair leg rests were on the chair at the time of the transfer, if the resident had the tubi-grips on, or if the CCP was followed. The investigation did not include any further information about the resident's report that the CNA dropped them. The 5/3/21 at 10:47 AM, medical provider's progress note documented the resident was seen for 2 large skin tears to the right lower leg, sustained during transfer as the leg was caught on the leg rest. The 5/3/21 In-Service Program Record completed by RN Manager #29 documented CNA #24 was educated about transferring residents in or out of the wheelchair, to take of the wheelchair legs to prevent skin tears, bruising, or any discomfort if the legs were bumped. During a telephone interview on 11/12/21 at 2:30 PM, CNA #24 stated they had no recollection of the 5/2/21 incident when Resident #5 sustained 2 large skin tears following transfer to bed. The CNA had no recollection of receiving education regarding the removal of wheelchair legs prior to transfer to avoid injury or if a front wheeled walker was used. During an interview with the Administrator on 11/16/21 at 3:30 PM, they stated CNA #24's documented education about removal of wheelchair legs prior to transfer included in the 5/2/21 incident report indicated the wheelchair legs were not removed. The Administrator was not made aware of a CCP violation. If CNA #24 did not follow the CCP and an injury occurred, it should have been included in the investigation and reported to the NYS DOH. The Administrator stated they expected the other aspects of the CCP to be verified including if the walker was used to determine if was a factor in the incident. During a telephone interview on 11/24/21 at 11:27 AM, RN Manager #29 stated when completing the 5/2/21 incident report they did not ask if the CCP was followed. RN Manager #29 declined to respond when asked if the investigation should include confirmation the CCP was followed. RN #29 stated they provided education to CNA #24 on 5/3/21 regarding removal of wheelchair legs prior to transferring and stated the reason was to ensure the CNA was aware of the CCP. During a telephone interview with RNS #27 on 11/24/21 at 2:09 PM, they stated upon entering Resident #5's room on 5/2/21, they observed the resident's wheelchair by the bed, the resident on the bed, and CNA #24 holding something on the resident's bleeding leg. There was no walker present, and the wheelchair legs were still on the wheelchair. Wheelchair leg rests should be removed during transfers and the RNS could not recall if education was provided to the CNA at that time. Typically, when responding to an incident, the supervisor who initiated the incident report should verify if the CCP was followed and the RNS could not recall if that was done. The RNS stated CNA #24 was not forthcoming with how the skin tears occurred or how the resident was transferred. The DON or RN Manager would have completed the investigation, and no one approached the RNS for follow up questions regarding the incident report. 2) Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/31/21 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment and required limited assistance of 2 people with transfers. The comprehensive care plan (CCP) revised 4/19/21 documented the resident transferred with limited assistance of one person with a front wheeled walker. The 4/23/21 physical therapy (PT) discharge summary documented nursing recommendations for transfers with limited assistance of one person with a front wheeled walker. The 5/4/21 Kardex Report (care instructions) documented the resident required limited assistance of one person and a front wheeled walker for transfers. The 5/7/21 Investigation Summary completed by registered nurse (RN) #25 (acting DON at the time of the incident) documented: - On 5/4/21 at 10:50 PM, Resident #3 was assisted to bed by certified nurse aide (CNA) #24 and bleeding was noted to their leg. Nursing staff were unable to stop the bleeding and the resident was sent to the emergency room (ER) for treatment. - CNA #24 reported after transferring the resident to bed, blood was noted on the leg, they applied pressure, and could not stop the bleeding. After the incident, CNA #24 reported feeling dazed due to the amount of blood. - Licensed practical nurse (LPN) #8 responded to the room and noted CNA #24 on the floor holding the resident's leg, and RNS #7 was called, the physician was notified, and the resident was sent to the ER. CNA #24 was unresponsive when asked what happened and was told to leave the floor. - LPN #9 responded to the resident's room and found CNA #24 sitting on the floor holding the resident's leg. CNA #24 was not responsive to directions from LPN #9 and was noted to have glassy eyes, slurred speech, staggered when walking, and unable to follow simple requests. The oncoming Supervisor escorted CNA #24 to the Supervisor's office. - CNA #10 reported they responded to the call light in the resident's room and found CNA #24 on the floor in front of the resident, the resident seated on the bed. CNA #10 told CNA #24 the call light was on, and CNA #24 responded okay. Moments later LPN #9 entered the room and said the resident had cut their leg and there was blood everywhere. - RNS #7 reported they responded to the room and upon arrival, found CNA #24 standing in the hall outside the resident's room with bloody hands and a visibly dazed appearance. LPN #8 told RNS #7 they told CNA #24 to leave the room as they appeared intoxicated. Following the resident's transfer to the hospital, RNS #7 asked oncoming RNS #11 to escort CNA #24 to the office so both RNs could assess the CNA