Every finding on record at Grand Manor Nursing & Rehabilitation Center

Based on observation, record review, and interviews, the facility failed to maintain an effective comprehensive, data driven Quality Assurance and Performance Improvement program. Specifically, the facility failed to implement sustained performance improvement activities to address previously cited deficient practices, resulting in repeated deficiencies during the current survey.The findings include:The facility's policy titled Quality Assurance and Performance Improvement, revised 01/2026, stated that the facility maintains an effective, comprehensive, data-driven Quality Assurance and Performance Improvement program designed to monitor, evaluate, and continuously improve the quality of care, quality of life, and resident safety. The policy further stated that the Quality Assurance and Performance Improvement program is facility wide, ongoing, proactive, and focused on identifying and correcting systemic issues, preventing recurrence, and sustaining compliance with federal, state, and professional standards.Cross-reference F568, F569, F610, F641, F656, F657, F711, F806, F835, and F865.The facility failed to provide documentation demonstrating that its Quality Assurance and Performance Improvement program identified recurring deficient practices as performance improvement activities. The facility was unable to provide evidence of a systematic process for identifying, reporting, investigating, analyzing, implementing corrective actions, and monitoring effectiveness of interventions related to repeated deficiencies.On 06/30/2026 at 3:22 PM, the Director of Nursing was interviewed and stated that the Quality Assurance and Performance Improvement committee primarily focused on auditing and monitoring citations associated with the most recent surveys requiring directed plan of corrections. They stated that the committee will need to expand to address overall regulatory non-compliance.On 06/30/2026 at 4:03 PM, the Administrator was interviewed and stated that the Quality Assurance and Performance Improvement committee had discontinued auditing the previously recurring citations from previous surveys.10 New York Codes, Rules and Regulations 415.27(a-c)

Based on observation, record review, and interviews, the facility failed to provide effective governance and oversight of the Quality Assurance and Performance Improvement program. Specifically, the Administration failed to ensure the Quality Assurance and Performance Improvement committee implemented, monitored, and sustained effective corrections for eight recurring deficiencies (F568, F569, F610, F641, F656, F657, F711, and F806).The findings include:A review of the facility's survey history revealed a documented history of non-compliance under F568, F569, F610, F641, F656, F657, F711, and F806. During the current survey, the facility was cited for repeat non-compliance in these same areas. There was lack of evidence that the facility's previous citations were continuously monitored to prevent recurrence.On 06/30/2026 at 4:03 PM, the Administrator was interviewed and stated the facility's Quality Assurance and Performance Improvement committee had discontinued auditing some previously recurring citations that were found from previous surveys and focused on the findings associated with the most recent survey that required directed plan of corrections.10 New York Codes, Rules and Regulations 415.26

Based on observation, record review, and interviews, the facility failed to ensure residents were free from misappropriation of property. This was evident in three (Residents #15, #74, and #101) of five residents reviewed for personal funds out of 29 total sampled residents. Specifically, the facility authorized withdrawals from the personal fund accounts of cognitively impaired residents to purchase clothing and shoes without documented authorization from their designated representatives. The findings include:The facility's policy titled Resident Purchases and Clothing, last reviewed January 2026, stated that when a resident lacks decision-making capacity, reasonable efforts will be made to notify the resident's designated representative of identified clothing or personal item needs and provide the representative with the opportunity to obtain the requested items. When reasonable efforts to contact the representative are unsuccessful, purchases using resident funds may be made only in accordance with facility policy and applicable regulations.The facility's policy and procedure titled Resident Banking and Personal Funds, last reviewed 01/2026, stated that charges shall only be made for items or services requested by the resident or the resident's designated representative.1. Resident #101 had diagnoses including dementia (loss of thinking, memory, and reasoning abilities), Type 2 diabetes (a condition where the body has trouble managing blood sugar), and epilepsy (repeated uncontrolled electrical activity in the brain that leads to rapid muscle contractions).The Minimum Data Set (a resident assessment tool) dated 03/25/2026 documented severe cognitive impairment and indicated that involvement of a family member in care discussions was very important to the resident.A psychiatry evaluation dated 06/06/2026 documented that Resident #101 lacked decision-making capacity.The Resident Funds Ledger documented withdrawals of $350.70 for six sweat suits, six knee-high socks, and three colored T-shirts on 07/23/2025; $421.66 for five sweat suits, five colored T-shirts, six knee-high socks, and one coat on 01/28/2026; and $149.99 for one pair of extra-depth shoes on 03/10/2026 from Resident #101's account. The withdrawals totaled $922.35.The facility was unable to provide inventory records for items purchased on 01/28/2026 and 03/10/2026. During an observation of Resident #101's room on 06/25/2026 at 10:59 AM with Certified Nursing Assistant #1, the clothing and shoes identified on the purchase invoices were not observed in the resident's room or on the resident. During an interview on 06/25/2026 at 6:23 PM, Resident #101's designated representative stated the resident was unable to make financial decisions, no authorization had been given for the purchases, and the facility had not notified them that additional clothing was needed. 2. Resident #15 had diagnoses including Alzheimer's disease (a condition that affects the brain and makes it harder for a person to think, remember, and carry out everyday tasks), bipolar disorder (a form of mental illness where the affected individual experiences episodes of mood fluctuations), and dysphagia (difficulty swallowing) following a cerebral infarction (stroke).The Minimum Data Set, dated [DATE] documented that Resident #15 had severe cognitive impairments and considered personal belongings, clothing choice, and family involvement in care discussions very important.The Resident Funds Ledger documented withdrawals of $317.76 for six sweat suits and six knee-high socks on 07/23/2025; $356.76 for five sweat suits, six knee-high socks, and one comforter on 01/28/2026; and $149.99 for one pair of extra-depth shoes on 03/10/2026 from Resident #15's account. The withdrawals totaled $824.51. The facility failed to provide documentation demonstrating Resident #15's designated representative authorized the purchases or that inventory records were completed for the purchased items.During an observation of Resident #15's room and interview on 06/29/2026 at 9:25 AM, Certified Nursing Assistant #1 stated many belongings had been packed because of the facility's impending closure but did not recall Resident #15 ever receiving the comforter purchased with resident funds. No comforter was observed being used by the resident.During an interview on 06/29/2026 at 9:18 AM, Resident #15's designated representative stated the facility had not requested permission to make the purchases, and they would not have authorized the expenditures. 3. Resident #74 had diagnoses including Alzheimer's disease, schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), and severe chronic kidney disease (a long-term condition where your kidneys gradually lose their ability to filter waste and extra fluid from your blood).The Minimum Data Set, dated [DATE] documented that Resident #74 had severe cognitive impairments and was unable to report preferences related to clothing choice, family involvement in care discussions, and care of personal belongings.The Resident Funds Ledger documented withdrawals of $394.62 for six sweat suits, seven colored T-shirts, and six knee-high socks on 07/23/2025; $454.72 for seven sweat suits, six knee-high socks, and one coat on 01/28/2026; and $149.99 for one pair of extra-depth shoes on 03/10/2026. The withdrawals totaled $999.33.The facility failed to provide documented evidence demonstrating Resident #74's designated representative authorized the purchases or that inventory records were completed for the purchased items.During an interview on 06/26/2026 at 5:46 PM, Resident #74's designated representative stated the family routinely supplied clothing and that the facility had not requested permission to purchase additional clothing using resident funds. They stated they were unaware that purchases had been made for the resident.During an interview on 06/30/2026 at 10:15 AM, the Accounts Payable Coordinator stated they are responsible for reviewing purchases made for the residents and that payment to the clothing vendor was issued after invoices containing two staff signatures were reviewed and approved. They stated that the signatures on the invoice are proof that the items were received by the residents.During an interview on 06/30/2026 at 11:20 AM, the Director of Social Services stated the facility used an outside vendor to purchase clothing for residents and acknowledged that designated representative authorization for purchases was not consistently documented. They stated if the resident's designated representative could not be reached, they would act as the resident's advocate and would authorize the clothing purchase using the resident's personal funds. The Director of Social Services stated that the Administrator's approval is needed before any withdrawals can be made from the resident's personal funds. They stated they had not contacted Resident 101's designated representative because the designated representative had not answered their phone in the past when they tried to get in contact. They believed they received verbal consent from Residents #15 and #74 designated representative to make the purchases but failed to document. The Director of Social Services stated they believed the ordered items had been delivered to the residents. They could not explain why inventory documentation was not completed and purchased items could not be located.During an interview on 06/30/2026 at 12:09 PM, the Director of Nursing stated designated representatives of cognitively impaired residents should provide permission before purchases were made using resident funds and acknowledged donated clothing was available for resident use. The Director of Nursing also stated inventory forms should have been completed when purchased items were delivered.During an interview on 06/30/2026 at 01:09 PM, the Administrator stated purchases for cognitively impaired residents should not occur without representative authorization. 10 New York Codes, Rules, Regulations 415.4(b)

