Every finding on record at Finger Lakes Center for Living

Based on observations and interviews (iQIES intake #26844070), the facility failed to follow proper sanitation practices to prevent the outbreak of food borne illness in one of one main kitchen. Specifically, the dish machine sanitizer concentration was not monitored, and dishware was not sanitized.Findings include:The facility policy Dishwashing, revised 03/2025, did not document dish machine sanitation or monitoring of temperatures or chemical concentrations to ensure the machine was functioning.The 12/10/2025 vendor invoice documented the dish machine booster heater was down and the dish machine was set up as a low temperature chemical sanitizer while waiting for the booster to come in.During an interview on 07/21/2026 at 5:23 PM, the Food Service Director stated the dish machine was usually a high temperature machine (sanitizes with temperatures over 180 degrees Fahrenheit) but had to be converted to a low temperature chemical sanitizing machine while they waited for a heating element to arrive. The required chemical strength for the dish machine was 55 to 100 parts per million and they tested the strength at the start of washing dishes for each meal and was documented on the Dish Machine Temperature and Sanitizer Testing Log.The facility Dish Machine Temperature and Sanitizer Testing Log documented the required chemical strength was 55 to 100 parts per million and was tested at each meal. The log was missing sanitizer testing data for breakfast on 07/20/2026, 07/21/2026, 07/22/2026, and 07/23/2026, and lunch on 07/22/2026 and 07/23/2026.During an observation and interview on 07/23/2026 at 10:10 AM, there was no documented evidence that the dish machine sanitizer strength was tested for the day. Food Service Worker #4 was running the dish machine and stated they usually tested the sanitizer strength when they started the machine at the beginning of the shift but had not done it yet because they were working a different shift from usual and they wanted to get the dishes caught up. They stated the sanitizer strength was checked to make sure the dishes were clean. The Food Service Director tested the sanitizer strength, and it was zero parts per million. They tested a second time with another test kit and got the same results, zero parts per million.During an observation and interview on 07/23/2026 at 10:40 AM, the Food Service Director checked the chemical sanitizer attached to the dish machine and recorded a sanitizer strength of zero parts per million. They called their chemical service company and switched to paper products until the machine could be looked at. The sanitizer strength was tested to ensure it would kill germs on the dishes. Food Service Worker #4 was supposed to test and read the sanitizer strength that morning and did not. The morning supervisor was supposed to ensure food service workers tested the sanitizer, and they did not know why that was not done.During an interview on 07/23/2026 at 10:50 AM, Food Service Supervisor #6 stated the sanitizer strength was tested to ensure the sanitizer was at the right strength to kill things on the dishes. They normally checked to make sure the sanitizer strength was tested by food service workers on the dish machine and forgot to check that day. The 07/23/2026 vendor invoice documented the gallon jug of sanitizer attached to the dish machine was filled with water instead of the chemical. A bottle of chemical sanitizer was hooked up to the dish machine, and the issue was resolved. 10 New York Codes, Rules and Regulations 415.14(h)

Based on record review and interviews, 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 legionella (a bacteria causing Legionnaires' disease-a respiratory disease) testing. Specifically, the facility's water management plan and Environmental Assessment of Water Systems in Healthcare Settings was not reviewed/updated since 2022 and legionella testing was not completed since 2024.Findings include: The Environmental Assessment of Water Systems in Healthcare Settings form documented the form was last updated on 09/27/2022.The facility's Water Management Plan documented it was last reviewed on 07/11/2022 and legionella sampling would be taken from 11 sources every quarter.The 03/28/2024 legionella testing results documented legionella was not detected.There was no documented evidence that the facility completed legionella sink testing since 03/28/2024.During an interview on 07/24/2026 at 10:35 AM, the Administrator stated they were responsible for making sure the water plans were updated, and testing was completed. The Director of Maintenance was responsible for obtaining the samples and an outside vendor performed the testing. The last time sink legionella testing was completed was 09/2024, and per the water management plan it should have been done quarterly. The Environmental Assessment of Water Systems in Healthcare Settings was completed in 2022 and should have been updated at least annually. The water management plan needed to be updated and reviewed annually. They could not attest as to why they were not done as they had only been in their position since mid-April. They stated they felt changes in leadership both in the maintenance department and administration may have contributed. During an interview on 07/24/2026 at 11:34 AM, the Operations Manager stated they thought legionella testing was done annually. The samples were obtained in house and tested by an outside vendor. The last testing was done in 2024. The Environmental Assessment of Water Systems in Healthcare Settings form was supposed to be updated annually by either themselves or the Director of Maintenance. The water management plan was updated annually, and they were unsure who was responsible. They thought the reason the testing and the updating of the forms was not done was due to changes in leadership in both the maintenance department and in administration. 10 New York Codes, Rules and Regulations 415.19 (a) (1-3)

Based on observations, record review, and interviews, the facility failed to ensure medication error rates were not greater than 5% for two of three residents (Residents #20 and #61) reviewed. Specifically, Residents #20 and #61 received discontinued medications resulting in a medication error rate of 9.38%.Findings include:The facility policy Medication Administration, last reviewed 12/14/2025, documented the medication nurse would read each medication on the medication label 3 times and verify accuracy on the medication administration record before administering the medication and the nurse would administer the right dose of the right medicine. 1) Resident #61 had diagnoses including high blood pressure. The 07/03/2026 Minimum Data Set assessment documented cognition was not assessed and the resident required supervision for most activities of daily living. The 07/20/2026 physician order documented magnesium oxide (a mineral supplement) 400 milligrams was discontinued on 07/20/2026.During an observation and interview on 07/23/2026 at 9:18 AM, Licensed Practical Nurse #7 removed the resident's medication packages from the cart. Each package was imprinted with the name of the medication and a description of what it looked like. One package was imprinted with and contained a magnesium oxide 400 milligram tablet. The pill was emptied into a medication cup along with the other medications and administered to the resident. Licensed Practical Nurse #7 referred to the computer and said the magnesium oxide was discontinued, and they should not have administered it. The July 2026 Medication Administration Record documented magnesium oxide 400 milligram tablet once daily at 9:00 AM. The record had x in the box beginning on 07/21/026-07/31/2026 (indicating not scheduled to be administered). 2)Resident #20 had diagnoses including diabetes. The 06/15/2026 Minimum Data Set assessment documented the resident had moderately impaired cognition and required maximum assistance for most activities of daily living. The 07/19/2026 physician order documented folic acid (vitamin supplement) 1 milligram and calcium 315 milligrams with vitamin D3 (vitamin/mineral supplement) 5 micrograms were discontinued on 07/19/2026.During an observation and interview on 07/23/2026 9:39 AM, Licensed Practical Nurse #7 removed the resident's medication packages from the cart. Each package was imprinted with the name of the medication and a description of what it looked like. One package was imprinted with and contained a calcium citrate with vitamin D3 tablet. The pill was emptied into a medication cup along with the other medications. Another medication package was imprinted with and contained a folic acid 1milligram tablet. The pill was emptied into the same medication cup along with the other medications and administered to the resident. Licensed Practical Nurse #7 referred to the computer and said they had both been discontinued and they should not have administered it. The July 2026 Medication Administration Record documented calcium 315 milligram/vitamin D3 5 milligram one tablet once daily at 9:00 AM and folic acid 1 milligram tablet once daily at 9:00 AM. The record had x in the boxes for both medications beginning on 07/20/026-07/31/2026 (indicating not scheduled to be administered). During an interview on 07/23/2026 at 11:30 AM, Licensed Practical Nurse #7 stated when administering medications, medications should be checked against the computer when removed from the cart, before administering them, and again after being administered. The pharmacy provided 3 days' worth of medications and if a medication was discontinued during that time the pharmacy did not usually issue new medication packages. Nurses would have to remove that discontinued medication and would be able to identify which pill to remove based on the description printed on the package. They gave the calcium citrate with vitamin D3, the folic acid to Resident #20 and the magnesium oxide to Resident #61 but should not have because they were discontinued. They felt like they did all the necessary checks but still missed those discontinued medications because they were distracted.During an interview on 07/23/2026 at 11:42 AM, Assistant Registered Nurse Manager #10 stated the pharmacy provided 3 days' worth of medications. If a medication was discontinued the pharmacy did not provide new medication packages. The nurses should check each medication against the orders and leave any discontinued medications in the package, tape it shut, and put it in the return to pharmacy bucket. There was a visual description of each medication on the package so the nurse could identify the discontinued medication. Discontinued medications should not be given if they were no longer listed in the computer. 10 New York Codes, Rules and Regulations 415.12(m)(1)