for impairment and ask what happened with the resident. After several inquiries, CNA #24 wrote a statement. A distinct smell of alcohol was noted on CNA #24 as they signed the statement, CNA #24 was advised they could not complete the shift, was instructed to go home, and to call the DON in the morning to schedule a time to go discuss the incident. - RNS #11 reported they were asked by RNS #7 to accompany them to assess CNA #24 for signs of impairment. RNS #11 found CNA #24 in the resident's room, swaying back and forth and appeared to have difficulty with their balance. The RNS escorted CNA #24 to the supervisor's office with RNS #7 so they could question CNA #24. After CNA #24 provided their statement, they were instructed to leave the building. - The facility was able to substantiate the allegation of neglect based on the CNA who provided care at the time of injury presented as impaired when assessed by their co-workers and supervisors immediately following the incident. The plan of care appeared to have been followed after reviewing statements from staff and well as the Kardex in use at the time. - The investigation did not address if the CNA utilized the front wheeled walker when transferring the resident. The 5/5/21 ER report documented the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . They were sent to the ER as the nursing home could not control the bleeding. Seven sutures were placed to close the wound. During a telephone interview on 10/28/27 at 1:40 PM, RNS #7 stated they interviewed CNA #24 following the incident when Resident #3 sustained the laceration to their leg. CNA #24 did not initially report any difficulty and after several attempts asking them, CNA #24 stated they had trouble with the transfer. RNS #7 could not recall anything about the use of a front wheeled walker for transfers. The CNA was suspected of being under the influence of alcohol and was sent home. During a telephone interview on 10/28/21 at 2:48 PM, LPN #9 stated they responded to Resident #3's room on 5/6/21 when CNA #24 was found on the floor holding their leg. The resident was seated on the bed, there was a large amount of blood. The resident's wheelchair was near the bed and the LPN had to move it, along with the bedside table to reach the resident. There was no walker present. The LPN suspected CNA #24 was under the influence as they were not responsive to instructions, had slurred speech, and unable to answer questions. LPN #9 reported their concerns to RNS #7. During a telephone interview on 10/28/21 at 3:58 PM, LPN #8 they stated upon arrival to Resident #3's room on 5/4/21, they observed the resident seated on the side of the bed and CNA #24 on the floor, holding the resident's leg, which was bleeding profusely. There was no walker in the room at the time of the incident. The LPN suspected the CNA was under the influence of alcohol as the CNA smelled of alcohol, appeared dazed, and was unable to answer questions. During a telephone interview on 10/29/21 at 12:42 PM, physical therapist (PT) #5 stated Resident #3 required the use of a front wheeled walker to stand and transfer from chair to bed or bed to chair. When the resident was in physical therapy, they were trained to use the walker for support while standing to transfer and this was on the CCP. During a telephone interview with CNA #24 on 11/12/21 at 2:30 PM, they stated on 5/4/21, they arrived for work at 10:00 PM, received their assignment and noticed Resident #3 was still up. The resident required assistance of one person for transfers and CNA #24 transferred them alone by telling the resident to hold onto CNA #24 as the resident stood from the chair. CNA #24 did not use a walker and was unaware of the CCP instruction to use the walker for transfers. CNA #24 reported they looked at the Kardex on the door prior to providing care. During the transfer, the resident began to fall, possibly hitting their leg against the side of the bed at the time. As soon as the resident was seated on the edge of the bed, CNA #24 noticed their leg was bleeding and immediately held a paper towel to the leg until the nurse arrived. During an interview on 11/16/21 at 3:30 PM, the Administrator stated the investigation into the incident should have included verification the CCP was followed. If the resident was care planned to use a front wheeled walker and it was not used, it was a CCP violation. The incident was reported to the NYS DOH as they felt the CNA was under the influence but was not reported related to a CCP violation. 10NYCRR 415.4 (b)(2)(3)

Based on observation, record review and interview during the recertification survey conducted 10/18/21-10/21/21, the facility failed to post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility conducted by Federal or State surveyors. Specifically, the facility did not post the Life Safety Code survey results from the 5/17/19 federal recertification survey. Findings include: The facility policy Administrator Functions and Communications dated 9/14/18 documents the Administrator ensures the posting of the results of the most recent survey including the statement of deficiencies, plan of correction, and enforcement actions. During an observation on 10/19/21 at 3:00 PM, the Life Safety Code recertification survey results from the most recent Federal survey on 5/17/19, were not in the survey results binder located near the reception desk. During an interview on 10/19/21 at 4:35 PM, the Administrator stated that the last Federal survey report binder was kept in a drawer near the reception area for residents and resident families to view. The Administrator stated that this was the