Based on record review and interview, the facility failed to ensure that allegations of abuse and an injury of unknown origin were thoroughly investigated. This was evident in three (Resident #164, #32, and #132) of four residents reviewed for abuse out of 29 total sampled residents. Specifically, 1.) The facility failed to conduct thorough investigation after Resident #164 was transferred to the hospital on [DATE] for complaints of chest pain radiating to the left side and was subsequently diagnosed with rib fractures (broken bone). In addition, the facility failed to document findings to determine whether abuse, neglect, or other factors contributed to the injury. 2.) The facility failed to conduct a thorough investigation of a resident-to-resident altercation involving Residents #32 and #132 on 04/23/2026. The findings include: The facility's policy titled Abuse Prohibition and Prevention, last reviewed December 2023, stated the facility is responsible for the prompt and thorough investigation of alleged violations and occurrences. The policy requires written statements from all parties involved and from all staff on the unit at the time of the incident, as well as statements from non-staff witnesses within 24 hours. 1. Resident #164 had diagnoses that included Alzheimer's disease (a brain disorder that slowly affects memory, thinking, and the ability to do everyday tasks), vitamin D deficiency (when your body doesn't have enough vitamin D), and anemia (a condition when blood doesn't have enough healthy red blood cells to carry oxygen around the body). The Comprehensive Minimum Data Set (a resident assessment tool) dated 01/20/2026 documented severely impaired cognition with wandering behaviors, rejection of care, and dependence on staff for most activities of daily living, including transfers and standing. A nursing progress note dated 02/02/2026 documented that Resident #164 was transferred to the hospital following reports of shortness of breath and chest pain radiating to the left side. A hospital progress note dated 02/03/2026 documented evaluation for left upper quadrant (upper left part of the abdomen) pain, with imaging revealing minimally displaced fractures (a type of broken bone where the two ends of the bone have cracked or broken, but they have only moved a very small amount from their normal position) of the ninth and tenth ribs. The resident was unable to provide a history of events. The facility's Summary of Investigation dated 02/17/2026, completed by the Director of Nursing, documented that the facility was notified by the hospital on [DATE] that Resident #164 had been diagnosed with minimally displaced ninth and tenth left rib fractures. The investigative summary documented that staff interviews were conducted and that no known or reported incident of fall or trauma was identified. There was no documented evidence in the Summary of Investigation of statements from staff reportedly interviewed or a documented conclusion as to whether the injury was a result of abuse, neglect, or was of unknown origin. During an interview on 06/25/2026 at 4:11 PM, the Director of Nursing stated they were responsible for completing this investigation and they received a hospital report on 02/10/2026 stating that Resident #164 was diagnosed with rib fractures. The Director of Nursing stated staff interviews were conducted with employees working all shifts on the day of and prior to Resident #164's hospital transfer and that no incident or trauma was identified. The Director of Nursing stated that staff written statements could not be located and may have been misplaced and that they could not recall why the investigation lacked a determination of whether abuse or neglect had occurred. 2. Resident #32 had diagnoses including Parkinson's disease (a condition where parts of the brain slowly stop working properly, causing movement and other body functions to become harder over time), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and osteoarthritis (a condition where the cartilage in your joints wears down). The Annual Minimum Data Set, dated [DATE] documented moderate cognitive impairment and no history of physical behavioral symptoms toward others. Resident #132 had diagnoses including Alzheimer's disease, cataract (clouding of the lens inside the eye) and schizophrenia (a serious mental health condition that affects how people think, feel and behave). The Quarterly Minimum Data Set, dated [DATE] documented moderately severe cognitive impairment and no behavioral symptoms toward others. The Resident Occurrence Forms dated 04/23/2026 documented that at 7:23 PM, Residents #32 and #132 were observed hitting each other. Resident #32 sustained a superficial scratch to the left hand, and Resident #132 sustained a superficial scratch to the left upper chest. Both residents were evaluated and transferred to the hospital. There was no documented evidence in the facility's investigation of statements from all staff working in the unit who may have potentially witnessed the incident. In addition, there was no documented evidence that available video surveillance was reviewed as part of the investigation. During an interview on 06/26/2026 at 8:30 AM, Certified Nursing Assistant #4 stated they were notified of the incident by other staff who heard a noise. They stated they intervened after being alerted and separated the residents, but could not identify the staff members who initially observed the incident. During an interview on 06/25/2026 at 3:48 PM, Registered Nurse #7 stated they did not fully witness the altercation and responded after hearing a noise, at which time they intervened. During an interview on 06/26/2026 at 12:38 PM, the Director of Nursing Services stated the facility's investigative process requires obtaining statements from all staff on the unit. The Director of Nursing Services acknowledged that additional employee statements could not be located and could not confirm whether they were completed or obtained verbally. The Director of Nursing Services further stated video surveillance was not reviewed because Registered Nurse #7 was believed to be a direct witness. 10 New York Codes, Rules and Regulations 415.4(b)(3)