Based on record review and interviews during a survey (iQIES #2733288), the facility failed to implement immediate measures to protect residents from abuse for two (2) of four (4) residents (Residents #1 and #2) reviewed. Specifically, there was witnessed verbal and physical abuse by Certified Nurse Aide #7 toward Resident #1. Certified Nurse Aide #7 continued to have access to residents, resulting in an incident of verbal abuse with Resident #2. There was no documented evidence that a registered nurse completed assessments on Resident #1 or Resident #2 on [DATE] after the incidents of witnessed abuse. Specifically:-On [DATE] at approximately 4:00 PM, Certified Nurse Aide #9 witnessed Certified Nurse Aide #7 handling Resident #1 roughly, spraying them with perfume when they were combative with care, and making a verbally abusive statement. Certified Nurse Aide #9 reported the incident to Registered Nurse Supervisor #12, who did not assess Resident #1. Certified Nurse Aide #7 continued to have access to residents, and after supper, Certified Aide #7 made a verbally abusive statement to Resident #2, which was witnessed by Certified Nurse Aide #10. There was no registered nurse assessment, and Certified Nurse Aide #7 continued to have access to residents. Certified Nurse Aide #7 was sent home on suspension at 8:00 PM.The facility's failure to protect residents from abuse resulted in potential for harm that is Immediate Jeopardy and Substandard Quality of Care and places all 74 residents in the facility at risk for the likelihood of serious injury, serious harm, serious impairment, or death.Findings include: The facility Abuse Policy - Prevention and Reporting, revised 06/2025, documented when a facility had identified abuse they must take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. Examples of verbal abuse included mocking, insulting, harassing, yelling or hovering over the resident with the intent to intimidate, and threatening the resident. Examples of physical abuse included hitting, slapping and holding the resident roughly. Protection for residents of suspected abuse included: provide for the immediate safety of the resident upon identification of suspected abuse; respond immediately to protect the alleged victim and integrity of the investigation; examine the victim for any sign of injury including a physical examination or psychosocial assessment if needed; increased supervision of the alleged victim and residents; and immediate suspension of the suspected employee pending the outcome of the investigation.1) Resident #1 had diagnoses including aphasia (difficulty speaking), hemiplegia (one-sided paralysis), and anxiety disorder. The [DATE] Minimum Data Set (a resident assessment tool) documented that the resident had severely impaired cognition, used a wheelchair, had limited range of motion in one leg and arm, and required substantial to maximal assistance for most activities of daily living.The Facility Accident/Incident Report completed by the Director of Nursing on [DATE], documented on [DATE]:-Licensed Practical Nurse #13 was taking their lunch break (time later identified as approximately 7:30 PM) when Certified Nurse Aide #8 told them Certified Nurse Aide #7 sprayed perfume in Resident #1's face (witnessed occurrence was 4:00 PM).-The Director of Nursing was notified (by phone) of the incident by Licensed Practical Nurse #13 at 7:49 PM. Certified Nurse Aide #7 was suspended from work (time later identified as approximately 8:00 PM).-A registered nurse assessment of Resident #1 was completed by the Director of Nursing on [DATE] at 7:30 AM.-Nurse Practitioner #16 was notified of the incident by the Director of Nursing on [DATE] at 10:00 AM.-Resident #1's family representative was notified of the incident by the Administrator on [DATE] at 6:00 PM. There was no documented evidence that a registered nurse assessment was completed for Resident #1 and Resident #2 on [DATE] immediately after the incidents occurred. Certified Nurse Aide #7 was not immediately relieved of duty after the witnessed abuse of Resident #1 at 4:00 PM on [DATE] and continued to have access to residents until approximately 8:00 PM. During a phone interview on [DATE] at 1:28 PM, Certified Nurse Aide #8 stated on [DATE] at 4:00 PM they and Certified Nurse Aide #7 were getting Resident #1 cleaned up before supper. Resident #1 was being combative with care. They stated out of their peripheral vision they saw Certified Nurse Aide #7 spray Resident #1 with perfume what they thought was over their head several times. A co-worker, Certified Nurse Aide #9 came into the room and offered to help. Certified Nurse Aide #9 told them they saw Certified Nurse Aide #7 spray Resident #1 with perfume. They told Certified Nurse Aide #9 they needed to report the incident to Registered Nurse Supervisor #12. Certified Nurse Aide #9 left to report the incident to Registered Nurse Supervisor #12 at approximately 4:45 PM. When Certified Nurse Aide #9 came back to the unit, they told them Registered Nurse Supervisor #12 would speak with them about the incident after supper. Registered Nurse Supervisor #12 left at 7:00 PM (when their shift was done) and never spoke with them about the incident. During Licensed Practical Nurse #13's supper break, they told them about the incident with Resident #1 and how Registered Nurse #12 never spoke with them about the incident. They did not know why Certified Nurse Aide #7 was still working after the incident. Licensed Practical Nurse #13 called the Director of Nursing and was given instructions to send Certified Nurse Aide #7 home on suspension. Certified Nurse Aide #7 was sent home at approximately 8:00 PM. Certified Nurse Aide #7 had resident assignments on both halls of the unit the evening of [DATE]. At the time of the incident that evening they had not heard anything about an incident involving Resident #2. Resident #2 resided on the other hall. During a phone interview on [DATE] at 10:37 AM, Certified Nurse Aide #7 stated on [DATE] during the evening shift they were assisting Certified Nurse Aide #8 with Resident #1's care. Resident #1 was combative with care, so they tried to, play word games to distract the resident. Certified Nurse Aide #9 came into the room to assist with Resident #1's care because they had a few minutes, as their resident was on the commode. They told Certified Nurse Aide #9 to, Please get your resident off the commode, they could die on the commode. Once they got Resident #1 into their wheelchair, they sprayed perfume on their body because, That was what they usually did after they got them cleaned up. They were told by Licensed Practical Nurse #13 at 8:00 PM they had to go home and that somebody from the facility would be calling them. They did not know why they were being sent home. During an interview on [DATE] at 11:15 AM, the Director of Nursing stated they received a text message from Registered Nurse Supervisor #12 before they left their shift on [DATE], acknowledging that Certified Nurse Aide #9 had come to them about how Certified Nurse Aide #7 sprayed perfume on Resident #1. Registered Nurse Supervisor #12 did not say Certified Nurse Aide #7 sprayed the perfume in the resident's face. The text message also documented that Certified Nurse Aide #8 wanted to speak with them about the perfume sprayed on Resident #1. Registered Nurse Supervisor #12 told them they looked at Resident #1 and they seemed fine. Ther was no documentation that Registered Nurse Supervisor #12 assessed Resident #1. When they interviewed Certified Nurse Aide #9 about the incident, they told them they did not see Certified Nurse Aide #7 spray the perfume into Resident #1's face. Registered Nurse Supervisor #12 did not say anything about physical or verbal abuse by Certified Nurse Aide #7 toward Resident #1. During a phone interview on [DATE] at 12:27 PM, Registered Nurse Supervisor #12 stated they worked on [DATE] from 3:00 PM - 7:00 PM on both floors of the nursing home. They usually worked on the hospital side of the facility. Just before supper that evening, Certified Nurse Aide #9 told them Certified Nurse Aide #7 sprayed perfume on Resident #1 and the resident slapped them away. They thought maybe Resident #1 did not want to wear perfume. That was the only thing Certified Nurse Aide #9 told them. They did not think any kind of abuse occurred. They were aware Certified Nurse Aide #8 wanted to speak with them that shift but they got busy and never spoke with them. No other staff member sought them out. They worked until 7:00 PM. If they had known it was suspected abuse they would have called the Director of Nursing. They did transport Resident #1 in their wheelchair to the dining room that evening around 4:45 PM and the resident appeared fine and was smiling, but they were not sure if they documented that assessment in the nursing progress notes. They were always told not to document something if they were not sure of something. They spoke with the Director of Nursing after the fact but made no formal statement. During an interview on [DATE] at 1:30 PM, the Administrator stated the physical abuse occurred when Certified Nurse Aide #7 sprayed perfume in Resident #1's face. The verbal abuse was when Certified Nurse Aide #7 stated to Certified Nurse Aide #9, in front of Resident #1, they hoped Resident #5 died on the commode. During a phone interview on [DATE] at 2:21 PM, Certified Nurse Aide #9 stated on [DATE] between 4:00 PM - 4:30 PM they told Certified Nurse Aides #7 and #8 they had a few minutes to assist them with Resident #1 as their resident (later identified as Resident #5) was on the commode. Certified Nurse Aide #7 stated, in front of Resident #1, maybe they would get lucky, and Resident #5 would die on the commode. Resident #1 was being combative with care for Certified Nurse Aide #7, and once the resident was placed into their wheelchair, Certified Nurse Aide #7 grabbed Resident #7's (Resident #1's roommate) perfume and sprayed it on Resident #1's clothes. They told Registered Nurse Supervisor #12 about the comment Certified Nurse Aide #7 had stated in front of Resident #1 and how they sprayed perfume on the resident when they were being combative. They also told Registered Nurse #12 that Certified Nurse Aide #8 also wanted to speak with them about the incident. Registered Nurse Supervisor #12 told them they were done with their shift at 7:00 PM. Before Registered Nurse Supervisor #12 left for the evening they saw them at the nurse's station. They did not know if Registered Nurse Supervisor #12 had spoken with Certified Nurse Aide #8. The Director of Nursing called them at home later that evening and asked them what had happened. They gave a handwritten statement about the incident. During an interview on [DATE] at 2:53 PM, Licensed Practical Nurse #13 stated on [DATE] at approximately 7:30 PM Certified Nurse Aide #8 was upset and wanted to tell them about an incident involving Resident #1 and Certified Nurse Aide #7. They told them Registered Nurse Supervisor #12 was supposed to speak with them about the incident but had left at the end of their shift. They told them they saw Certified Nurse Aide #7 spray perfume at Resident #1's face, then changed the story to they had heard them spray perfume at Resident #1 but did not actually see them (Certified Nurse Aide #7) do it. They told Certified Nurse Aide #8 it sounded like abuse, and they needed to call the Director of Nursing. After speaking with the Director of Nursing, they were directed to send Certified Nurse Aide #7 home, which was around 8:00 PM. After Registered Nurse Supervisor #12 left at 7:00 PM, they did not have another nursing supervisor on the nursing home side of the building. If they needed a supervisor, they had to call the hospital side of the building. They had not heard anything on the evening of [DATE] regarding an abuse incident with Resident #2. 2) Resident #2 had diagnoses including osteoarthritis, knee replacement, and Alzheimer's disease. The [DATE] Minimum Data Set documented the resident had severely impaired cognition, used a wheelchair, had lower extremity impairment on one side, was dependent to roll left and right and sit to stand, and did not ambulate. The Facility Accident/Incident Report completed by the Director of Nursing on [DATE], documented on [DATE]:-Resident #2's roommate (later identified as Resident #8, no longer at the facility) stated to staff (later identified as Licensed Practical Nurse #11), that Certified Nurse Aide #7 was rude to Resident #2, telling them they were not going to be doing that up and down thing all night.-The Director of Nursing was notified (by phone) of the incident by Licensed Practical Nurse #13 at 7:49 PM. Certified Nurse Aide #7 was suspended from work (later identified as approximately 8:00 PM). During an interview on [DATE] at 2:53 PM, Licensed Practical Nurse #13 stated they had only been made aware of the incident on [DATE] with Resident #1, and had not heard anything that evening about Resident #2.-A registered nurse assessment by the Director of Nursing was completed on Resident #2 on [DATE] (no time documented).-Nurse Practitioner #16 was notified of the incident by the Director of Nursing on [DATE] at 10:00 AM.-Resident #2's family representative was notified of the incident by the Administrator on [DATE] at 6:00 PM. During a phone interview on [DATE] at 10:37 AM, Certified Nurse Aide #7 stated on [DATE] during the evening shift, they had resident care assignments on both halls of Stillwater Unit. Resident #2 was ringing their call bell numerous times, and they told them they had other residents to care for and they could not keep coming into their room every few minutes to get them in and out of bed. They were told by Licensed Practical Nurse #13 at approximately 8:00 PM they had to go home and that somebody from the facility would be calling them. They were called by the facility on [DATE] to come into the facility on [DATE] for a meeting with Human Resources. They were told they were terminated from employment due to physical and verbal abuse toward Residents #1 and #2. During a phone interview on [DATE] at 11:00 AM, Certified Nurse Aide #10 stated Certified Nurse Aide #7 was assigned to Resident #2 and they were asked to help with putting Resident #2 to bed after supper. During the transfer into bed, Certified Nurse Aide #7 was rough when they put their arm under the resident's arm and when they lifted their legs into bed. Resident #2 stated it hurt and was crying. Certified Nurse Aide #7 stated to the resident they were done with the up and down game and to not get out of the bed. They (Certified Nurse Aide #10) asked Certified Nurse Aide #7 to leave the room. Before Certified Nurse Aide #7 left the resident's room, they went around to the side of the bed, leaned down towards the resident, and stated to them, They had been nothing but nice to them, and they were tired of the up and down game. They asked Certified Nurse Aide #7 to leave the room again, then they reported the incident to Licensed Practical Nurse #11 because they thought it was verbal abuse. Licensed Practical Nurse #11 went into Resident #2's room to speak with them. Resident #2 was upset for the rest of the shift. They did not see a registered nurse assess Resident #2. The registered nurse would have been Registered Nurse Supervisor #12. During an interview on [DATE] at 2:53 PM, Licensed Practical Nurse #13 stated on [DATE] during the evening shift, they were not aware of any incident of abuse towards Resident #2 by Certified Nurse Aide #7. The only incident they were made aware of was with Resident #1, which they reported to the Director of Nursing on [DATE] at 7:49 PM. During a phone interview on [DATE] at 5:35 PM, Licensed Practical Nurse #11 stated they were told by Certified Nurse Aide #10 on [DATE] after 7:00 PM about a verbal incident between Resident #2 and Certified Nurse Aide #7. Certified Nurse Aide #10 told them Certified Nurse Aide #7 was rude and curt with Resident #2 and seemed frustrated the resident kept wanting to get in and out of bed. They asked Resident #2's roommate (Resident #8, no longer at facility) about the verbal incident and it matched what Certified Nurse Aide #10 told them. Certified Nurse Aide #7 was not physically rough with Resident #2, they were just shaming and scolding them. When the incident was reported to them by Certified Nurse Aide #10, Certified Nurse Aide #7 had already been sent home (sent home at 8:00 PM). They did not feel it was verbal abuse, so they did not think it needed to be reported to a supervisor. Registered Nurse Supervisor #12 left at 7:00 PM so there was no supervisor to give a statement to. There was no registered nurse assessment of Resident #2 that evening. If Certified Nurse Aide #7 was physically inappropriate or demeaning to Resident #2, they would have reported it to the Director of Nursing. The Facility Investigation Summary for the [DATE] incidents involving Residents #1 and #2, completed by the Administrator on [DATE], documented:-On [DATE] in the early evening hours, Certified Nurse Aide #7 verbally and physically abused Residents #1 and #2. There was no serious bodily injury to either resident, but both may have suffered psychological harm.-Certified Nurse Aide #7 treated and turned Resident #1 very roughly and sprayed cologne over the resident's head and into their eyes as they were trying to hit and push Certified Nurse Aide #7 away. Certified Nurse Aide #9 came into the room and offered to assist (as their resident was on the commode). Certified Nurse Aide #7 then stated in front of Resident #1, Maybe they will get lucky and (the other resident) will die on the commode.-Certified Nurse Aide #7 was verbally rude to Resident #2, telling them they, Were not going to do this up/down, up/down thing all night! Resident #2 replied they were just trying to get comfortable. The conversation was overheard by Resident #2's roommate.-Certified Nurse Aide #7 was asked to leave the building.-At the close of the investigation it was determined that both physical and verbal abuse had occurred.-Certified Nurse Aide #7 was terminated from employment. During an interview on [DATE] at 4:10 PM the Administrator stated Residents #1 and #2 did not receive registered nurse assessments immediately after their incidents of verbal and physical abuse by Certified Nurse Aide #7 on [DATE]. They also stated the other residents on Stillwater Unit were not assessed by a registered nurse on [DATE] to see if any further abuse by Certified Nurse Aide #7 occurred. They stated they were Registered Nurse Supervisor #12's supervisor. Registered Nurse Supervisor #12 usually worked on the hospital side of the facility, and they did not know for certain if Registered Nurse Supervisor #12 had training as a supervisor for the nursing home side of the facility or if they knew what the expectation was if resident abuse was alleged. 10 New York Codes, Rules and Regulations 415.4(b)(3) Immediate Jeopardy was issued on [DATE] at 3:15 PM. The facility was notified Immediate Jeopardy was lifted as of [DATE] at 3:50 PM based on the following corrective actions:- All staff currently working in the facility (including staff who are employed by the hospital and work on the nursing home side) have been educated on Abuse, Identification of Abuse, and Reporting of Abuse.- 91% of all staff received education as of [DATE], with a plan to provide education to any staff on leave, prior to the start of their shift. - Confirmation of education via staff interviews on [DATE] including nursing staff, activity staff, social work, management, and environmen