only posted report within the facility. The Administrator verified that the last Life Safety Code survey report was missing. The Administrator stated they were not aware the results were missing until it was identified during the current Federal survey. The Administrator stated they knew it was required to have Life Safety Code survey results posted and it was the task of receptionist #5 to check and ensure the binder was kept in the drawer near the reception area. During an interview on 10/20/21 at 2:55 PM, receptionist #5 stated they would do a weekly check to ensure that the survey results binder from the previous Federal survey was present in the lobby area for residents and families to review. The receptionist stated they had been doing these checks since being hired over [AGE] years ago. They stated the previous Administrator provided the survey results from the 5/2019 Health Survey, but they did not know what the Life Safety Code survey was, and they were unsure if a family member had taken it out of the binder. 10NYCRR 415.3(c)(v)

Based on observation, interview, and record review during the recertification and abbreviated survey (NY 317) conducted from 10/18/21 through 10/21/21, the facility failed to ensure each resident receives and is provided food and drink that is palatable, attractive, and at a safe and appetizing temperature for 2 of 2 meals (breakfast and lunch) reviewed. Specifically, sampled breakfast and lunch meals were not served at palatable or appetizing temperatures. This is evidenced by: The facility Meal Service Audit Form dated 4/2018 documented taste, temperature, quantity, and appearance of the meal should be enjoyed. The form did not document acceptable food temperatures. During an interview on 10/18/21 at 11:49 PM, Resident #346 stated the hot food was cold. During an interview on 10/18/21 at 12:19 PM, Resident #94 stated the food was cold by the time they were served their meals. During an interview on 10/18/21 at 12:47 PM, Resident #137 stated the food was not always hot and the eggs were always cold. During an observation on 10/18/21 at 12:49 PM, the last tray assembly was finished and the trays were brought to the third-floor west wing. At 12:59 PM, the last assembled tray, containing grilled cheese, was taken from the cart for testing and a replacement was requested. At 1:02 PM, food temperatures were measured, and the milk was 55 degrees Fahrenheit (F), the grilled cheese was 104 degrees F, the green beans were 105 degrees F, and the apple juice was 58 degrees F. The grilled cheese and green beans were not palatable and lukewarm. The milk was not cold or palatable. During an interview on 10/18/21 at 3:54 PM, Resident #114 stated the meals were lukewarm. During an interview on 10/18/21 at 4:15 PM, Resident #446 stated the food was not served at the correct temperature. During an observation on 10/20/21 at 8:28 AM, a breakfast tray for Resident #94 was sampled for palatability and temperature and a replacement was requested. The poached eggs were 110 degrees F, the hot tea was 125 degrees F, the orange juice was 61 degrees F, Boost (oral nutrition supplement) was 57.6 degrees F, the yogurt was 62 degrees F, and the toast was 92 degrees F. The eggs were lukewarm, the hot tea was not hot to taste, the orange juice was not chilled to taste, the Boost was not cold, and the toast tasted less than lukewarm. The yogurt appeared thin in the container and had started to separate. During an interview on 10/20/21 at 12:36 PM, the Food Service Director stated the food temperature complaints had been addressed on a resident-to-resident basis. Steam table temperatures were taken at every meal and test trays were done on the last tray from the cart. They had not been keeping the logs of food temperatures since 5/2021. The beverages were poured the night before and placed in the main kitchen cooler for the first-floor meals and the kitchenette refrigerators for the second and third floors; the trays of cold drinks were pulled out of the coolers 25-30 minutes prior to food service for all three floors. The Food Service Director stated the milk, orange juice, and apple juices from the test trays were not served at a palatable temperature. The yogurt which was 62 degrees F and separating was not acceptable or palatable. The hot foods that were served at lukewarm temperatures were not acceptable or palatable. The facility was not set up for a tray line and was forced to use a tray line due to COVID-19 precautions. The facility had not made changes from their standard protocol for the previous two years. When the dining rooms were open from 2/2021 through 9/2021 the food was sent out a lot faster and they also had the proper staffing to send out the food. The Food Service Director stated when they were serving the lunch meal on 10/18/21, they were slower than the usual staff which had impacted the temperatures. Hot foods should be over 140 degrees F and the cold foods should be under 41 degrees F when served to the residents. 10NYCRR 415.14