Based on observation, record review, and interviews, the facility failed to ensure comprehensive care plans were reviewed and revised after each resident assessment, including quarterly review assessments. This was evident in two (Residents #96 and #101) of five residents reviewed for discharge planning. Specifically, Residents #96 and #101's care plan on discharge plans were not reviewed or revised after each quarterly review assessments.The findings include:The facility's Care Plan policy, reviewed 01/2026, stated that the facility will develop and maintain a comprehensive, person-centered care plan for each resident based on comprehensive assessment, goals, preferences, strengths, needs, and clinical condition. The care plan will be reviewed and revised, as appropriate, following each comprehensive assessment, significant change in condition, or when resident needs, goals, or preferences change and that all revisions will be documented in the residents' medical record.1. Resident #96 had diagnoses including hypertensive heart disease (a type of heart problem that happens when high blood pressure is left uncontrolled for a long time), hypertension (high blood pressure), and anxiety disorder (mental health condition where a person feels excessive, persistent, and often uncontrollable worry or fear).The Quarterly Minimum Data Set (a resident assessment tool) dated 03/25/2026, documented that Resident #96 was cognitively intact.The resident's Comprehensive Care Plan for discharge planning, effective 10/03/2022, documented the goal was to discharge resident to a community setting where their medical and psychosocial needs would be met. Record review showed the care plan was last revised on 08/27/2025. The facility was unable to provide documentation that the discharge care plan was reviewed or revised following the quarterly assessment completed on 03/25/2026. 2. Resident #101 had diagnoses including type 2 diabetes mellitus (a condition where the body has trouble using insulin properly, causing high blood sugar levels), asthma (a condition in which the airways narrow and swell), and dementia (loss of thinking, memory, and reasoning abilities that interfere with daily life).The Quarterly Minimum Data Set, dated [DATE] documented that Resident #101 had severe cognitive impairment.The resident's Comprehensive Care Plan for discharge planning, initiated on 07/12/2024, documented that the resident required skilled nursing care and was not a candidate for discharge to the community. Record review showed the care plan was last revised on 09/29/2025. The facility was unable to provide documentation that the discharge care plan was reviewed or revised following the quarterly assessment completed on 03/25/2026.During an interview on 06/26/2026 at 11:21 AM, the Director of Social Services stated they were responsible for completing quarterly reviews of discharge care plans and that the reviews had not been completed because of staffing shortages within the social services department.During an interview on 06/29/2026 at 2:34 PM, the Administrator stated that care plan revisions had not been prioritized due to the facility's impending closure.New York Codes, Rules, Regulations 415.11(c)(2)(i-iii)

Based on record review and interviews, the facility failed to ensure residents or their designated representatives received quarterly personal funds account statements. This was evident in three (Residents #15, 74, and #101) of five residents reviewed for personal funds out of 29 total sampled residents. Specifically, the facility was unable to provide documentation demonstrating quarterly personal funds account statements were provided to the designated representatives of Residents #74 and #101 for the quarters ending 06/30/2025, 09/30/2025, 12/31/2025, and 03/31/2026, and to Resident #15's designated representative for the quarters ending 09/30/2025 and 12/31/2025.The findings include:The facility policy titled Resident Banking and Personal Funds, reviewed January 2026, stated the facility is responsible for managing and accounting for resident personal funds in accordance with applicable regulations and that quarterly account statements shall be provided to the resident or the resident's designated representative.1. Resident #101 had diagnoses including dementia (loss of thinking, memory, and reasoning abilities), Type 2 diabetes (a condition where the body has trouble managing blood sugar), and epilepsy (repeated uncontrolled electrical activity in the brain that leads to rapid muscle contractions).The Minimum Data Set (a resident assessment tool) dated 03/25/2026 documented severe cognitive impairment and indicated that involvement of a family member in care discussions was very important to the resident.The resident face sheet identified Resident #101's designated representative as the resident's first contact and next of kin.The facility failed to provide documentation demonstrating quarterly personal funds account statements were provided to Resident #101's designated representative for the quarters ending 06/30/2025, 09/30/2025, 12/31/2025, and 03/31/2026.During an interview on 06/25/2026 at 6:23 PM, Resident #101's designated representative stated they were unaware the resident maintained a personal funds account at the facility, had never received quarterly account statements. 2. Resident #15 had diagnoses including Alzheimer's disease (a condition that affects the brain and makes it harder for a person to think, remember, and carry out everyday tasks) and dysphagia (difficulty swallowing) following a cerebral infarction (stroke), and bipolar disorder (a form of mental illness where the affected individual experiences episodes of mood fluctuations).The Minimum Data Set, dated [DATE] documented that Resident #15 had severe cognitive impairments and considered personal belongings, clothing choice, and family involvement in care discussions very important.The resident face sheet identified Resident #15's designated representative as the resident's first contact and next of kin.The facility failed to provide documentation demonstrating quarterly personal funds account statements were provided to Resident #15's designated representative for the quarters ending 09/30/2025 and 12/31/2025.During an interview on 06/29/2026 at 9:18 AM, Resident #15's designated representative stated they did not regularly receive quarterly account statements and were unaware of purchases that had been made using the resident's personal funds. 3. Resident #74 had diagnoses including Alzheimer's disease, schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), and severe chronic kidney disease (a long-term condition where your kidneys gradually lose their ability to filter waste and extra fluid from your blood).The Minimum Data Set, dated [DATE] documented that Resident #74 had severe cognitive impairments and was unable to report preferences related to clothing choice, family involvement in care discussions, and care of personal belongings.The resident face sheet identified Resident #74's designated representative as the resident's primary contact, emergency contact, and next of kin.The facility failed to provide documentation demonstrating quarterly personal funds account statements were provided to Resident #74's designated representative for the quarters ending 06/30/2025, 09/30/2025, 12/31/2025, and 03/31/2026.During an interview on 06/26/2026 at 5:46 PM, Resident #74 designated representative stated they were the primary contact for Resident #74 and had never received quarterly account statements from the facility. The designated representative stated statements had occasionally been mailed to another individual listed in the face sheet who was not the primary contact; however, this individual also does not receive the statements on a quarterly basis.During an interview on 06/29/2026 at 10:50 AM, the Director of Social Services stated they were responsible for providing quarterly personal funds account statements to residents or their designated representatives. They stated cognitively intact residents received statements directly, while statements for cognitively impaired residents were mailed to their designated representatives. The Director of Social Services stated they believed statements had been mailed to the designated representatives of Residents #15 and #74 but were unable to provide documentation verifying they had been sent. They further stated quarterly statements were not mailed to Resident #101's designated representative because no mailing address was on file.During a follow-up interview on 06/30/2026 at 11:10 AM, the Director of Social Services stated they did not verify that quarterly statements were mailed to the resident's designated primary contact.During an interview on 06/30/2026 at 1:09 PM, the Administrator stated the Director of Social Services was responsible for mailing quarterly statements to the resident's designated primary contact and documenting compliance by retaining a photocopy of the dated mailing envelope.New York Codes, Rules, Regulations 415.26(h)(5)(ii)(a-c)