Based on record review and interviews during a survey, the facility failed to timely report witnessed verbal and physical abuse for two (2) of four (4) residents (Residents #1 and #2) reviewed, resulting in the alleged perpetrator having continued access to residents. Specifically, on 02/01/2026 at approximately 4:00 PM, Certified Nurse Aide #9 witnessed Certified Nurse Aide #7 handling Resident #1 roughly, spraying them with perfume when they were combative with care, and making a verbally abusive statement. Certified Nurse Aide #9 reported the incident to Registered Nurse Supervisor #12, who did not assess Resident #1. Certified Nurse Aide #7 continued to have access to residents, and after supper, they made a verbally abusive statement to Resident #2, which was witnessed by Certified Nurse Aide #10. Certified Nurse Aide #7 continued to have access to residents until they were suspended from duty on 01/01/2026 at 8:00 PM. Certified Nurse Aide #7 was sent home on suspension at 8:00 PM.The facility's failure to report abuse timely resulted in potential for harm that is Immediate Jeopardy and Substandard Quality of Care and places all 74 residents in the facility at risk for the likelihood of serious injury, serious harm, serious impairment, or death.Refer to F 600 Findings include:The facility policy Abuse Policy - Prevention and Reporting, revised 06/2025, documented when a facility had identified abuse, they must take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. The facility would begin the investigation process immediately upon notification of the incident and would prevent further potential abuse while the investigation was in process. Steps involved in reporting abuse included the shift supervisor/charge nurse was identified as responsible for immediate initiation of the reporting process.1) Resident #1 had diagnoses including aphasia (difficulty speaking), hemiplegia (one-sided paralysis), and anxiety disorder. The 11/09/2025 Minimum Data Set (a resident assessment tool) documented the resident had severely impaired cognition, used a wheelchair, had impairment on one side of their lower and upper extremities and required substantial to maximal assistance for most activities of daily living.The Facility Accident/Incident Report completed by the Director of Nursing on 02/02/2026 for the incident that occurred on 02/01/2026 at 4:00 PM documented:-Licensed Practical Nurse #13 was taking their lunch break (time later identified as approximately 7:30 PM) when Certified Nurse Aide #8 told them Certified Nurse Aide #7 had sprayed perfume in Resident #1's face (witnessed occurrence was 4:00 PM). -The Director of Nursing was notified (by phone) of the incident by Licensed Practical Nurse #13 at 7:49 PM. Certified Nurse Aide #7 was suspended from work (time later identified as approximately 8:00 PM). There was no documented evidence the 4:00 PM witnessed incident was reported immediately to the Nursing Supervisor or Administrator. During an interview on 02/09/2026 at 12:10 PM, the Administrator stated the incident that occurred with Resident #1 on 02/01/2026 at 4:00 PM was not reported to the Director of Nursing until 8:00 PM. They knew they had two (2) hours to report physical abuse and up to 24 hours for all other abuse.During a phone interview on 02/09/2026 at 1:28 PM, Certified Nurse Aide #8 stated on 02/01/2026 at around 4:00 PM, they and Certified Nurse Aide #7 were getting Resident #1 cleaned up before supper. Resident #1 was combative with care. They thought they saw Certified Nurse Aide #7 spray Resident #1 with perfume from their peripheral vision, and they could smell perfume. Certified Nurse Aide #9 came into the room to see if assistance was needed and they saw Certified Nurse Aide #7 spray Resident #1 with perfume. They told Certified Nurse Aide #9 they needed to report the incident to Registered Nurse Supervisor #12. Certified Nurse Aide # 9 left the room at around 4:20 PM to report the incident to Registered Nurse Supervisor #12. Certified Nurse Aide #9 returned to the unit and told them Registered Nurse Supervisor #12 would speak to them after supper about the incident. They reminded Registered Nurse Supervisor #12 again that they needed to speak with them and they told them they would do so before 7:00 PM (when Registered Nurse Supervisor #12's shift ended). Registered Nurse Supervisor #12 left their shift before they spoke with them about the incident. Certified Nurse Aide #7 was still working, and they did not know why. They told Licensed Practical Nurse #13 about the incident at around 7:30 PM. Licensed Practical Nurse #13 stated they thought it sounded like abuse. Licensed Practical Nurse #13 called the Director of Nursing and was given instructions to send Certified Nurse Aide #7 home.During a follow-up interview on 02/09/2026 at 4:10 PM, the Administrator stated Registered Nurse Supervisor #12 should have started the Facility Accident/Incident Report form for the incident that had occurred on 02/01/2026 at 4:00 PM. They did not know if Registered Nurse Supervisor #12 had training as a supervisor on the nursing home side of the building (the facility was part of the hospital) or if Registered Nurse Supervisor #12 knew what was expected of them if abuse was alleged (Registered Nurse Supervisor #12 usually worked on the hospital side of the facility). All staff received annual abuse training.During an interview on 02/10/2026 at 11:15 AM, the Director of Nursing stated on 02/01/2026 Registered Nurse Supervisor #12 texted them before they left their shift (Registered Nurse Supervisor #12's shift ended at 7:00 PM) to update them on their shift. They told them Certified Nurse Aide #9 came to them about perfume sprayed on Resident #1 by Certified Nurse Aide #7, and how Certified Nurse Aide #8 also wanted to speak with them about it. Registered Nurse Supervisor #12 did not say if the perfume was sprayed into Resident #1's face. Registered Nurse Supervisor #12 also told them they looked at Resident #1 and they seemed fine. The Director of Nursing stated Certified Nurse Aide #9 told them they did not see Certified Nurse Aide #7 spray the perfume into Resident #1's face. They did not think there had been any abuse at that time.During a phone interview on 02/10/2026 at 12:27 PM with Registered Nurse Supervisor #12, they stated they worked on 02/01/2026 from 3:00 PM - 7:00 PM on both floors of the nursing home that evening. They usually worked on the hospital side of the facility. Certified Nurse Aide #9 had come to them before supper (before 5:00 PM) to inform them Certified Nurse Aide #7 sprayed perfume on Resident #1 and the resident slapped them away. They were not told about any other abuse issues with Resident #1. They did not think any type of abuse had occurred. They were aware Certified Nurse Aide #8 wanted to speak with them about the incident, but they got busy and left their shift (at 7:00 PM) before speaking with Certified Nurse Aide #8. They had annual abuse training and knew when to call immediately if abuse was suspected. During a phone interview on 02/10/2026 at 2:21, PM Certified Nurse Aide #9 stated they went into Resident #1's room on 02/01/2026 at around 4:00 PM to assist Certified Nurse Aides #7 and #8, as their resident (Resident #5) was on the commode. Certified Nurse Aide #7 then stated, in front of Resident #1, Maybe they will get lucky, and Resident #5 would die on the commode. Once Resident #1, who was being combative with care, was placed in their wheelchair, Certified Nurse Aide #7 sprayed perfume several times onto Resident #1's clothes. They reported the incident to Registered Nurse Supervisor #12 and told them Certified Nurse Aide #8 wanted to speak with them about the incident as well. Registered Nurse Supervisor #12 left their shift around 7:00 PM and never spoke with Certified Nurse Aide #8. During an interview on 02/10/2026 at 2:53 PM, Licensed Practical Nurse #13 stated Certified Nurse Aide #8 came to them on 02/01/2026 at around 7:30 PM to inform them Certified Nurse Aide #7 sprayed perfume at Resident #1 when they were being combative with care around 4:00 PM. They thought it was abuse, so they called the Director of Nursing. Certified Nurse Aide #7 was sent home on suspension at 8:00 PM. 2) Resident #2 had diagnoses including osteoarthritis (breakdown of cartilage in the joints) and Alzheimer's disease (a progressive brain disorder that leads to memory loss and cognitive decline). The 01/22/2026 Minimum Data Set documented the resident had severely impaired cognition, used a wheelchair, had lower extremity impairment on one side, was dependent to roll left and right and sit to stand, and did not ambulate.The Facility Accident/Incident Report for Resident #2 completed by the Director of Nursing on 02/02/2026 documented on 02/01/2026 at supper time: -Resident #2's roommate (later identified as Resident #8, no longer at the facility) stated to staff (later identified as Licensed Practical Nurse #11), that Certified Nurse Aide #7 had been rude to Resident #2, telling them they were not going to be doing that up and down thing all night. -The Director of Nursing was notified (by phone) of the incident at 7:49 PM by Licensed Practical Nurse #13. Certified Nurse Aide #7 was suspended from work (later identified as approximately 8:00 PM. There was no documented evidence the incident was reported immediately to a nursing supervisor or the Administrator on 02/01/2026. The New York State hotline intake for the incident documented the Administrator was made aware of the incident with Resident #2 on 02/01/2026 at 8:18 PM. During an interview on 02/09/2026 at 12:10 PM the Administrator stated the incident that occurred with Resident #2 on 02/01/2026 after supper was not reported to the Director of Nursing until 8:00 PM.During an interview on 02/10/2026 at 2:53 PM, Licensed Practical Nurse #13 stated they only reported the incident with Resident #1 to the Director of Nursing on 02/01/2026 at 7:49 PM. At that time, they were not aware of the incident with Resident #2 on 02/01/2026 after supper. During a phone interview on 02/10/2026 at 5:35 PM, Licensed Practical Nurse #11 stated they were told by Certified Nurse Aide #10 on 02/01/2026 after supper that Certified Nurse Aide #7 was rude, curt, shaming, and scolding Resident #2 because they wanted to keep getting out of bed after being put into bed multiple times. They did not think the incident needed to be reported to a nursing supervisor because Certified Nurse Aide #7 had only been verbally inappropriate like a lot of the certified nurse aides were. If Certified Nurse Aide #7 was physically inappropriate or demeaning, they would have reported it to a nursing supervisor. Registered Nurse Supervisor #12 left their shift at 7:00 PM that evening so they did not have a nursing supervisor to report to. During a phone interview on 02/10/2026 at 11:00 AM, Certified Nurse Aide #10 stated when they were helping with Resident #2's care on 02/01/2026 after supper Certified Nurse Aide #7 was rough with the resident when they were putting them into bed and then told the resident, they were not going to play the up and down game all night. Certified Nurse Aide #10 stated they reported the incident to Licensed Practical Nurse #11 because they thought it was abuse. They were unaware if the incident had been reported to Registered Nurse Supervisor #12. 10 New York Codes, Rules and Regulations 415.4(b)(2)__________________________________________________________Immediate Jeopardy was issued on 02/13/2026 at 3:15 PM. The facility was notified Immediate Jeopardy was lifted as of 02/17/2026 at 3:50 PM based on the following corrective actions:- All staff currently working in the facility (including staff who are employed by the hospital and work on the nursing home side) have been educated on Abuse, Identification of Abuse, and Reporting of Abuse.- 91% of all staff received education as of 02/17/2025, with a plan to provide education to any staff on leave, prior to the start of their shift. - Confirmation of education via staff interviews on 02/17/2026 including nursing staff, activity staff, social work, management, and environmental services.