Based on interview and record review during the abbreviated survey (NY 364), the facility did not promote and facilitate self-determination and did not ensure residents had the right to make choices about aspects of their lives that are significant to them for 1 of 3 residents reviewed (Resident #1). Specifically, Resident #1 was care planned for no male caregivers and a male certified nurse aide (CNA) assisted with positioning the resident during personal care. Findings include: A policy addressing residents' wishes for no male caregivers was requested and the surveyor was informed the facility did not have a written policy. Resident #1 had [DIAGNOSES REDACTED]. The 6/9/20 Minimum Data Set (MDS) assessment documented the resident's cognition was moderately impaired and extensive assistance was required with most activities of daily living (ADLs). The 1/17/20 comprehensive care plan (CCP) documented the resident had potential for alteration in daily customary routine, had deficits in ADL function, and the potential for alteration in mood due to anxiety and depression. Interventions included limited assistance from one person with rolling side to side in bed, extensive assistance from one person with hygiene, dressing and bathing, two staff members present during care, and no male caregivers. The 8/14/20 facility investigation documented at 11:15 AM, the resident reported to a family member they were sexually assaulted by a male the prior evening (8/13/20). Statements obtained by the facility included: - Certified nurse aide (CNA) #1 (male staff member) denied providing personal care to the resident however, he assisted licensed practical nurse (LPN) #3 (female staff member) with placing the resident in bed. - CNA #2 toileted the resident a few times and with the help of LPN #3, transferred the resident out of bed into the wheelchair. - LPN #3 reported the resident was agitated towards staff on 8/13/20 and was yelling loudly. The resident quieted down after being transferred to bed. She and CNA #1 assisted the resident to bed while she provided personal care. - The resident stated in an interview with the social worker that males were not allowed in the room due to the resident not trusting them. The conclusion documented the allegation of sexual assault was unsubstantiated and the facility determined there was a male caregiver in the resident's room on 8/13/20 but he was not alone with the resident at any time, he did not provide any personal care, and only assisted with transfer and positioning. On 8/17/20 at 10:15 AM, the Director of Nursing (DON) stated in an interview, the resident was not to have male caregivers for personal care. When a male CNA was assigned to care for the resident, they were to have a female CNA do all personal care. On 8/17/20 at 1:17 PM, CNA #2 stated in a telephone interview, the resident did not want male caregivers. She stated personal care was provided to the resident several times on 8/13/20 and she did not recall CNA #1 going into the resident's room that evening. She stated she was not sure if male staff could transfer or position a resident if their wishes were for no male caregivers. On 8/17/20 at 1:35 PM, CNA #1 stated in a telephone interview, he was occasionally assigned as the resident's primary CNA even though her wishes were for no male caregivers. He stated when he was assigned to the resident, he needed to find a female CNA to provide personal care and he was not sure if he could transfer or reposition the resident. He stated on 8/13/20, he was assigned as the resident's primary CNA. When the resident needed to use the bathroom, he asked CNA #2 to assist the resident. Later on during the shift, the resident was agitated, kept trying to get out of the chair, and LPN #3 asked for his assistance with the resident. He brought linens and towels to the resident's room and prepared a basin in the resident's room while waiting for LPN #3. When LPN #3 came into the room, they transferred the resident to the bed from the chair. He remained in the room while LPN #3 provided personal care to the resident which included undressing the resident, providing peri care and putting pajamas on the resident. He stated the resident did not say anything about him being in the room, he knew the resident did not want male caregivers, and believed it went against the resident's wishes when he remained in the room during personal care. On 8/17/20 at 2:05 PM, LPN #3 stated in a telephone interview, when male CNAs were assigned to residents that wanted no male caregivers, it was up to the male CNA to find a female CNA to switch residents with. LPN #3 stated CNA #1 switched residents with CNA #2 that evening but CNA #2 was busy when the resident needed assistance, so she asked CNA #1 to help. She and CNA #1 assisted the resident to bed and CNA #1 got washcloths and a basin. She pulled the resident's pants down and began peri care while CNA #1 assisted by holding the resident in position. She then put the resident's incontinence briefs and pajamas on while CNA #1 remained in the room. She stated she forgot the resident did not want male caregivers and CNA #1 never said anything to her. On 8/17/20 at 3:45 PM, the DON was re-interviewed and stated the resident was care planned for no male caregivers and also required 2 staff to be present during care. When a resident was care planned for no male caregivers, the facility's practice was male staff would not provide personal care but could assist with transferring and positioning. On 8/14/20, when the resident made the allegation, she called CNA #1 and had him walk her through his shift from the day before. CNA #1 told her CNA #2 provided personal care to the resident during the shift and that he did assist with repositioning and transferring. She stated she was not aware CNA #1 remained in the room with LPN #3 during the resident's personal care, he should not have remained in the room, and should have at least closed the privacy curtain. She stated when residents' care plans documented no male caregivers, it was open for interpretation and not clear what the instruction was. The facility needed to clarify instructions, needed to meet the residents' preferences, and needed to keep residents safe. 10NYCRR 415.5(b)(1-3)