Based on record review and interviews, the facility failed to ensure designated representatives of cognitively impaired residents were notified when resident personal funds accounts approached or exceeded the Supplemental Security Income resource limit. This was evident in two (Residents #74 and #101) of five residents reviewed for personal funds out of 29 total sampled residents. Specifically, the facility failed to provide documented evidence that designated representatives were notified, or that attempts to notify them were made, when resident personal fund balances reached or exceeded the Supplemental Security Income resource limit.The findings include:The facility's policy and procedure titled Resident Banking and Personal Funds , last reviewed January 2026, stated that Medicaid residents shall be notified when their personal funds account balance reaches $200 less than the Supplemental Security Income (SSI) resource limit for one individual.The Centers for Medicare and Medicaid Services Informational Bulletin dated 12/09/2025 documented that the Supplemental Security Income Resource Standard for 2026 was $2,000 per individual.1. Resident #101 had diagnoses including dementia (loss of thinking, memory, and reasoning abilities), epilepsy (repeated uncontrolled electrical activity in the brain that leads to rapid muscle contractions), and Type 2 diabetes (a condition where the body has trouble managing blood sugar).The Minimum Data Set (a resident assessment tool) dated 03/25/2026 documented severe cognitive impairment and indicated that involvement of a family member in care discussions was very important to the resident.A psychiatry evaluation dated 06/06/2026 documented that Resident #101 lacked decision-making capacity.The Resident Funds Ledgers for the quarters ending 06/30/2025, 09/30/2025, and 12/31/2025 documented account balances more than $2,000, exceeding the Supplemental Security Income resource limit.The facility failed to provide documentation demonstrating Resident #101's designated representative was notified, or that attempts were made to notify the designated representative, when the resident's account approached or exceeded the Supplemental Security Income resource limit.During an interview on 06/25/2026 at 6:23 PM, Resident #101's designated representative stated they were unaware the facility managed the resident's personal funds and had never been contacted regarding the resident's personal funds account. 2. Resident #74 had diagnoses including Alzheimer's disease (a condition that affects the brain and makes it harder for a person to think, remember, and carry out everyday tasks), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), and severe chronic kidney disease (a long-term condition where your kidneys gradually lose their ability to filter waste and extra fluid from your blood).The Minimum Data Set, dated [DATE] documented that Resident #74 had severe cognitive impairments and was unable to report preferences related to clothing choice, family involvement in care discussions, and care of personal belongings.The Resident Funds Ledgers for the quarters ending 06/30/2025, 09/30/2025, 12/31/2025, and 03/31/2026 documented account balances more than $2,000, exceeding the Supplemental Security Income resource limit.The facility failed to provide documented evidence demonstrating Resident #74's designated representative was notified, or that attempts were made to notify the designated representative, when the resident's account approached or exceeded the Supplemental Security Income resource limit.During an interview on 06/26/2026 at 5:46 PM, Resident #74designated representative stated they were the resident's primary contact, and they expected to receive financial information from the facility. The designated representative stated they had not received communications regarding Resident #74 personal funds account.During an interview on 06/30/2026 at 3:35 PM, the Director of Social Services stated they were responsible for notifying designated representatives when a cognitively impaired resident's personal funds account was within $200 of the Supplemental Security Income resource limit. They stated notification attempts for Resident #101 were not documented and they believed Resident #74 designated representative had been notified; however, documentation of notification or attempted notification was not available.New York Codes, Rules, Regulations 415.26(h)(5)(i)(a)

Based on observation, record review and interviews, the facility failed to ensure that each resident received food in accordance with their preferences. This was evident in one (Resident #140) of 29 sampled residents reviewed for food preferences. Specifically, Resident #140 repeatedly received meal items containing chicken despite a documented preference to avoid chicken.The findings include:The facility's Food Preference policy, revised 06/2025, required that resident food preferences be honored to the extent possible and accurately reflected in the dietary system, with appropriate communication to dietary staff to ensure compliance.Resident #140 had diagnoses including gastroesophageal reflux disease (a condition when stomach acid flows back up into the throat and causes heartburn) and essential hypertension (high blood pressure).The Minimum Data Set (a resident assessment tool) dated 05/14/2026 documented that Resident #140 was cognitively intact, independent with eating, and without swallowing deficits.The physician's order dated 11/19/2025 last renewed on 06/21/2026 indicated a regular diet.A review of facility menu tickets for Resident #140 from 06/01/2026 through 06/21/2026 documented No Pork/No Chicken.The facility menu tickets for Resident #140 documented multiple meals containing chicken, including: 06/04/2026 dinner: Chicken burrito 06/09/2026 dinner: Chicken sausage 06/13/2026 dinner: Lemon chicken 06/14/2026 lunch: Chicken and broccoli 06/14/2026 dinner: Chicken pot pieOn 06/25/2026 at 11:54 AM, Resident #140 was interviewed and stated they frequently received chicken despite requesting no chicken/no pork. They stated that this concern had been communicated to multiple staff members.On 06/25/2026 at 12:12 PM, Certified Nursing Assistant #3 was interviewed and stated that Resident #140 frequently complained about receiving chicken with their meals.On 06/25/2026 at 12:16 PM, Registered Nurse #3 was interviewed and stated that Resident #140 has complained in the past about receiving chicken with their meals.On 06/29/2026 at 10:12 AM, Dietary Aide #1 was interviewed and stated they are aware that Resident #140 disliked chicken and pork and that they accommodate this preference. However, they are not sure if this preference is accommodated when they are not on shift.On 06/29/2026 at 1:45 PM, the Assistant Food Service Director was interviewed and stated the issue may have resulted from inaccurate or incomplete entry of dislikes in the meal tracking system, leading to failure to consistently remove chicken-containing items from meal selections.On 06/25/2026 at 10:53 AM, the Director of Food Services was interviewed and stated that Resident #140's food preferences were not correctly updated in the meal tracking system, resulting in continued service of meals containing chicken despite the documented preference to avoid it.10 New York Code Rules and Regulations 415.14(d)(4)

Based on observation, record review and interviews, the facility failed to ensure that each resident's drug regimen was free from unnecessary medications, including ensuring that required clinical monitoring was completed to support safe and appropriate use of medications. This was evident in one (Resident #13) of five residents reviewed for unnecessary medications out of 29 total sampled residents. Specifically, the facility failed to ensure completion of recommended laboratory monitoring for a resident receiving Allopurinol (medication used to treat gout, which is a disease marked by a painful inflammation of the joints), despite a pharmacy consultant recommendation and physician acknowledgment to order the test.Cross Reference tag F711 Physician Visits Review Care/Notes/OrderThe findings include:The facility's policy titled Monthly Drug Regimen Review, last reviewed 01/2026, documented that the Consultant Pharmacist shall review the medical record of each resident and perform a drug regimen review at least once each calendar month. The Consultant Pharmacist shall identify, document and report possible medication irregularities for review and action by the attending physician, where appropriate. The attending physician or licensed designee shall respond to the drug regimen review within 30 days or more promptly, whenever possible.Resident #13 had diagnoses that included anemia (a condition when blood does not have enough healthy red blood cells to carry oxygen around the body) and gout.The Minimum Data Set (a resident assessment tool) dated 04/24/2026 documented gout as an active diagnosis.A physician's order with a renewal date of 04/09/2026 and 06/13/2026 included 50 milligrams Allopurinol to be administered by oral route every three days for the treatment of gout.A Consultant Pharmacist Drug Regimen Review dated 01/12/2026 identified that Resident #13 was receiving Allopurinol and that no serum uric acid level was documented in the medical record, recommending annual serum uric acid monitoring to assess ongoing therapy. The physician response dated 01/20/2026 documented agreement with the recommendation and that the laboratory test would be ordered.A review of the medical record revealed no evidence that a serum uric acid level was ordered or obtained following the physician's documented agreement.During a telephone interview on 06/29/2026 at 11:23 AM, Attending Physician #1 stated that the Medical Director is the Attending Physician who manages the care for Resident #13.During an interview on 06/29/2026 at 11:36 AM, the Medical Director, the resident's attending physician, stated that serum uric acid monitoring is generally indicated for residents receiving Allopurinol for gout and stated that upon review of Resident #13's record, no order or results were present and could not explain why the monitoring was not completed.During an interview on 06/30/2026 at 4:03 PM, the Administrator stated that the Medical Director is responsible for ensuring follow-through on pharmacy consultant recommendations and coordination with attending physicians to ensure orders are implemented and completed.10 New York Codes, Rules and Regulations 415.12(l)(1)