Based on record review and interviews during the abbreviated survey (IQIES #2626859), the facility failed to ensure residents were free from significant medications errors for one (1) of five (5) residents (Resident #1) reviewed for admission orders. Specifically, Resident #1's hospital discharge medications included an anticoagulant (blood thinner). The medication was not ordered upon admission, and the resident did not receive an anticoagulant from 09/02/2025 - 09/18/2025. Resident #1 was subsequently sent to the hospital and diagnosed with a deep vein thrombosis (a blood clot in a vein). This resulted in actual harm to Resident #1 and the likelihood of serious injury, serious harm, serious impairment, or death that was Immediate Jeopardy and Substandard Quality of Care to resident's health and safety for all residents with potential admission/readmission orders.Findings include:The facility policy Medication Ordering, revised 05/07/2025, documented all medication orders were transcribed into the resident's Medication Administration Records, the medication must include drug name, dosage, route, frequency, start date, and prescriber, and changes to orders must be documented promptly and verified by nursing.The facility policy Medication Transcription, revised 09/15/2025, documented all medication must be transcribed accurately and promptly into the resident's Medication Administration Record by licensed nursing personnel. Transcription must reflect the prescriber's intent. Orders must be received from a licensed prescriber, verbal orders must be transcribed immediately and continued by and countersigned by the prescriber within 48 hours. Electronic orders were reviewed for completeness and clarity. Orders were transcribed exactly as written, including drug names, dosage, route, frequency, and duration. The double check protocol included a second nurse would verify transcriptions of high-risk medications, which included anticoagulants, and any discrepancies would be resolved before administration. All nursing staff would report concerns or errors to the Director of Nursing immediately.The facility policy Anticoagulant Therapy, revised 09/2025, documented anticoagulants were prescribed by a licensed practitioner with appropriate clinical justification. Double check protocols would be followed for high-risk medications and administration times and dosages would match the prescriber's orders exactly.Resident #1 had diagnoses including fractures of the left femur (thigh bone) and left humerus (arm bone), and dislocation of the left shoulder joint. The 09/09/2025 Minimum Data Set assessment (a resident assessment tool) documented the resident was cognitively intact and did not receive an anticoagulant on admission or while a resident at the facility.The 09/02/2025 Hospital Discharge Summary documented the resident was admitted to the hospital with a hip fracture and would be discharged to a skilled nursing facility for rehabilitation. The discharge medication list included Eliquis (anticoagulant) 2.5 milligrams twice daily.The 09/02/2025 Hospital Discharge Medication Reconciliation Order Report documented Eliquis 2.5 milligrams twice daily.A 09/02/2025 at 1:28 PM progress note by Registered Nurse #3, documented Resident #1 was admitted to the facility at 12:10 PM with a diagnosis of left femoral fracture, there was no noted edema (swelling) to their bilateral lower extremities, and the medication reconciliation was completed with Nurse Practitioner #4.A 09/02/2025 at 2:27 PM progress note by Nurse Practitioner #4, documented the resident was admitted to the facility for short term rehabilitation for a fracture of the left femur. The assessment and plan included Eliquis 2.5 milligrams twice daily.There was no documented evidence an anticoagulant was ordered upon admission to the facility.A 09/03/2025 at 2:37 PM progress note by Registered Nurse #3, documented the resident's baseline care plan was reviewed with the resident and they left a copy of the medication list at the resident's bedside.A 09/18/2025 at 11:12 AM progress note by Registered Nurse Manager #15, documented the resident was transferred to the emergency room from their orthopedic specialist appointment for an ultrasound due to edema (fluid build-up) in the lower extremity.The 09/25/2025 Nursing Home Investigative Report submitted to the New York State Department of Health documented Resident #1 was seen for a follow-up orthopedic appointment, complained of edema in their leg and was sent to the hospital and diagnosed with a deep vein thrombosis. Through investigation, it was discovered Registered Nurse #3 did not follow up when they had questions regarding the resident's anticoagulant orders documented on the hospital medication reconciliation order report.During an interview on 10/15/2025 at 3:13 PM, Registered Nurse #3 stated they were the admissions nurse on 09/02/2025 as the regular admission nurse was off. Resident #1 was scheduled to be admitted to the facility that day. On 09/02/2025, prior to the arrival of the resident, they accessed the resident's hospital records. At that time, the Hospital Medication Reconciliation Order Form was marked as completed and the Discharge Summary was not available. When they entered the resident's medications, they questioned an order for Lovenox (an anticoagulant) on the Hospital Medication Reconciliation Order Form, as this was not a medication residents were typically admitted on . They asked the Director of Social Work to reach out to the discharging hospital to clarify the medication orders. They placed a copy of the discharge medication reconciliation order form on Nurse Practitioner #4's desk and did not let them know they had questions regarding the resident's medications. When Resident #1 was admitted to the facility, they did not review the discharge summary or follow up to clarify the resident's medication orders. They were notified Resident #1 was admitted to the hospital on [DATE] from an orthopedics appointment and developed a deep vein thrombosis. They received a disciplinary write up regarding the incident and could not recall if they received any education from the facility regarding the incident.During an interview on 10/16/2025 at 10:09 AM, Registered Nurse Educator #5 stated on 09/25/2025 the Director of Nursing and the facility's Administrator asked them to create education on deep vein thrombosis prophylaxis. On 10/03/2025, they met with the Director of Nursing to review and finalize the education. They started educating the facility's licensed practical nurses and registered nurses on 10/10/2025 and education was ongoing. They did not document when staff completed the education, but had each nurse sign they received the education. Registered Nurse #3 signed they received the education. During an interview on 10/16/2025 at 12:40 PM, admission and Discharge Registered Nurse #6 stated they were off on 09/02/2025 and Registered Nurse #3 filled in for them. The admitting nurse was supposed to review both the medication reconciliation order form and the discharge summary prior to entering the medications into the computer system. They provided a copy of both the medication reconciliation order form and discharge summary to the nurse practitioner, who reviewed the documents and signed the orders. There was a third nurse who reviewed the documents to check for accuracy.During an interview on 10/16/2025 at 1:48, PM the Director of Social Work stated when a resident was admitted to the facility, they printed out the medication reconciliation order forms and discharge summary to give to the admitting nurse. The nurse was also able to access the forms and could print them out as well. At times the admission nurses asked them to reach out to clarify orders and they would put them in touch with the hospital physicians. They could not recall if they provided Registered Nurse #3 with the medication reconciliation order form or discharge summary on 09/02/2025. They thought Registered Nurse #3 accessed that information on their own. They could not recall if Registered Nurse #3 contacted them to reach out for clarification regarding Resident #1's medication orders.During an interview on 10/16/2025 at 3:03 PM, Nurse Practitioner #4 stated the admitting nurse entered the medications and treatment orders into the computer and they reviewed both the discharge summary and medication reconciliation order form and signed the orders entered into the computer. If the admission nurse had questions regarding the orders, they should reach out to the discharging physician for clarification. On 09/02/2025, Registered Nurse #3 was the admitting nurse at the facility and provided them with a copy of the medication reconciliation order form, but did not provide them with a copy of the discharge summary. Registered Nurse #3 entered the medication orders in the computer, and they signed off on the orders. After they completed Resident #1's physical exam, they documented their visit and reviewed the discharge summary from the hospital. They were unsure when they were provided with the discharge summary but reviewed it when they were completing their documentation. They documented in their note the resident was on 2.5 milligrams of Eliquis twice daily, as it was noted on the discharge summary. They did not check to ensure the medications listed on it the discharge summary matched those listed on the medication reconciliation form and did not review those documents against the orders entered into the resident's medical record. They could not recall if Registered Nurse #3 had questions regarding the resident's medications. Resident #1 was sent to the hospital from their orthopedic follow up appointment and it was discovered the resident had not had an anticoagulant for several days.During an interview on 10/17/2025 at 10:39 AM, the Director of Nursing stated when a resident was admitted to the facility, the admission nurse should review both the discharge summary and medication reconciliation order form and enter the orders into the electronic record. The medical providers were supposed to review the discharge summary and medication reconciliation order form along with the orders entered into the medical record and sign them. A third person, typically the evening supervisor, should verify the orders for accuracy using the medication reconciliation order form. On 09/02/2025, the evening supervisor was Registered Nurse #10, and they signed they reviewed the orders. If a nurse had questions regarding the orders, they should reach out to the discharging provider. On 09/19/2025, Nurse Practitioner #4 notified them Resident #1 was admitted to the hospital, had a deep vein thrombosis, and did not receive any anticoagulant medication during their stay at the facility. They alerted the facility Administrator and the discharging hospital's Risk Management Team. The facility started an investigation into the incident when they were notified by the hospital. Their investigation revealed Registered Nurse #3 questioned the medication reconciliation order form from the discharging hospital and did not clarify the orders. The investigation also revealed Hospital Physician #12 made an addendum to the medication reconciliation and did not alert the skilled nursing facility of the change. During an interview with the Administrator on 10/17/2025 at 1:31 PM, they stated Registered Nurse #3 did not follow through when they had questions and was negligent. During an interview on 10/17/2025 at 2:43 PM, Registered Nurse Supervisor #10 stated they worked as the evening supervisor at the facility. Some of their responsibilities included reviewing new orders as the third check. The admission nurse entered the medications and treatment orders into the resident's medical records, and medical providers reviewed and signed the orders. Registered Nurse #10 did not review the discharge summary or the medication reconciliation order forms when completing the third check. They only reviewed the orders in the medical record to ensure if it was the correct resident, right drug, right dose, right route, and right time. They were unaware there were any questions regarding Resident #1's medication orders.During a follow up interview with Nurse Practitioner #4 on 10/17/2025 at 3:09 PM, they stated on 09/19/2025, Physician #12 called them to clarify when the resident last received their anticoagulant medication.During an interview on 10/17/2025 at 5:03 PM, the Medical Director stated medical providers should review the orders entered in the computer and compare them to the hospital medication reconciliation order form and the discharge summary. If there were discrepancies, the admission nurse should alert the medical provider or contact the discharging medical provider to clarify the orders. They were made aware Resident #1 did not receive an anticoagulant during their stay at the facility and developed a deep vein thrombosis but could not recall when. They stated the hospital physician would review each post operative patient and determine anticoagulant medication use on a case-by-case basis. If the discharging hospital physician ordered an anticoagulant medication and the resident did not receive it at the Skilled Nursing Facility, the resident could possibly develop a deep vein thrombosis. They stated the resident might not have developed a vein thrombosis had they been on an anticoagulant medication. 10NYCRR 415.12 (m)(2)The facility has taken the following steps to lift the Immediate Jeopardy in F760, issued 10/17/2025 at 1:36 PM: The facility educated nursing staff to no longer view or print the discharge summary or medication reconciliation order form until a resident was discharged from the hospital. For each new admission/re-admission, medication would be transcribed from the discharge summary/medication reconciliation order form by the admitting nurse, reviewed by the advanced practice provider, a second nurse, the Director of Nursing, and a licensed pharmacist. Plan for immediacy removal was accepted on 10/17/2025 at 6:25 PM. 92% of staff were educated based on education outline as of 10/19/2025 at 1:30 PM. Staff education sign in sheets were reviewed and compared to the current nursing staff list. Staff education was verified during an onsite visit 10/20/2025, multiple staff including licensed nurses and providers were interviewed, no discrepancies identified. Staff were able to report content of education and the facility staff who presented the education. Administrator was notified on 10/20/2025 at 3:42 PM. IJ officially lifted 10/19/2025.

Based on record review and interviews during the abbreviated survey (#2626859) the facility did not ensure a significant medication error was reported to the State Agency as required for one (1) of five (5) residents (Resident #1) reviewed. Specifically, Resident #1's hospital discharge medications included an anticoagulant (blood thinner), the medication was not ordered upon admission to the facility, and the resident did not receive an anticoagulant from 9/2/2025 - 9/18/2025. Resident #1 was subsequently sent to the hospital and diagnosed with deep vein thrombosis (a blood clot in a vein). The facility did not report the incident to the New York State Department of Health in the required time frame.Findings include:The August 2016 New York State Department of Health Incident Reporting Manual documented neglect as the failure to provide timely, consistent, safe, adequate and appropriate services, treatment and/or care to a resident of a residential health care facility while the resident is under the supervision of the facility. Neglect may include but is not limited to failure to carry out physician orders, medication omission, treatment omission or failure to follow the care plan or provide emergency services.The facility policy Abuse Policy-Prevention and Reporting, revised 6/2025, documented the facility would begin the investigation process immediately upon notification of the incident and would prevent further abuse, neglect, exploitation, or mistreatment while the investigation was ongoing. The Administrator, Director of Nursing, or designee would notify the appropriate Agency/ State office according to State specific guidelines for timeliness of reporting as applicable. Resident #1 had diagnoses including fractures of the left femur (thigh bone) and left humerus (arm bone), and dislocation of the left shoulder joint. The 9/9/2025 Minimum Data Set assessment (an assessment tool) documented the resident was cognitively intact and did not receive an anticoagulant on admission or while a resident at the facility.The 09/02/2025 Hospital Discharge Summary documented the resident was admitted to the hospital with a hip fracture and would be discharged to a skilled nursing facility for rehabilitation. The discharge medication list included Eliquis (anticoagulant) 2.5 milligrams twice daily.The 9/2/2025 Hospital Discharge Medication Reconciliation Order Report documented Eliquis 2.5 milligrams twice daily.A 9/2/2025 at 1:28 PM, Registered Nurse #3 progress note documented Resident #1 was admitted to the facility at 12:10 PM with a diagnosis of left femoral fracture, there was no noted edema (swelling) to their bilateral lower extremities, and the medication reconciliation was completed with Nurse Practitioner #4.A 9/2/2025 at 2:27 PM, Nurse Practitioner #4 progress note documented the resident was admitted to the facility for short term rehabilitation for a fracture of the left femur. The assessment and plan included Eliquis 2.5 milligrams twice daily.There was no documented evidence an anticoagulant was ordered upon admission to the facility.A 9/3/2025 at 2:37 PM, Registered Nurse #3 progress note documented the resident's baseline care plan was reviewed with the resident and they left a copy of the medication list at the resident's bedside.A 9/18/2025 at 11:12 AM, Registered Nurse Manager #15 progress note documented the resident was transferred to the emergency room from their orthopedic specialist appointment for an ultrasound due to edema in the lower extremity.The 09/25/2025 Nursing Home Investigative Report submitted to the New York State Department of Health documented Resident #1 was seen for a follow-up Orthopedic appointment, complained of edema in their leg and was sent to the hospital and diagnosed with deep vein thrombosis. Through investigation it was discovered Registered Nurse #3 did ask for clarification when they had questions regarding the resident's anticoagulant orders documented on the hospital medication reconciliation order report.There was no documented evidence the significant medication error was reported to the New York State Department of Health within the required time frame.During an interview on 10/17/2025 at 10:39 AM the Director of Nursing stated they were made aware by Nurse Practitioner #1 on 09/19/2025, Resident #1 had not received any anticoagulant medication and developed a deep vein thrombosis. They alerted the facility Administrator and the discharging hospital's Risk Management Team of the incident. The facility started an investigation when they were notified by the hospital.During a follow up interview with the Director of Nursing on 10/17/2025 at 11:53 AM, they stated the facility's Administrator was responsible for reporting incidents to the New York State Department of Health and was unsure when the incident was reported.During an interview with the facility's Administrator on 10/20/2025 at 2:25 PM, they stated it was their responsibility to report incidents to the New York State Department of Health. They referred to the New York State Department of Health Incident Reporting Manual to determine what incidents to report. They stated any incidents of abuse and neglect, which resulted in physical harm should be reported within 2 hours of being them being notified and 24 hours if there was no physical harm to the resident. The Director of Nursing and themselves worked together completing the investigation. They were notified of the incident with Resident #1 on 9/19/2025. On 9/24/2025, it was determined Registered Nurse #3 never clarified Resident #1's anticoagulant orders and the resident never received an anticoagulant at the facility and was hospitalized with deep vein thrombosis They submitted a report to the New York State Department of Health on 9/25/2025. They stated this was not a timely submission as they were unsure which entity (discharging hospital or the Skilled Nursing Facility) should report the incident. 10 NYCRR 415.4

Based on observations, record review and interviews during the abbreviated survey (NY00383652), the facility did not ensure one (1) of three (3) residents (Resident #1) reviewed received their needed respiratory care. Specifically, Resident #1 had a medical order for oxygen at bedtime, and on 6/13/2025 their oxygen tubing with the nasal cannula was not applied as ordered by Licensed Practical Nurse #3. This resulted in a decrease in Resident #1's oxygen saturation, and they were subsequently transferred to the emergency department to be evaluated for their respiratory distress. Findings include: The 3/6/2025 facility policy, Oxygen Administration, documented the nurse should: - verify a physician's order for oxygen before administration of oxygen; - assess for signs and symptoms of cyanosis (skin, nails and lips turn a blue color due to lack of oxygen in the blood) and hypoxia (low levels of oxygen in body tissues that can cause confusion and difficulty breathing); - check to make sure oxygen tubing was connected to the oxygen source and oxygen turned on; and - place appropriate oxygen delivery device (nasal cannula, mask) on the resident. Resident #1 was admitted with diagnoses including pneumonia and cerebral vascular accident (CVA). The 5/16/2025 Minimum Data Set assessment documented the resident had moderate cognitive impairment, required partial to moderate assistance with personal hygiene and sit to lying, required substantial to maximal assistance to roll left to right, was dependent for sit to stand, was on an antibiotic and used a wheelchair. The resident did not use oxygen therapy. A Physician's Order on 6/10/2025 documented to obtain and send sputum sample, overnight oximetry (non-invasive measurement for oxygen saturation level in the blood) due to hypoxia on room air, and oxygen at 2 liters/minute via nasal cannula for shortness of breath at bedtime. The Comprehensive Care Plan, effective date 6/10/2025 and revised 6/17/2025 documented the resident had pneumonia, and interventions included monitor vital signs as ordered, evaluate for shortness of breath, chest pain and discomfort with breathing or coughing, and administer prescribed antibiotics. The 6/13/2025 Medication Administration Record for oxygen at 2 liters/minute via nasal cannula applied at bedtime was signed as administered by Licensed Practical Nurse #3 at 9:38 PM. A nursing progress note on 6/13/2025 at 10:41 PM by Licensed Practical Nurse #3 documented antibiotics complete, no complaints voiced, condom catheter on, temperature 97.6 degrees Fahrenheit and oxygen saturation 95%. A Physician's Order on 6/14/2025 at 12:10 AM documented to send resident to emergency department for respiratory distress. A nursing progress note on 6/14/2025 at 12:41 AM by Registered Nurse Supervisor #6 documented resident experienced shortness of breath, oxygen saturation was 54% on room air, oxygen increased to 6 liters/minute via nasal cannula, breathing treatment administered and oxygen saturation increased to 80%. The family representative was called and resident was transferred to the emergency department. The facility incident report, dated 6/14/2025, documented: The incident involving Resident #1 occurred at 12:10 AM. The resident was found in their bed short of breath in respiratory distress, without their nasal cannula on, but the tubing was attached to the oxygen regulator on the wall. Their oxygen saturation at the time was 54% and their face was gray in color. Oxygen was increased to 6 liters/minute and a nebulizer was applied. They were coughing up blood-tinged sputum and were unable to speak. The resident was then placed with a non-rebreather mask after the other interventions were attempted and their oxygen saturation did not improve. The resident's representative was notified and medical was notified, and the resident was transported to the emergency department (in the same building as the nursing home). The Emergency Department admission Report dated 6/14/2025 at 12:27 AM documented Resident #1 presented at the emergency department for evaluation due to having an oxygen saturation on room air of 54% and coughing up blood-tinged sputum after receiving a breathing treatment. The resident was currently being treated for aspiration pneumonia. During an interview on 6/26/2025 at 11:50 AM Licensed Practical Nurse #3 stated they were the medication nurse on the evening shift of 6/13/2025 (3 PM - 11 PM). They were not sure what time Resident #1 was put to bed. The resident's oxygen order was to apply oxygen at 2 liters/minute via nasal cannula at bedtime. On the evening of 6/13/2025 they recalled applying the resident's condom catheter (urine collection device) while they were in bed, but they could not recall what time that was or if the resident was wearing their oxygen at that time. The resident was not in respiratory distress when they applied their condom catheter; if they had been, they would have done something about it. No staff approached them about the resident being in respiratory distress. They gave report to oncoming Licensed Practical Nurse #5 and left their shift at 11:00 PM. They were told the next day they were suspended from work pending the facility investigation. They returned to work on Monday, 6/23/2025, and received re-education on oxygen administration and medication administration. During a follow-up interview on 6/26/2025 at 1:04 PM Licensed Practical Nurse #3 restated they could not remember putting Resident #1's nasal cannula on them and turning on the oxygen 6/13/2025. They would know if a resident needed oxygen because it was a medical order and would be documented in the Medication Administration Record (on the computer on the medication cart). The oxygen was on a wall regulator with the oxygen tubing plugged into a port on the wall, and there was a button to push to get the oxygen flowing. Certified Nurse Aides were not supposed to touch the oxygen. During a disciplinary meeting on 6/18/2025 with Human Resources they were told they (Licensed Practical Nurse #3) had signed for Resident #1 wearing their oxygen on 6/13/2025 at 9:38 PM but the resident was found by night shift staff not wearing their nasal cannula, which resulted in them not receiving oxygen and in respiratory distress. They stated they typically would apply the oxygen at the same time as applying the resident's condom catheter. It was a very busy shift on 6/13/2025. During an interview on 6/26/2025 at 4:06 PM Certified Nurse Aide #4 stated they worked the night shift on 6/14/2025 (11:00 PM - 7:00 AM). They were doing their first rounds on the unit when, around midnight, they found Resident #1 in respiratory distress. The resident was sitting up in their bed, but they could not remember if the resident was wearing their oxygen tubing with nasal cannula or not. They notified Licensed Practical Nurse #5 about Resident #1's respiratory distress. A few minutes later they saw Registered Nurse Supervisor #6 go into the resident's room with Licensed Practical Nurse #5 to assess the resident. During an interview on 6/27/2025 at 3:58 PM Registered Nurse Supervisor #6 stated on the night of 6/14/2025 they were in another resident room when Certified Nurse Aide #4 was calling out for help with Resident #1 and stating they were not breathing right. They brought the vital signs machine to Resident #1's room because they remembered a week earlier the resident had a similar episode with respiratory distress, and the resident currently had a diagnosis of pneumonia. When they got to the room the resident was struggling to breathe. When they checked the resident's oxygen saturation it was 54% on room air. They reached for the resident's nasal cannula and oxygen tubing which were tangled and on top of the oxygen humidifier and regulator on the wall. The oxygen and humidifier were not turned on. They turned on the dial to the regulator and it was in working condition. They turned the oxygen to 2 liters/minute. At the time they did not know what the resident's oxygen orders were and 2 liters/minute was the normal starting rate. When the 2 liters of oxygen did not improve the resident's breathing they increased the oxygen to 6 liters/minute and had Licensed Practical Nurse #5 start a breathing treatment for the resident. After that, they applied a non-rebreather mask and called the emergency department on the phone right outside the resident's room. They had been instructed by the facility if a resident was in respiratory distress to call the emergency department immediately to let them know a resident was being transported to them. They called the resident's family representative and informed them of the resident's transport to the emergency department. They called the on-call Medical Provider after the emergency department transport to inform them of the situation. Licensed Practical Nurse #3 was probably very busy during their shift, had many interruptions, and forgot to apply the oxygen to Resident #1. During an interview on 6/27/2025 at 4:55 PM the Director of Nursing stated during the facility investigation of the 6/14/2025 incident, they obtained a verbal statement from Licensed Practical Nurse #3 admitting to signing for the administration of oxygen but forgetting to apply the oxygen tubing and nasal cannula on the resident and turning the oxygen on. Licensed Practical Nurse #3 had signed for applying both the condom catheter and oxygen on 6/13/2025 at 9:38 PM. During an interview with the Administrator on 6/30/2025 at 11:09 AM they stated they were first notified of the incident with Resident #1 on 6/14/2025 at 2:20 AM by a text message from Registered Nurse Supervisor #6. Licensed Practical Nurse #3 forgot to put the nasal cannula on the resident and turn the oxygen on; they had many things going on that shift. Licensed Practical Nurse #3 was suspended from work in the morning on 6/14/2025 pending the facility investigation, and had re-education of oxygen and medication administration when they returned to work. Resident #1 had recurring aspiration pneumonia and had been on several courses of antibiotics prior to the 6/14/2025 incident. Resident #1 was re-admitted back to the facility on 6/18/2025 with a diagnosis of pneumonia. 10 NYCRR 415.12(k)(6)