Based on observation, record review, and interview, the facility failed to ensure that physician services were adequately provided, responsive, and coordinated to meet residents' clinical needs, including timely follow-up on clinical recommendations and required monitoring. This was evident in one (Resident #13) of five residents reviewed for unnecessary medications out of 29 total sampled residents. Specifically, the physician failed to ensure that resident's serum uric acid level (a blood test that measures how much uric acid is in your bloodstream. Uric acid is a natural waste product the body makes when it breaks down substances found in certain foods) was completed after the pharmacy consultant identified the need for monitoring a resident receiving Allopurinol (medication used to treat gout which is a disease marked by a painful inflammation of the joints).Cross Reference tag F757 D Drug Regimen is Free from Unnecessary DrugsThe findings include:The facility's policy titled Physician Visits and Physician Delegation, revised 01/2026, documented that each resident will remain under the care of an attending physician who is responsible for the resident's medical management. The facility will ensure physician services are available and facilitate access to care in accordance with regulatory requirements. Physician services shall be available, responsive to residents' needs, properly documented and effectively coordinated with the interdisciplinary team to support residents' health, safety and quality of care. The physician takes an active role in supervising the care of residents.Resident #13 had diagnoses that included anemia (a condition when blood does not have enough healthy red blood cells to carry oxygen around the body) and gout.The Minimum Data Set (a resident assessment tool) dated 04/24/2026 documented gout as an active diagnoses.A physician's order with a renewal date of 04/09/2026 and 06/13/2026 included 50 milligrams Allopurinol to be administered by oral route every three days for the treatment of gout.A Consultant Pharmacist Drug Regimen Review dated 01/12/2026 identified that Resident #13 was receiving Allopurinol and that no serum uric acid level was documented in the medical record, recommending that the physician consider ordering annual serum uric acid monitoring. Physician response dated 01/20/2026 documented agreement with the recommendation and that the laboratory test would be ordered.A review of the medical record revealed no evidence that a serum uric acid level was ordered or obtained following the physician's documented agreement.During an interview on 06/29/2026 at 11:36 AM, the Medical Director, the resident's attending physician, stated that serum uric acid monitoring is generally indicated for residents receiving Allopurinol for gout and stated that upon review of Resident #13's record, there was no evidence that the test was ordered or completed and could not explain the omission.During an interview on 06/30/2026 at 4:03 PM, the Administrator stated that the Medical Director is responsible for ensuring follow-through on pharmacy consultant recommendations and coordination with attending physicians to ensure orders are implemented and completed.10 New York Codes, Rules and Regulations 415.15 (b)(2)(iii)

Based on observation, record review, and interview, the facility failed to ensure that a comprehensive, person-centered care plan was developed and implemented for each resident to address identified medical conditions. This was evident in one (Resident #13) of five residents reviewed for unnecessary medications out of 29 total sampled residents. Specifically, a care plan was not developed to address Resident #13's diagnosis of gout (a disease marked by a painful inflammation of the joints).The findings include:The facility's policy titled Care Plans, reviewed 01/2026, requires that a comprehensive, person-centered care plan be developed based on the resident's assessment and clinical condition, include measurable objectives and interventions, and be implemented and communicated to staff. The policy further stated that the comprehensive care plan is developed and reviewed by the interdisciplinary team.Resident #13 had diagnoses that included anemia (a condition when blood does not have enough healthy red blood cells to carry oxygen around the body), major depressive disorder (a serious mental health condition that goes beyond just feeling sad or having a bad day), and gout.The Minimum Data Set (a resident assessment tool) dated 04/24/2026 documented gout as an active diagnoses.A review of Resident #13's medical record revealed no comprehensive care plan developed or implemented addressing gout, including goals, interventions, or measurable outcomes related to management of the condition.During an interview on 06/25/2026 at 5:02 PM, Registered Nurse #6, who was the nursing supervisor, stated it is the Minimum Data Set Coordinator's responsibility to develop the care plan on gout and that Registered Nurse #6 only initiates care plan when there is a change in a resident's condition.During an interview on 06/26/2026 at 9:44 AM, the Minimum Data Set Coordinator stated it is the nursing supervisor's responsibility to develop or initiate care plans and that the Minimum Data Set Coordinator only identify missing care plans during review of resident assessments.During an interview on 06/25/2026 at 4:11 PM, the Director of Nursing stated the Registered Nurse Supervisors or Minimum Data Set assessors are responsible for completing the care plans based on diagnoses and assessments.10 New York Codes, Rules and Regulations 415.11(c)(1)

Based on record review and interviews, the facility failed to ensure that a resident or their representative was afforded the opportunity to participate in their care planning process. This was evident in one (Resident #101) of five residents reviewed for resident rights related to care planning out of 29 total sampled residents. Specifically, the facility failed to provide documentation that advance notice was provided to Resident #101's designated representative, or attempted to be provided, before the care plan meetings occurred.The findings include:The facility's policy titled Care Plan, reviewed January 2026, stated that the facility will develop and maintain a comprehensive, person-centered care plan based on the resident's assessment, goals, preferences, strengths, needs, and clinical condition. The policy further stated that the resident and/or the resident's designated representative will be encouraged to participate in the care planning process, as appropriate.Resident #101 had diagnoses including dementia (loss of thinking, memory, and reasoning abilities), Type 2 diabetes (a condition where the body has trouble managing blood sugar), and epilepsy (repeated uncontrolled electrical activity in the brain that leads to rapid muscle contractions).The Minimum Data Set (a resident assessment tool) dated 03/25/2026 documented severe cognitive impairment and indicated that involvement of a family member in care discussions was very important to the resident.A psychiatry evaluation dated 06/06/2026 documented that Resident #101 lacked decision-making capacity.Social work progress notes dated 01/05/2026 and 04/14/2026 documented that interdisciplinary care plan meetings were conducted in the resident's room and stated that the designated representative was invited but did not attend.The facility was unable to provide documented evidence demonstrating that Resident #101's designated representative received advance notice of either care plan meeting or that staff attempted to provide advance notice before the meetings occurred.During an interview on 06/25/2026 at 6:23 PM, Resident #101's designated representative stated they had not been invited to any care plan meetings and would have wanted to participate in the resident's care planning.During an interview on 06/26/2026 at 11:21 AM, the Director of Social Services stated they telephoned Resident #101's designated representative before each quarterly care plan meeting; however, the designated representative did not answer the calls. The Director of Social Services stated this notification attempts were not documented and stated they should have been documented.10 New York Codes, Rules, Regulations 415.11(c)(2)(ii)

Based on record reviews and interviews, the facility failed to ensure that resident assessments accurately reflected the residents' clinical diagnoses and conditions. This was evident in two (Residents #2 and #61) of 29 residents reviewed for accuracy of assessments. Specifically, the Minimum Data Set (a resident assessment tool) assessments failed to capture documented mental health conditions for Residents #2 and #61. The findings include: The facility's policy titled, Minimum Data Set Accuracy, reviewed January 2026, requires that Minimum Data Set coding be supported by documentation in the medical record and that assessments be reviewed for accuracy and consistency prior to submission. 1. Resident #2 had diagnoses including schizophrenia (a serious mental health condition that affects how people think, feel and behave), bipolar disorder (a mental health condition that causes extreme mood swings), and dementia (loss of thinking, memory, and reasoning abilities that interfere with daily life). The Annual Minimum Data Set, dated [DATE] documented Resident #2 had intact cognition and indicated that only the resident participated in the assessment. A psychiatric evaluation dated 04/26/2025 documented diagnoses of schizophrenia and bipolar disorder. The care plan dated 04/23/2025 also reflected a diagnosis of schizophrenia. There was no documented evidence that the Annual Minimum Data Set, dated [DATE] included diagnoses of schizophrenia or bipolar disorder. During an interview on 06/25/2026 at 11:13 AM, the Minimum Data Set Coordinator stated they were responsible for ensuring that the Minimum Data Set assessments were accurate. They stated they completed the assessment for Resident #2 and acknowledged that schizophrenia and bipolar disorder were not coded. The Minimum Data Set Coordinator stated this was an oversight. 2. Resident #61 had diagnoses including acute respiratory failure (is a serious condition where the body doesn't get enough oxygen), panic disorder, and depression. On 06/22/2026 at 11:42 AM, Resident #61 was interviewed and stated they had post- traumatic stress disorder (a mental health condition that can happen after someone experiences or witnesses a very scary, shocking, or dangerous event). A trauma focused care plan dated 04/07/2026 documented that Resident #61 experienced a traumatic event and stated they had been attacked badly. The psychiatric consults dated 02/19/2024, 04/09/2024, 04/25/2024, and 06/10/2024 consistently documented that Resident #61 had post-traumatic stress disorder. The Quarterly Minimum Data Set, dated [DATE] documented that Resident #61 had intact cognition and used antidepressant. There was no documented evidence that the Quarterly Minimum Data Set, dated [DATE] included a diagnosis of post-traumatic stress disorder. During an interview on 06/26/2026 at 9:34 AM, the Minimum Data Set Coordinator stated they are responsible for completing and verifying the Minimum Data Set assessments and acknowledged that post-traumatic stress disorder was not coded for Resident #61. They stated the omission was an oversight and could not provide a reason why the diagnosis was missed. 10 New York Codes, Rules, Regulations 415.11(b)