Based on observations, record review, and interviews during the abbreviated survey (NY00381595), the facility did not ensure allegations of abuse and neglect were thoroughly investigated for 4 of 4 residents (Residents #1-4) reviewed. Specifically, the facility investigation was not thorough and did not identify concerns related to: -Resident #1's roommate (Resident #2) alleged on 5/19/2025 Certified Nurse Aides #1 and 2 yelled at Resident #1 while providing care. There was no documentation Resident #1 was assessed by a qualified professional, Certified Nurse Aides #1 and 2 continued to work at the facility after the allegation was made, and there was no documentation the Administrator was notified of the allegation. -Resident #2 reported on 5/19/2025, they developed a headache due to Certified Nurse Aides #1 and 2 yelling at Resident #1 and they (Resident #2) required a pain-relieving medication for the headache. There was no documentation Resident #2 was assessed by a qualified professional. - Certified Nurse Aide #6 reported while they provided care to Resident #3 on 5/19/2025, Certified Nurse Aides #1 and 2 yelled and used profanities in Resident #3's room, and Resident #3 was upset by the incident. There was no documentation Resident #3 was assessed by a qualified professional. -Resident #4 shared a room with Resident #3 and was in the room at the time of the incident on 5/19/2025 and there was no documentation Resident #4 was assessed by a qualified professional. Additionally, the incidents were not reported timely to the New York State Department of Health as required. Findings include: The 2/2025 facility policy, Abuse Policy-Prevention and Management documented the Shift Supervisor was responsible for immediate initiation of the reporting process. The Administrator, Director of Nursing, and Risk Manager, if applicable, were responsible for investigation and reporting. The facility provided for the immediate safety of the resident upon identification of suspected abuse. They examined the alleged victim for signs of injury, including physical exam or psychosocial assessment if needed. The facility would begin the investigation process immediately and the findings recorded in the resident's record. The Administrator, Director of Nursing/designee were responsible for completion of investigative paperwork, interviewing persons reporting the incident, interviewing witnesses, interviewing the resident and resident roommate and interviewing other residents to which the accused employee provided care/services. Any time an allegation involving abuse that named a specific employee, the employee was suspended until the completion of the investigation. The employee was not to remain on duty and was not to be assigned to any other area of the facility. The facility reported abuse timely within the Federal/State requirements. Resident #1 had diagnoses including Alzheimer's disease. The 5/8/2025 Minimum Data Set assessment documented the resident's cognition was severely impaired. Resident #2 had diagnoses including anxiety and depression. The 5/7/2025 Minimum Data Set assessment documented the resident's cognition was intact. Resident #3 had diagnoses including chronic heart failure. The 5/8/2025 Minimum Data Set assessment documented the resident's cognition was intact. Resident #4 had diagnoses including dementia. The 2/26/2025 Minimum Data Set Assessment documented the resident's cognition was severely impaired. Statements completed on 5/19/2025 documented: -Licensed Practical Nurse #3 was told by Resident #2 Certified Nurse Aides #1 and 2 were yelling at Resident #1 during care and the yelling gave Resident #2 a headache. The curtains were left open during care and Resident #2 witnessed the incident. Resident #2 was given pain reliever and Licensed Practical Nurse #3 reported Resident #2's statement to Registered Nurse Supervisor #4. - Certified Nurse Aide #6 was in the bathroom providing care to Resident #3 when Certified Nurse Aides #1 and 2 entered the room and began cursing and talking loud about another resident. The three aides exited the room into the hall where Certified Nurse Aide #1 continued to talk loudly and told Licensed Practical Nurse #7 they would quit their job. Resident #3 later reported to Certified Nurse Aide #3 they were upset by the incident with the aides and Licensed Practical Nurse #7 and Registered Nurse Supervisor #4 were notified. There was no evidence of staff statements from Certified Nurse Aides #1 or 2, or from Licensed Practical Nurse #7 on 5/19/2025. The 5/19/2025 at 10:16 PM Medication Administration Record documented Resident #2 received acetaminophen (pain reliever) 650 milligrams for headache. The 5/19/2025 at 10:50 PM Registered Nurse Supervisor #4's email to the Director of Nursing documented Licensed Practical Nurse #3 reported Resident #2 complained about Certified Nurse Aides #1 and 2 and they left Licensed Practical Nurse #3's statement for the Director of Nursing to review. Certified Nurse Aide #6 overheard Certified Nurse Aides #1 and 2 using foul language in Resident #3's room and Resident #3 was upset. Licensed Practical Nurse #7 overheard conversations between Certified Nurse Aides #1 and 2 and they would provide a statement. There was no documented evidence of a statement provided by Licensed Practical Nurse #7. There was no documented evidence Registered Nurse Supervisor #4 assessed Residents #1, 2, 3 or 4 (roommate of Resident #3 present in the room during the incident) after the incidents, no evidence Certified Nurse Aide #1 and 2 were suspended, and the incident was not reported to the Administrator. Certified Nurse Aide #1's timesheet documented they worked at the facility on 5/21 and 5/22/2025. Certified Nurse Aide #2's timesheet documented they worked at the facility 5/20, 5/21, 5/22 and 5/23/2025. On 5/24/2025, Certified Nurse Aide #1 was terminated. Certified Nurse Aide #2 continued to work at the facility. The 5/27/2025 at 4:39 PM Director of Social Services note documented on 5/23/2025, they received an email from the family of Resident #1 with concerns Resident #1 was involved in an incident with suspicion of abuse. The Director of Social Services was not informed of any incident prior to receipt of the email. Information from resident interviews they completed on 5/23/2025 included: - Resident #2 reported their roommate (Resident #1) was being provided care by Certified Nurse Aide #1 and an unknown aide (later identified as Certified Nurse Aide #2). Resident #2 witnessed the incident because the curtain was left open. Resident #1 was not being cooperative and Certified Nurse Aide #1 was being aggressive with turning and lifting the resident, pushing on the resident and lifting them off the bed. Profanities were used by Certified Nurse Aide #1. - Resident #1 was not able to recall details of the incident. - Resident #3 reported their aide (Certified Nurse Aide #6) was caring for them and 2 other aides came in their room and were swearing while talking to their aide. Resident #3 stated they were not swearing at them (Resident #3) but having a conversation about others and swearing and talking. The 5/27/2025 Certified Nurse Aide #2's statement (8 days after the incident) documented on 5/19/2025, they were providing care to Resident #1 with Certified Nurse Aide #1 when they (Certified Nurse Aide #2) accidentally said a curse word two times. They knew they should not have cursed and turned themselves in to the Director of Nursing the following day. They never cursed in Resident #3's room and Certified Nurse Aide #1 cursed in Resident #3's room. Certified Nurse Aide #2's statement did not document what they observed during care with Resident #1 and Certified Nurse Aide #1 on 5/19/2025. On 5/29/2025, Registered Nurse Managers and Supervisors received education regarding abuse reporting and the New York State Incident Reporting Manual. On 5/30/2025, Resident #1 was observed in their wheelchair in their room. The resident smiled when asked questions, did not respond to questions when asked, and appeared confused. On 5/30/2025, Certified Nurse Aide #2 received counseling regarding using inappropriate language. During an interview on 6/2/2025 at 9:20 AM, Resident #2 stated they did not recall the date of the incident. The curtain was open between their bed and Resident #1's bed while Certified Nurse Aide #2 and an unknown aide (Certified Nurse Aide #1) provided care to Resident #1. When the aides were changing Resident #1, the aides seemed rough, lifting the resident up. The aides were cursing, and Resident #1 seemed agitated. They (Resident #2) requested acetaminophen because they had a headache from all the yelling. They had conversations regarding the incident including the social worker and the Director of Nursing a couple of days after the incident. During an interview on 6/2/2025 at 10:15 AM, Certified Nurse Aide #2 stated on 5/19/2025, they and Certified Nurse Aide #1 were providing incontinence care to Resident #1. When they rolled the resident over, they pulled a muscle in their back and said a curse word out loud. The curse was not directed at the resident. They did not recall exactly what Certified Nurse Aide #1 said during care, however they were typically a loud talker and they were cursing about something not related to the resident. They did not report their own inappropriate language until the next day when they self-reported to the Director of Nursing they used foul language in the resident's room. They could not recall why they completed their statement 8 days after the incident. During an interview on 6/2/2025 at 12:45 PM, Certified Nurse Aide #6 stated on 5/19/2025 around 7:30 PM, they were assisting Resident #3 in the bathroom. Certified Nurse Aides #1 and 2 entered Resident #3's room and were yelling and cursing about something unrelated to Resident #3. Certified Nurse Aide #6 told the aides to leave the room. After they left the room, Licensed Practical Nurse #7 heard Certified Nurse Aide #1 cursing and told them they were being unprofessional. Licensed Practical Nurse #7 also spoke with Certified Nurse Aide #2. Licensed Practical Nurse #7 reported the incident to Registered Nurse Supervisor #4. During an interview on 6/2/2025 at 1:12 PM, Licensed Practical Nurse #3 stated on 5/19/2025, Resident #2 rang their call bell, asked for acetaminophen and said they had a bad headache. Licensed Practical Nurse #3 thought the resident looked upset and asked what was wrong. The resident reported 2 aides were providing care to Resident #1, they did not pull the privacy curtain, and they were screaming at Resident #1 because Resident #1 was not cooperating. Resident #2 did not allege any physical abuse and only discussed privacy concerns and yelling. Licensed Practical Nurse #3 reported the conversation with Resident #2 to Registered Nurse Supervisor #4 and asked them to see Resident #2. It was towards the end of shift, and they did not believe the supervisor saw the resident. Registered Nurse Supervisor #4 asked Licensed Practical Nurse #3 to provide a statement. During an interview on 6/2/2025 at 3:05 PM, Registered Nurse Supervisor #4 stated on 5/19/2025 around 7 PM, they assessed Resident #3 after the resident alleged Certified Nurse Aides #1 and 2 were cursing in their room (there was no documented evidence of an assessment). Around 10:50 PM, they were notified by Licensed Practical Nurse #3 that Resident #2, who was alert and oriented, heard 2 aides using foul language while providing care to Resident #1. They did not assess Resident #1 or 2 because it was the end of their shift. They did not suspend the aides because they were not sure if they could suspend them. They sent a text message and email the Director of Nursing that night regarding the incidents and thought by morning, the Director of Nursing would be aware and address the situation accordingly. On 6/3/2025 at 2 PM, Certified Nurse Aide #1 was not reached in an interview. During an interview on 6/4/2025 at 9:15 AM the Director of Nursing stated when an abuse allegation was made, the resident needed to be assessed, an incident report started, statements obtained immediately, and accused staff suspended. The Administrator would be notified of the allegation. They first became aware of the incident on 5/20/2025 when they received a vague email from Registered Nurse Supervisor #4 and a few statements that they reviewed from staff. They read the staff statements and immediately forwarded the email and statements to their Human Resources Department. They spoke with Resident #2 that morning who gave a very different report. Resident #2's main concern was Resident #1 being put to bed early at 6:30 PM on 5/19/2025. Resident #2 reported the aides were swearing while providing care to Resident #1 though the swearing was not directed at the resident. Nothing Resident #2 stated to the Director of Nursing seemed abusive. They asked Resident #2 about the curtain not being pulled and they stated the curtain was pulled but when the aides were moving about the room, and the curtain moved enough to see the incident. The Director of Nursing stated when Resident #1 was resistive to care, the aides should have left the room and reapproached later. When Resident #2 developed a headache from the aides yelling in their room, they did not consider that abuse and when they interviewed Resident #2, the resident did not report this to them. Resident #1 should have been assessed on 5/19/2025 by Registered Nurse Supervisor #4 when the allegation of abuse was made. Resident #3 should have also been assessed for the reaction they had to the aides cursing in their room. They were not aware any of the residents were not assessed. In retrospect, they (the Director of Nursing) should have notified the Administrator of the incident and they did not. All registered nurses were re-educated on the abuse reporting process. When the email of abuse from Resident #1's family was received on 5/23/2025, that was when the Administrator became aware. They were aware Certified Nurse Aide #2 continued to work and Certified Nurse Aide #2 was given a directive to not work with Resident #1. Both Certified Nurse Aide #1 and 2 should have been suspended on 5/19/2025. They did not remove the staff when they became aware of the incident on 5/20/2025 because they were going by Human Resources directives. During an interview on 6/4/2025 at 9:45 AM, the Administrator stated they expected to be notified when there was an allegation of abuse, and they would notify the Department of Health within 2 hours. Resident assessments were needed as well as staff statements and any accused staff suspended. On 5/23/2025, they first became aware of the incident when it was reported an email was received from Resident #1's family regarding abuse. They filed a report with the Department of Health on 5/23/2025. On 5/19/2025, Registered Nurse Supervisor #4 should have contacted them about the incidents and did not. They would have directed them to gather statements, and the accused staff would have been suspended. When they became aware of the incident on 5/23/2025, they felt Certified Nurse Aide #1 verbally abused Resident #1. Resident #2 reported Certified Nurse Aide #2 did not curse and the Administrator did not consider suspension at that time. When Resident #1 became agitated with care on 5/19/2025, both Certified Nurse Aides #1 and 2 should have stopped and reapproached and they did not do that. They were not sure if Certified Nurse Aide #2 was re-educated about reapproaching when a resident was agitated with care. They stated the facility did not thoroughly investigate the incidents, the incident was not investigated timely, and it was not reported timely. During an interview on 6/4/2025 at 2:10 PM, Resident #3 stated they were not afraid when the incident occurred with Certified Nurse Aides #1 and 2 however, they did not feel good about it. Their roommate (Resident #4) was also in the room at the time of the incident. On 6/4/2025 at 2:13 PM, Resident #4 was observed in their bed across from Resident #3. The resident was unable to respond to questions. 10NYCRR 415.4(b)(2-3)

Based on observation, interview, and record review 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 the main kitchen. Specifically, the main kitchen had multiple unclean areas, expired food, and unwrapped and undated food. Findings include: The facility policy, Food Storage, dated ,d+[DATE] documented food and supplies would be received and stored properly by the general kitchen worker. Food was rotated so the first food in was the first food out. The facility policy Infection Control for nutritional services dated ,d+[DATE] documented the work area was kept clean and sanitary. All work surfaces, except the cooking surface, and all floors in the Nutritional Services food preparation area were cleaned daily with an approved disinfectant. Storage areas shall be adequate, cleaned thoroughly weekly, and inspected daily by the Director of Nutritional Services. All refrigerator units were cleaned thoroughly weekly. Food stored in opened original containers must be covered and dated. The following observations were made in the main kitchen on [DATE]: - at 9:41 AM, the kitchen hoods were soiled and unclean with grease buildup over the stove top. Food debris was on the floor and under the cooking area. - at 9:44 AM, there was grime and grease buildup on the back wall and the floor surrounding the deep fryer. Food debris was on the floor under the fryer including 2 chicken tenders and French fries. - at 9:47 AM, the cooking area cooler had 4 undated wrapped sandwiches. - at 9:50 AM, the walk-in meat cooler had food debris on the floor under the food storage racks. An undated hotel pan of cooked ground beef was on the bottom shelf covered with plastic wrap. Manager of Nutrition #7 stated they thought it was cooked that morning and they would put a date on it immediately. - at 10:00 AM, the walk-in freezer ceiling had dripping condensation throughout the cooler and ice buildup in the corners of the ceiling. - at 10:02 AM, the food storage rack had 4 gallon jugs of apple cider vinegar that expired ,d+[DATE], and a 1 gallon jug of apple cider that expired ,d+[DATE]. Manager of Nutrition Services #7 stated they did not realize the vinegar was expired. - at 10:09 AM, the food storage rack had 11 packages of hot dog rolls that expired on [DATE], and 1 package of hot dog rolls that expired on [DATE]. 6 of the expired packages had green mold spots on the underside of the rolls. - at 10:10 AM, the food storage rack had 5 packages of dinner rolls that expired between [DATE] and [DATE]. 2 of the expired packages had green mold spots. - at 10:29 AM, the food storage area walk-in cooler rack had a plastic covered storage bin filled with large packages of shredded lettuce and spinach. 2 packages of lettuce were brown and filled with a tan liquid, and a soft and mushy cucumber was at the bottom of the bin. - at 10:38 AM, the metal cart washroom floor was wet and had food debris, and the hose handle was on the floor by the doorway. Manager of Nutrition Services #7 stated the hose handle should have been kept on the wall mount and not on the dirty floor. During an interview at [DATE] at 10:36 AM, Manager of Nutrition Services #7 stated they were ultimately responsible for maintaining a clean kitchen. They stated a janitor was scheduled to clean the kitchen and the kitchen floors every night. If something was spilled in the refrigerator, the person who spilled the item was responsible for cleaning it. Their assistant was responsible for completing the inventory and ordering twice a week. The stock person should date the inventory, rotate the inventory, and put it away. Staff were educated to discard dented cans and moldy food items. The Assistant Manager of Nutrition Services should catch any items missed by staff. Food should be labeled with the date to prevent potentially hazardous food from reaching the resident. Moldy food should always be discarded because if it was eaten, the resident could become sick. Grease on equipment should be cleaned by the cook. 10NYCRR 415.14(h) 48895

Based on observation and interview during the recertification survey conducted 9/3/2024-9/6/2024, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 1 of 2 medication rooms (Interlaken). Specifically, the Interlaken medication room refrigerator temperatures were not consistently documented. Findings include: The facility policy, Medication Refrigerator Temperature Logs, created 12/2019, documented medication refrigerator temperatures were documented once in the morning and once in the evenings. If the refrigerator temperature was above 46 degrees Fahrenheit or below 36 degrees Fahrenheit both maintenance and the Director of Nursing should be notified. During an observation on 9/3/2024 at 2:11 PM the Interlaken medication room refrigerator did not have documented temperatures for the day shifts on 8/6/2024, 8/7/2024, and 8/12/2024; and for the evening shifts on 8/3/2024, 8/4/2024, 8/5/2024, 8/6/2024, and 8/11/2024. During an interview on 9/6/2024 at 8:30 AM, Licensed Practical Nurse #4 stated medication refrigerator temperatures were taken and documented twice a day to ensure medications were stored at proper temperatures. On 9/3/2024 at 2:11 PM they noticed many missing dates for 8/2024. The 8/2024 log was no longer in the refrigerator log binder. During an interview on 9/6/2024 at 9:36 AM, Registered Nurse Unit Manager #3 stated refrigerator temperatures were monitored to make sure medications were stored at proper temperatures and the temperature was recorded on a log twice a day. If medication temperatures were out of range medications should not be used. If medication refrigerator temperature checks were not completed there would be no way to know if the temperatures were within an acceptable range. They noticed multiple missing temperatures on the refrigerator temperature log the last day or two. They filled in the temperature for multiple missing dates and should not have. They were not sure why they documented refrigerator temperatures when they did not know the actual temperatures and the temperatures could not be verified. During an interview on 9/6/2024 at 10:30 AM, the Administrator stated refrigerator temperatures were monitored and documented twice a day because certain medications had to be stored at certain temperatures to ensure effectiveness. If the refrigerator temperatures were not monitored, the medications in the refrigerator should not be administered to residents. They did not expect medication room refrigerator temperatures to be documented days later when temperatures were unknown. 10NYCRR 483.45 (g)(h)