Based on observation, record review, and interviews conducted during the survey, the facility failed to establish and maintain a system to accurately reconcile, verify, and oversee methadone medications received from an external opioid treatment program. This was evident for 10 (Residents #2, 16, 28, 49, 50, 53, 114, 142, 146, 177) of 23 residents enrolled and receiving methadone (a long-acting opioid used to treat opioid use disorder) through an opioid treatment program. Specifically, a review of methadone administration records revealed 10 of 23 residents received dosages inconsistent with physician's orders. The licensed nurses reported the administration process of methadone doses obtained and intended for residents registered with an external opioid treatment program did not include medication-order reconciliation. In addition, the facility failed to provide a policy or procedure outlining the process for ensuring that the dosage and formulation of methadone supplied by external opioid treatment programs are consistent with facility physicians' orders. This resulted in no actual harm with a likelihood for serious harm that is Immediate Jeopardy to residents receiving methadone maintenance therapy. See F-760.The findings are:The undated facility policy titled, Controlled Substance Handling, documented that all controlled drugs will be subject to special receipt, handling and storage, disposal and record keeping. All controlled substances received shall be delivered to the nursing unit and logged into the official count by two (2) nurses: the nurse who received the delivery and the nurse in charge of the unit, to verify the count and log the receipt. A controlled drug accountability record shall be prepared when receiving and checking-in a controlled drug and includes the following information: name of resident, prescription number, date received, and quantity received. Immediately after a dose is administered, the licensed nurse administering the drug enters all the following information on the medication administration record: date and time of administration, dose administered and signature of the nurse administering the dose. A physical inventory of all controlled drugs is made at the change of each shift by two licensed nurses and is documented on an audit record. The undated facility policy titled, Medication Administration Policy Documentation-General, documented that medication administration and documentation shall occur in a timely and accurate manner. The electronic administration record shall serve as the source from which all medications are poured and administered and on which medication doses are charted. The licensed nurse assures the five rights: compares the resident's name, medication name, strength, route and dosage schedule on the medication administration record against the prescription label and to always check three times prior to administration of medication.The undated facility policy titled, Consultant Pharmacist, documented that the facility would contract a qualified pharmacist to provide consultant pharmacist services to maintain compliance with federal and state regulations for pharmaceutical services. The Consultant Pharmacist shall perform monthly medication regimen review by reviewing all active physician orders for each resident within the facility in accordance with the federal code. The Consultant Pharmacist shall perform quality assurance audits monitoring medication storage areas throughout the facility for appropriate storage and handling of medications and shall report findings to the Director of Nursing. The policy also stated the Pharmacy Consultant shall assist in the development and revision of policies and procedures related to the use and handling of medications.The facility was unable to provide any documented agreement outlining coordination with the external opioid treatment programs.A review of methadone administration records for 10 of 23 residents revealed multiple methadone administrations with discrepancies of dosage between the physician's orders and the label on the medication bottles. 1. Resident #2 had diagnoses of endocarditis (inflammation of the inner lining of your heart valves) and opioid use disorder (a complex illness characterized by compulsive and harmful use of opioid drugs despite negative consequences). The Minimum Data Set (a resident assessment tool) dated 01/27/2026 documented that the resident had intact cognition and required partial assistance for activities of daily living. A physician's order dated 01/27/2026 documented methadone oral solution 60 milligrams daily. The methadone bottle was labeled methadone oral solution 70 milligrams daily. The electronic Medication Administration Record from 01/27/2026 to 02/11/2026 documented 60 milligrams of methadone oral solution was administered daily. 2. Resident #16 had diagnoses of heart failure (a long-term condition that affects the heart's ability to pump blood well), anemia (a condition in which the number of red blood cells concentration is lower than normal) and opioid use disorder. The Minimum Data Set, dated [DATE] documented that the resident had intact cognition and required supervision with activities of daily living.A physician's order dated 01/18/2026 documented methadone oral solution 115 milligrams daily. The methadone oral solution bottle was labeled with a dosage of 125 milligrams daily. The electronic Medication Administration Record from 01/18/2026 to 02/11/2026 documented 115 milligrams of methadone oral solution was administered daily. The controlled drug accountability record listed methadone oral solution 115mg as the medication obtained, stored, and dispensed for the resident from 01/18/2026 to 02/11/2026. 3. Resident #28 had diagnoses of anemia, asthma (a persistent respiratory condition, narrows airways, causing breathlessness and difficulty breathing) and opioid use disorder. The Minimum Data Set, dated [DATE] documented that the resident had intact cognition and required partial to moderate assistance for activities of daily living. A physician's order dated 01/23/2026 documented methadone oral solution 80 milligrams daily. The methadone oral solution bottle was labeled with a dosage of 90 milligrams daily. The electronic Medication Administration Record from 01/23/2026 to 02/11/2026 documented 80 milligrams of methadone was administered daily. 4. Resident #49 had diagnoses of anxiety disorder (an intense, excessive and persistent worry and fear about everyday situations), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and opioid use disorder. The Minimum Data Set, dated [DATE] documented that the resident had intact cognition and was independent with activities of daily living.A physician's order dated 02/05/2026 documented Methadone oral solution 40 milligrams daily. The methadone oral solution bottle was labeled with a dosage of 30 milligrams daily. The electronic Medication Administration Record from 10/01/2024 to 02/11/2026 documented 40 milligrams of methadone was administered daily. The controlled drug accountability record listed methadone oral solution 40 mg as the medication obtained, stored, and dispensed for the resident from 02/1/2026 to 02/11/2026. 5. Resident #50 had diagnoses of diabetes mellitus (a condition that affects blood sugar levels), hypertension (commonly known as high blood pressure) and opioid use Disorder. The Minimum Data Set, dated [DATE] documented that the resident had intact cognition and required partial to moderate assistance with activities of daily living.A physician's order dated 06/26/2025 with a renewal date of 02/01/2026 documented methadone oral solution 95 milligrams daily. The methadone oral solution bottle was labeled with a dosage of 85 milligrams daily. The electronic Medication Administration Record from 06/26/2025 to 02/11/2026 documented 95 milligrams of methadone was administered daily. 6. Resident #53 had diagnoses of coronary artery disease (general term for plaque buildup in the arteries), Hypertension, and opioid use disorder. The Minimum Data Set, dated [DATE] documented that the resident had intact cognition and required partial to moderate assistance with activities of daily living.A physician's order dated 01/08/2026 documented methadone oral solution 30 milligrams daily. The methadone oral solution bottle was labeled with a dosage of 24 milligrams daily. The electronic Medication Administration Record from 01/28/2026 to 02/11/2026 documented 30 milligrams of methadone was administered daily.The controlled drug accountability record listed Methadone Oral Solution 30mg as the medication obtained, stored and dispensed for the resident from 01/28/2026 to 02/11/2026. 7. Resident #114 had diagnoses of cerebral infarction (a medical condition where an area of brain tissue dies due to a lack of blood supply), schizophrenia (a serious brain disorder that causes people to interpret reality abnormally) and opioid use disorder. The Minimum Data Set, dated [DATE] documented that the resident had severely impaired cognition and was dependent with activities of daily living.A physician's order dated 11/18/2025 documented methadone oral solution 20 milligrams daily. The methadone oral solution bottle was labeled with a dosage of 30 milligrams daily. The electronic Medication Administration Record from 11/18/2025 to 02/10/2026 documented 20 milligrams of methadone was administered daily. 8. Resident #142 had diagnoses of anemia, benign prostatic hypertrophy (an enlarged prostate), and opioid use disorder. The Minimum Data Set, dated [DATE] documented that the resident had intact cognition and required substantial assistance for activities of daily living.A physician's order dated 11/06/2025 documented methadone oral solution 120 milligrams daily. The methadone oral solution bottle was labeled with a dosage of 130 milligrams daily. The electronic Medication Administration Record from 11/07/2025 to 02/11/2026 documented 120 milligrams of methadone was administered daily. 9. Resident #146 had diagnoses of hypertension, viral hepatitis (enlargement of the liver caused by a few specific viruses that primarily attack the liver), and opioid use disorder. The Minimum Data Set, dated [DATE] documented that the resident had intact cognition and was independent for activities of daily living.A physician's order dated 11/20/2023, with a renewal date of 02/01/2026 documented methadone oral solution 280 milligrams daily. The methadone oral solution bottle was labeled with a dosage of 295 milligrams daily. The electronic Medication Administration Record from 11/20/2023 to 02/11/2026 documented 280 milligrams of methadone was administered daily. 