Based on observation, interview, and record review during recertification survey conducted 9/3/2024-9/6/2024, the facility did not provide each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional needs, taking into consideration the preferences of each resident for 2 of 3 residents (Resident #29 and #50) reviewed. Specifically, Residents #29 and #50 were missing food items or had the wrong items on their meal trays. Findings include: The facility policy, Meal Tray Accuracy, dated 12/2022, documented residents were provided with appropriate supplements, adaptive equipment, and items requested at mealtimes within the current diet order to ensure accuracy of residents' meal trays. 1) Resident #29 had diagnoses including tachycardia (fast heartbeat), anxiety, and hypertension (high blood pressure). The 6/22/2024 Minimum Data Set assessment documented the had severe cognitive impairment, was dependent on staff with eating, and weighed 112 pounds. A 6/7/2024 Physician #10 order documented the resident was to receive a ground solid diet. The comprehensive care plan initiated 3/17/2023 and revised on 8/7/2024 documented the resident was at risk for an alteration in nutritional status related to dysphagia (difficulty swallowing), decreased mobility, and age, and required assistance with feeding. Interventions included a ground solid diet with honey thickened liquid, 2 handled cups for beverages, fortified potatoes daily, weekly weights due to significant weight loss, and quarterly nutritional assessments. The 7/5/2024 progress note by Registered Dietitian #9 documented Resident #29 lost 5 pounds in the last month. They recommended weekly weights, added fortified potatoes daily, and Ensure Compact (nutritional supplement) twice daily. During an observation and interview on 9/4/2024 at 12:52 PM the resident's lunch meal included 2 ounces ground meatloaf with piquant sauce, 4 ounces diced pears, 4 ounces creamed corn, 4 ounces water, 4 ounces apple juice, and 4 ounces milk. Fortified potatoes were listed on the meal ticket and were not on the tray. Certified nurse aide #6 stated the fortified potatoes were missing from the tray and they did not request them from the kitchen. 2) Resident #50 had diagnoses including obesity, insulin dependent diabetes, and dysphagia (difficulty swallowing). The 6/29/2024 Minimum Data Set assessment documented the resident was moderately cognitively impaired and was independent with eating. A 1/16/2023 Physician #10 order documented the resident was to receive a regular diet. The comprehensive care plan initiated 4/11/2023 and revised on 8/26/2024 documented the resident was at risk for elevated blood sugars due to diabetes mellitus. Interventions included a dietary consult, monitoring for signs and symptoms of high and low blood sugars, administration of insulin based on the blood sugar, and honoring preferences for snacks within diet restrictions. During an interview on 9/3/2024 at 12:51 PM, Resident #50 stated the food was not hot and lacked flavor. During an observation on 9/4/2024 at 12:43 PM, Resident #50's lunch meal tray was used as a test tray and a replacement was requested. The tray was missing the low calorie cranberry juice and yogurt. The tray had Pepsi and the meal ticket documented Diet Pepsi. The yogurt was on ice in the meal cart and provided to the resident. The replacement tray did not include low calorie cranberry juice. The corn was overcooked and dry. The outer casing had a plastic-like texture and was difficult to chew. During an interview on 9/5/2024 at 9:43 AM, Certified Nurse Aide #6 stated meal trays were often missing items or had the wrong items. If a resident's tray was missing an item, staff should catch it and notify the kitchen staff to bring the item. They stated they were not sure why Resident #29 got fortified mashed potatoes, but they should have notified the kitchen staff they were missing from the resident's tray on 9/4/2024. During an interview on 9/5/2024 at 10:09 AM Licensed Practical Nurse #4 stated meal trays were often missing items or had the wrong items. They stated fortified potatoes ordered for residents because they required extra nutrients and calories. Fortified potatoes were ordered for residents who were losing weight. If the resident did receive them, they might not meet their caloric needs. During an interview on 9/6/2024 at 9:36 AM, Registered Nurse Unit Manager #3 stated when residents got the wrong items or missing items on their meal trays the kitchen staff should be notified. During an interview on 9/6/2024 at 10:35 AM, Registered Dietitian #9 stated they expected trays to have all items listed on the resident's meal ticket. The meal ticket was initially checked for accuracy by the server and double checked by staff bringing trays to the residents. If something was missing from a tray staff should notify the server and if it was not available from the unit kitchen area, the server should call the main kitchen. If a resident did not get their fortified potatoes, they were not receiving the calories, protein and nutrients needed and may have weight loss and delayed wound healing. They stated Resident #29 received fortified potatoes because their weight was down, and the resident usually ate the potatoes because they liked them. A diabetic should Diet Pepsi because there were more carbohydrates and calories in the regular Pepsi. It was important to give Resident #50 Diet Pepsi as that was their preference. 10NYCRR 415.14 48895

Based on observation, interview, and record review during the recertification survey conducted 9/3/2024-9/6/2024, the facility did not ensure the Director of Nursing served as a unit manager only when the facility had an average daily occupancy of 60 or fewer residents. Specifically, Acting Director of Nursing #2 served as the Unit Manager for the Stillwater Unit in addition to their full time Director of Nursing role. The findings are: The undated facility Director of Nursing job description documented the Director of Nursing had the authority and responsibility for planning, directing, and supervising all nursing personnel and services to ensure that safe, adequate, and quality care was delivered to all residents. Additionally, the Director of Nursing supported the vision of uncompromising dedication to excellence in assisting the community members to grow in spirit, experience dignity, live with a sense of fulfillment, and meet the challenges of their changing lives. The undated Facility Unit Manager job description documented the Unit Manager reported to the Director of Nursing and was responsible for direction of resident care in the skilled nursing setting. Additionally, they managed licensed personnel, consulted with staff, physicians, and management team on nursing problems and interpretation of policies to ensure resident needs were met, and maintained performance improvement activities within the department, participated in continuous quality improvement activities, and assisted in formulating budget. The facility census at the time of survey entrance on 9/3/2024 at 10:22 AM was 75 residents. The facility list of key personnel received 9/3/2024 at 12:18 PM documented Acting Director of Nursing #2 was the Unit Manager for the Stillwater Unit. During observations and interview on 9/3/2024 at 12:47 PM and 9/4/2024 at 9:54 AM, Acting Director of Nursing #2 was on the Stillwater unit and identified themselves as the Acting Director of Nursing and the Unit Manager for the Stillwater Unit. During an interview on 9/6/2024 at 9:09 AM, Administrative Coordinator #8 stated Acting Director of Nursing #2 was also the Unit Manager for the Stillwater unit. They stated Acting Director of Nursing #2 had been in the role of Acting Director of Nursing for about 10 months. During an interview on 9/6/2024 at 10:25 AM, the Acting Director of Nursing #2 stated they functioned in two roles as both the Unit Manager and the Acting Director of Nursing role since 12/5/2023. They accomplished the responsibilities for both roles by working 10-11 hours every day. There were no nurse waivers at this time. They stated they accepted the Assistant Director of Nursing position as of 9/9/1024 and the Director of Nursing position had not yet been posted. During an interview on 9/6/2024 at 10:30 AM, the Administrator stated Acting Director of Nursing #2 had been in the position since December 2023. They were unaware Acting Director of Nursing #2 was listed as both the Acting Director of Nursing and the Unit Manager of Stillwater and stated that was an error. 10 NYCRR 415.13(b)(1) 48895

Based on observation, interview, and record review during the recertification survey conducted 10/11/22-10/14/22, the facility failed to provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse for 1 of 3 medication carts (the stepdown unit medication cart) reviewed. Specifically, all prescribed controlled drugs on the stepdown unit were stored in an untethered medication cart and not in a permanently affixed compartment as required. Findings include: The 12/10/2020 facility policy addendum titled Medication Administration/Storage--Covid documented narcotics would be removed from the medication lock box in med room for individual med pass and placed back in the lock box in the medication room in lock box designated per hall for C hall and top of A hallway following completion of medication pass. Step down narcotics will follow the same medication count each shift, however, they will remain in step down medication cart. Medication carts will be locked and tethered to the wall when not in use. During an observation on 10/12/22 at 3:27 PM, the medication cart for the step down hall of Stillwater unit was locked, the narcotic box was locked, and the cart was not tethered to the wall. At the time of the inspection the cart was not in use and was not tethered to the handrail. The medication cart contained the following controlled drugs: 32 tablets of [MEDICATION(S)]/APAP (opioid pain killer with acetaminophen) 5/325 milligrams (mg), 52 tablets of [MEDICATION(S)] (opioid pain killer) 2.5 mg, 34 tablets of [MEDICATION(S)] (antianxiety) 0.25 mg, 12 tablets of [MEDICATION(S)] (sedative) 5 mg, 16 tablets of [MEDICATION(S)] (antianxiety) 0.5 mg, 30 vials of [MEDICATION(S)] (opioid) 20mg/ml, and 27 tablets of [MEDICATION(S)] 5 mg. During an interview on 10/12/22 at 3:30PM, licensed practical nurse (LPN) #1 stated all narcotics for the step down hall were kept in the cart. The cart was supposed to be locked and tethered to the handrail when it was not in use. LPN #1 locked the cart to the handrail at the time of inspection. They stated the narcotic box contained drugs that were not needed for the shift and only narcotics needed for the current medication pass should be in the cart. They were not sure why all the narcotics were stored in the cart. They stated possible medication diversion was the reason the cart should be locked to the wall. During an interview on 10/12/22 at 3:34 PM, the registered nurse (RN) Unit Manager #2 stated they believed only the narcotics needed for the current shift should be in the medication cart. They stated the cart was supposed to be locked to the wall when not in use. They were not sure why it was not locked at the time of the observation. The danger of narcotic diversion was the reason for the recommended locking of the cart. During an interview on 10/14/22 at 11:09 AM, the Director of Nursing (DON) stated narcotics were kept in medication storage rooms and required a 2 nurse count for the transfer of keys for the storage cabinet. The nurses were to only take what was needed for their medication pass and return to the locked storage after the medication pass. Narcotics were kept under triple lock, in the locked medication room and double locked cabinet. Narcotics should not be left in the medication cart when not in use, the only exception was the stepdown cart. During COVID-19 the stepdown hall was used for isolation. The narcotics were stored in the medication cart to prevent the nurse from having to go back and forth from the hallway. The facility added a third medication cart, but only had two narcotic lock boxes (permanently affixed) in the medication storage room. They did not want 2 nurses to have to share responsibility for one med closet. The expectation was for the stepdown medication cart to be tethered to the wall when not in use. This was not permanently affixed storage. Narcotics for the stepdown unit were stored in the cart, so it needed to be triple locked when not in use. The goal was to prevent misappropriation of drugs, and the potential for staff abuse/accessibility. 10NYCRR 483.45(h)(2)

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #28) of three residents reviewed for non-pressure related skin conditions, the facility did not identify or investigate a new purple discoloration on the resident's arm to rule out abuse, neglect or mistreatment, and for one of five employees hired in the last four months, the facility did not ensure that the State nurse aide registry was checked for new employees to identify potential concerns related to abuse, neglect, exploitation, or mistreatment of [REDACTED]. 1. Resident #28 has [DIAGNOSES REDACTED]. A Minimum Data Set Assessment, dated 5/31/17, documented that the resident's cognitive skills for daily decision making are moderately impaired and has no skin conditions (ulcers, rashes, cuts, surgical wounds, skin tears or moisture associated skin damage). In an observation on 6/12/17 at 1: 55 p.m., a small purple area was on the resident's right arm, slightly below the elbow and a small (pinpoint) open area below that. The resident said someone caused the bruised that day during morning care. Review of the current Resident Interdisciplinary Care Plan (CP) Record, revealed that the resident requires the assistance of one staff for dressing, bed mobility, toileting and requires the assistance of two staff for transfers and ambulation. The back of this form, Narrative Notes, (used for documenting unusual observations), dated 6/1/17 to 6/12/17, is blank. A current CP Activity Report, At Risk for Impaired Skin Integrity, included interventions for Certified Nursing Assistants (CNAs) to evaluate skin condition daily during care and report any skin abnormalities to a nurse, and weekly skin checks by licensed staff. For Anticoagulant Therapy, the CP includes interventions to monitor for abnormal or unexplained bleeding and bruising, to assess the skin every shift and report any impairment of skin. A Nursing Progress Note, dated 6/10/17, documented that the resident had a shower with skin check and had no skin issues. Review of the 24-Hour Report Sheets, dated 6/10/17 to 6/12/17, did not reveal documentation of any skin issues for the resident. Interviews and observations conducted on 6/14/17 included the following: a. At 10:02 a.m., CNA #1/Days said the resident was on her assignment that day, but she had not noticed any purple marks on her arm. b. At 10:07 a.m., a Registered Nurse Manager (RNM) said she did not know if staff had reported any skin issues for the resident. c. Between 10:12 a.m. to 10:18 a.m., the RNM observed the resident's right arm and said this is an issue. The RNM said that the CNAs should have seen the bruise while dressing her, during bathing, or performing Range of Motion. d. At 11:40 a.m., the RNM said she would have a physician look at the area the next day. She said she thought it was a bruise or maybe it could be purpura. The RNM said that staff should have identified and reported the area for investigation. e. At 3:04 p.m., CNA #2/Evenings said she had not noticed the purple area on the resident's arm. f. At 3:07 p.m. and 3:08 p.m., Licensed Practical Nurse (LPN) #1/Days and LPN #2/Evenings said no one had reported the purple area to them or they would have looked at it and started an investigation. When interviewed on 6/15/17 at 11:15 a.m., the Director of Nursing (DON) said she expects staff to report anything on the skin they had not noticed before such as an open area, bruise, lesion, or unusual markings to a nurse for investigation. Review of the facility policy, Prevention of Resident Abuse/Neglect-Reporting Requirements for Long Term Care Facilities under the Elder Justice Act, dated 1/9/17, directs that facility staff are instructed to promptly report any events, such as suspicious bruising, skin tears, or occurrences that may constitute abuse. 2. Review of the employee file for Employee #4, a CNA, on 6/14/17, revealed the employee was hired on 6/5/17 and the file did not contain a Nurse Aide Registry Verification Report for the employee. Review of time sheets for Employee #4 on 6/15/17 revealed the employee had worked at the facility for nine days between 6/5/17 and 6/15/17. The Human Resources Director (HR Director) stated on 6/15/17 at 10:55 a.m., that a Nurse Aide Registry Verification Report for Employee #4 had been conducted prior to 6/5/17, but she was unable to find the report. The HR Director said the New Hire Checklist for the employee showed that a Nurse Aide Registry Verification Report had been conducted for the employee, but it did not have a date as to when the report was conducted. Review of the New Hire Checklist for Employee #4 on 6/15/17 documented that a Nurse Aide Registry Verification Report had been checked off as being conducted for the employee but it did not have a date as to when the report was conducted. Review of the policy, procedure and regulations, dated July 2016, directs to ensure all potential candidates and employees of the facility were compliant with State Department of Health and that Human Resources is to validate that all applicants are current CNAs with no findings of abuse by checking the New York State Nurse Aide Registry. (10 NYCRR 415.4(b)(3))

Based on interview, record review, and observation conducted during the recertification survey, it was determined the facility did not ensure food was served in a way that was palatable and attractive on 1 of 2 nursing units (Interlaken unit). Specifically, milk at an evening meal, and the main entree, vegetables and milk at a noon meal were not served at palatable temperatures. During the resident group meeting, anonymous residents stated they waited extended periods of time for meals to be served after the trays were placed on the serving cart. Findings include: GROUP MEETING: During the resident group meeting held on 3/17/2016 at 2:00 PM with 8 anonymous residents present, 4 residents stated the food was not always served at a palatable temperature. They stated this was more of a problem for residents eating in their rooms, as the carts were not always passed timely. The residents specifically stated the coffee was not always hot and the evening meal was often a problem for them. Review of the resident council minutes for the previous 12 months, and the food committee minutes for the previous 3 months, revealed food temperatures had been discussed at the resident meetings, without resolution. A plan to monitor the tray temperatures following the January 2016 resident council meeting was not completed. MEALS: The Interlaken unit was observed on 3/16/2016 during the evening meal from 5:05 PM through 5:55 PM. At 5:29 PM, a resident tray was requested from the room tray serving cart (the resident tray was immediately replaced). The tray included coffee, minestrone soup, sloppy joe on a bun, lemon pudding parfait, and a carton of milk. The soup, sloppy joe and coffee were at acceptable temperatures when tasted and checked with a thermometer. The carton of milk was lukewarm to taste and the temperatures recorded by the surveyor were 64 and 66 degrees Fahrenheit (F). The noon meal on Interlaken unit was observed on 3/17/2016 from 12:00 PM to 1:02 PM. A resident dining room tray was tested (the tray was immediately replaced) at 12:58 PM. The tray included corned beef, potatoes, carrots, cabbage and a glass of milk. At 1:02 PM, the following temperatures were recorded by the surveyor: - milk was 66 degrees F; - corned beef was 109 degrees F; - potatoes were 105 degrees F; - carrots were 110 degrees F; and - cabbage was 118 degrees F. When interviewed on 3/17/2016 at 12:00 PM, Food Service Worker #9 stated the 4 and 8 ounce milk cartons were held in the refrigerator before they were served on the room trays. The foods held in the steam table had temperatures taken between 12:05 PM and 12:20 PM. She stated the milk was brought out to the dining room tables/served to the residents at 11:20 AM. 10NYCRR 415.14(d)(1)(2)

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure the resident environment remained free of accident hazards for 2 of 2 resident units (Stillwater unit and Interlaken unit). Specifically, clean and dirty utility rooms containing potentially hazardous products and materials were unlocked and accessible to residents, placing them at potential risk for accidents. Findings include: STILLWATER UNIT: On 3/16/2016 at 10:10 AM, a surveyor observed the Stillwater unit clean utility room was not secured. On 3/16/2016 at 5:15 PM, a surveyor observed both doors to the Stillwater unit clean utility room, and the door to the Stillwater unit dirty utility room, were not secured. During interview with licensed practical nurse (LPN) #1 on 3/17/2016 at 4:25 PM, she stated there were two female residents that wandered through the Stillwater unit without purpose during the 3 PM - 11 PM shift. During interview with CNA #4 on 3/17/2016 at 4:50 PM, she stated there were two residents that wandered on the Stillwater unit during the 3 PM - 11 PM shift. She stated on one occasion she found one of these residents attempting to go inside the clean utility room and she intervened. During interview with CNA #7 on 3/18/2016 at 9:25 AM, she stated she used to work on the 3 PM - 11 PM shift on the Stillwater unit and during that time there were two female residents that wandered on the unit, including one resident that went in to other resident rooms. The Stillwater clean utility room was not secured on 3/18/2016 at 9:25 AM. The room contained numerous items including skin care products, shaving cream, razor blades, oxygen tanks and computer wiring. INTERLAKEN UNIT On 3/16/2016 at 6:10 PM and on 3/17/2016 at 8:50 AM, the clean utility room on the Interlaken unit was observed to have two doors leading inside, one on the A side hall and one on the B side hall. Both doors were unlocked and accessible from the hallways. The room contained numerous items including skin care products, shaving cream, razor blades, oxygen tanks and computer wiring. The dirty utility room was located adjacent to the clean utility room room in hallway A. The room was unlocked and contained a regulated medical waste bin with a red liner. The registered nurse (RN) Unit Manager for the Interlaken unit was interviewed on 3/17/2016 at 4:40 PM. She stated full sharps containers were placed in the medical waste bin and housekeeping would empty the bin frequently throughout the day. Any other regulated medical waste such as blood and body fluid soaked items would be placed in a bag with a label before being placed in the regulated medical waste bin. The RN Unit Manager was interviewed a second time on 3/18/2016 at 9:25 AM. She stated the medical waste bin was usually only for sharp containers. The only other type of waste that would be placed in the bin would be blood saturated items and they would be double bagged before being placed in the bin. She stated that she had never witnessed or received a report that a resident had attempted to enter either the clean or dirty utility rooms. 10NYCRR 415.12(h)(1)

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure food was stored under sanitary conditions in 3 of 3 food service areas observed (the main kitchen, Interlaken unit, Stillwater unit). Specifically, the food service items were soiled/dirty, and the floors were in disrepair. THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY OF 2/12/2015. Findings include: MAIN KITCHEN: On 3/16/2016 between 10:10 AM and 10:51 AM, a surveyor in the main kitchen observed: - the floor behind/under the fryer had a layer on grease on it; - there were three metal muffin tins by the cold preparation area that were stained/soiled; and - the floor finish of the dish cart spray area was cracked/bubbled. On 3/17/2016 between 3:45 PM and 4:00 PM, a surveyor in the main kitchen observed the floor under the steam kettle was cracked/damaged. RESIDENT GROUP MEETING: During the resident group meeting held on 3/16/2016 at 2:00 PM with 8 anonymous residents in attendance, the residents stated the trays they were served on were worn and unpleasant to eat on, and the coffee cups were worn and did not hold heat. INTERLAKEN UNIT: On 3/16/2016 at 5:20 PM, during an evening meal on the Interlaken unit, a surveyor observed multiple gouged/scratched entree dome covers. STILLWATER UNIT: On 3/16/2016 at 6:11 PM, a surveyor in the Stillwater unit kitchenette observed five hot beverage mugs on a drying rack that each had white film at the top of the mug around the lip and edges. When interviewed on 3/18/2016 at 10:00 AM, the Director of Nutritional Services stated the dish cart spray area floor had been resurfaced twice since the last survey and he was aware the floor was cracked/bubbled. He also stated the fryer had not been used for the 3/16/2016 breakfast meal, and was not aware of the grease layer on the floor under the fryer. 10NYCRR 415.14(h)

Based on observation, interview, and record review conducted during the recertification survey, it was determined the facility did not ensure there was an effective pest control program to maintain the facility free of pests for 1 of 3 kitchens (main kitchen/cafeteria) and in 2 of 2 nursing units (ground floor Stillwater unit and first floor Interlaken unit). Specifically, small black flies were observed in the kitchen/cafeteria and in both floors/units of the facility. Findings include: KITCHEN/CAFETERIA: On 3/16/2016 between 10:10 AM and 11:00 AM, a surveyor observed multiple small black flies in the back stairwell and the dishwasher area of the main kitchen. Five small black flies were observed in the cafeteria. On 3/17/2016 between 3:45 PM and 4:00 PM, a surveyor observed multiple small black flies in the dishwasher area and by the walk-in cooler and freezer in the main kitchen. Over 10 small black flies were observed in the cafeteria. GROUND FLOOR STILLWATER UNIT: On 3/16/2016 at 12:00 PM, a surveyor observed a small black fly in the ground floor Stillwater unit conference room. FIRST FLOOR INTERLAKEN UNIT: On 3/16/2016 at 11:15 AM, a surveyor observed a small black fly in the first floor Interlaken unit by the television area in front of the nurse's station. On 3/17/2016 at 12:34 PM, a surveyor observed a small black fly in the first floor Interlaken unit hallway by room 201. When interviewed on 3/16/2015 at 3:00 PM, the Director of Housekeeping stated he was aware of the small black flies in the kitchen, but was not aware of small black flies in the cafeteria, the ground floor Stillwell unit, or the first floor Interlaken unit. He also stated the facility had a contract with an outside service pest control company, which did monthly monitoring and control for the small black flies. The outside service pest control company's 2015/2016 Service Reports dated 10/1/2015, 11/12/2015, 12/3/2015, 1/21/2016, and 2/5/2016 had no documented sightings of small black flies. 10NYCRR 415.29(j)(5)

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure 2 of 2 nursing units (Stillwater and Interlaken units) were maintained in a sanitary, orderly and comfortable manner. Specifically, there were damaged walls, floors, baseboards, furniture, and curtains. Additionally, nurse call cords were disabled. Findings include: STILLWATER UNIT: On 3/16/2016 between 10:12 AM and 10:54 AM, a surveyor on the Stillwater unit observed the following: - in room 102, the bathroom walls had delaminated/loose baseboards; - in room 104, the bathroom floor was soiled/dirty, the bathroom walls had delaminated/loose baseboards; - in room 105, the bathroom floor was soiled/dirty, and the door for nightstand was in disrepair; - in room 108, a bathroom wall baseboard by the sink/toilet was delaminated/loose, and a spackle patch under the drying rack was not smooth; - in room 111, the bathroom walls had delaminated/loose baseboards; - in room 116, a nightstand door was in disrepair, and a nurse call cord was wrapped around a grab bar in the bathroom; - in room 117, the bathroom floor had a six inch scrape, and the bathroom walls had black marks; - in room 118, the bathroom walls had delaminated/loose baseboards, and there were four holes in the wall below the bathroom towel rack; - in room 119, the bathroom toilet base had brown rust-like matter on it, and a nurse call cord was wrapped around a grab bar in the bathroom; and - in room 121, the bathroom floor was soiled/dirty. On 3/16/2016 between 1:45 PM and 2:10 PM, a surveyor on the Stillwater unit observed the following: - in room 101, a nurse call cord was wrapped around a grab bar in the bathroom; - in room 106, the ceiling paint was peeling, and the floor had a four foot long crack in it; - the hallway floor outside room 104 had a six foot long crack in it; - the hallway floor outside room 106 had a six foot long crack in it; - the hallway floor outside room 127 had a eight foot long crack in it; - in room 115, a nurse call cord was wrapped around a grab bar in the bathroom; - in room 117, the A2 bedside divider curtain was torn; and - in room 118, there was a one foot crack/cut in the floor, and four deep scratches on the A1 side wall. On 3/17/2016 at 9:46 AM a surveyor observed the Stillwater unit dining room floor had a 22 foot long crack in it. INTERLAKEN UNIT: On 3/16/2016 at 11:00 AM, Resident #17 was observed to be seated in a cushioned wheelchair with torn armrests. On 3/18/2016 at 9:20 AM, Residents #16 and 17 were observed to be seated in cushioned wheelchairs with torn armrests. When interviewed on 3/17/2016 at 2:04 PM, the Director of Maintenance stated the floor cracks were created by the shifting of the building and he was aware of them. He also stated he was not aware of the specific rooms with wrapped nurse call cords found during survey, and stated this is an ongoing facility issue. 10NYCRR 415.5(h)(2)