10. Resident #177 had diagnoses of coronary artery disease, heart failure and opioid use disorder. The Minimum Data Set, dated [DATE] documented that the resident had intact cognition and was dependent on activities of daily living.A physician's order dated 07/06/2022 with a renewal date of 02/01/2026 documented methadone oral solution 90 milligrams daily. The methadone oral solution bottle was labeled with a dosage of 80 milligrams daily. The electronic Medication Administration Record from 07/06/2022 to 02/12/2026 documented 90 milligrams of methadone was administered daily.The facility was unable to provide policy, procedure or documented evidence of reconciliation of clinic-supplied methadone doses. During an interview on 02/13/2026 at 11:03 AM, Licensed Practical Nurse #4 stated when administering methadone to the residents, they first check the physician's order in the electronic medical record and then administer the methadone labeled with the resident's name. They stated they do not cross-check the dosage listed on the methadone bottle against the physician's order. Licensed Practical Nurse #4 stated they had not noticed the discrepancies in dosages between the physician's orders and the dosage documented on the methadone bottle. Licensed Practical Nurse #4 stated they just realized that Residents #50 and #177's physician's order does not match the dosage on the methadone bottles. They stated they should have paid more attention. During an interview on 02/11/2026 at 10:34 AM, Registered Nurse #2 stated that residents on methadone maintenance therapy are escorted to the methadone clinic to pick up the medication. The escort hands over the methadone to the nurse on the unit. The nurse then logs the number of methadone bottles received in the controlled drug accountability record and stores it in a locked box. Registered Nurse #2 stated they do not receive any paperwork from the methadone clinic to verify the number of methadone bottles and the dosage. They stated they check the resident's name on the bottle when they receive the methadone from the escort, but they do not check for any changes in the dosage. Registered Nurse #2 stated when administering methadone to the residents, they only check the resident's name on the bottle. They stated they do not check and compare the physician's order to the dosage listed on the bottle because they are familiar with the residents. During an interview on 02/13/2026 at 11:15 AM, Registered Nurse #10 stated the escort hands them the methadone bottles when they come back from the clinic with the resident. Registered Nurse #10 stated they would not know if there were any changes in the dosage as they do not receive any type of paperwork from the methadone clinic. They stated they never contacted the clinic to verify methadone orders. Registered Nurse #10 stated they administered 30 milligrams of methadone to Resident #114 as stated on the bottle. They stated they were not aware the dosage on the bottle was different from the physician's order. During an interview on 02/13/2026 at 11:35 AM, Registered Nurse #11 stated when administering methadone to the residents, they did not check if the dosage listed on the bottle accurately reflected the physician's order. They stated they would have notified the nursing supervisor if they noticed the discrepancy. Registered Nurse #11 stated they are unsure where methadone is delivered from, but stated they assumed that it was coming from a clinic. During an interview on 02/12/2026 at 11:33 AM, Attending Physician #1 stated they have residents who attend the outpatient methadone clinic where the physician from that clinic prescribes the dosage and frequency of methadone. They stated they do not receive any physical or electronic orders from the methadone clinic. Attending Physician #1 stated the licensed nurses enter the order from the label on the methadone bottles received from the clinic into the electronic medical record and then they sign the orders. They stated they are unsure what methadone dosage each resident is supposed to receive. However, the residents must receive the dosage indicated on the methadone bottle. Attending Physician #1 further stated that the physician's order and the dosage labeled on the methadone bottle do not necessarily need to match for the nurse to administer the medication. During an interview on 02/12/2026 at 10:11 AM, the Director of Nursing stated they have residents on methadone maintenance therapy who are escorted to the methadone clinic to pick up the medication. They stated the methadone clinic determines the methadone dosage and frequency for the residents. When the resident returns from the clinic, the escort hands the medication over to the unit nurse. The unit nurse calls the attending physician with the dosage then enters the order in the electronic medical record. The Director of Nursing stated there is no receipt or other paperwork received from the clinic that will alert the nurses if there is a change in the dosage. The Director of Nursing stated that the nurse who receives the methadone from the escort is responsible for ensuring that the methadone dose as listed on the prescription bottle matches the physician's order. During an interview on 02/19/2026 at 11:42 AM, the Pharmacy Consultant stated that the medication record reviews are conducted on medications that are dispensed from the pharmacy since the pharmacy is linked with the facility's electronic medical record. They stated there is no way for them to know if the physician's order for methadone is correct or if the order matches the prescribed dosage because methadone is dispensed from an outpatient clinic. During an interview on 02/11/2025 at 1:00 PM, the Medical Director stated they have residents in the facility that are engaged in an external methadone maintenance program. They stated they did not know the process by which the methadone is delivered to the facility. They stated that the methadone dosage is determined by the methadone clinic. They stated the methadone clinic sends a report to the facility indicating the dosage and frequency for each resident, and the nurse enters it in the electronic medical record under physician's order. The Medical Director stated they electronically sign the orders without looking at the report. They stated their only responsibility is to assess the residents and renew the orders. During a follow-up interview with the Medical Director on 02/13/2026 at 2:51 PM, they indicated that the lack of established processes and communication between the facility and the methadone clinics represents a system failure. During an interview on 02/24/2026 at 2:46 PM, the Administrator stated the nurses are responsible for reconciling the physician's order and the methadone regimen as listed on the prescription bottles provided by the opioid treatment programs. They stated that the attending physicians should have performed monthly record review to ensure that there is no discrepancy between the physicians' orders and the methadone doses the residents are receiving.Immediate Jeopardy was identified, and the Director of Nursing was notified on 02/13/2026 at 6:49 PM. An acceptable immediate corrective action plan from the facility was received on 02/14/2026 at 8:50 PM. Immediate Jeopardy was removed prior to the survey exit of 02/24/2026 based on the following corrective actions taken by the facility: 1. The Director of Nursing reviewed all residents receiving methadone from an external opioid treatment program on 02/13/2026 . The review confirmed ten (10) residents (Residents #2, 16, 28, 49, 50, 53, 114, 142, 146, 177) with discrepancies of dosage between the physician's orders and the labeled methadone bottles. These 10 residents were clinically assessed and found to have no signs and symptoms of toxicity or any adverse reactions. 2. The Director of Nursing contacted each methadone clinic to confirm the current prescribed methadone dose and frequency. This was completed on 02/24/2026. 3. The Director of Nursing contacted the Medical Director and obtained telephone orders to ensure the physician's orders correspond with the doses on the methadone bottles. 4. The Pharmacy Consultant completed a regimen review of residents prescribed methadone on 02/18/2026. The audit revealed that all previous discrepancies were corrected and there were no other discrepancies identified.5. A new policy and procedure on methadone administration, order verification, reconciliation, and chain of custody was created and reviewed by the Administrator, Medical Director, and the Director of Nursing. The facility's Methadone administration order verification and reconciliation policy, establishes a formal, documented chain-of-custody process for methadone received from the external opioid treatment programs.The procedure addresses the implementation of the Reconciliation and Chain of Custody Receipt Form which documents methadone disposition from the methadone clinic to the facility. The methadone clinic program is now required to complete the reconciliation and chain of custody form when providing methadone bottles to the facility/escort, accounting for the number of bottles dispensed and any changes in the dosage or frequency of methadone as prescribed by the program. Upon facility receipt of the form and the medication on the unit, the license nurse will reconcile the received medication with the facility physician's order. In the event a discrepancy is identified, the licensed nurse will notify the RN supervisor to contact the opioid treatment program to verify the change. The RN supervisor will notify the attending physician and request an updated and accurate medication order. The discrepancy and resolution will be documented in nursing progress notes in the electronic medical record. The receipt of Methadone disposition will be signed by the escort upon receipt at the location of the program and will be signed by the receiving licensed nurse at the facility. The licensed nurse will provide the Reconciliation and Chain of Custody Receipt Form to the Registered Nurse Supervisor and will be filed in a binder to be kept in the nursing office for record and verification.This policy was effective on 02/14/2026.6. All licensed nurses, attending physicians, the pharmacy consultant, and the facility escorts received in-service on the new policy. 10 New York Codes, Rules, and Regulations 80.7510 New York Codes, Rules, and Regulations 415.18(a)

Based on observations, record reviews, and interviews conducted during the survey, the medical director failed to collaborate with the facility to develop procedures for the safe and accurate provision of medications. Specifically, the medical director failed to ensure that current standards of practice were followed regarding the development and implementation of policies to reconcile, verify, and oversee methadone medications received from external opioid treatment programs. The findings are:Please refer to F755 and F760. The facility's policy titled Physician Visits and Physician Delegation with a reviewed date of 01/2026 stated that the medical director's role is to provide oversight of medical care practices and regulatory compliance programs; and to oversee clinical standards. During an interview on 02/12/2026 at 11:33 AM, Attending Physician #1 stated they have residents on methadone maintenance program. They stated they are unsure what methadone dosage each resident is supposed to receive. However, the residents must receive the dosage indicated on the methadone bottle. Attending Physician #1 further stated that the physician's order and the dosage labeled on the methadone bottle do not necessarily need to match for the nurse to administer the medication.During an interview on 02/11/2025 at 1:00 PM, the Medical Director stated they have residents in the facility that are on methadone maintenance programs. They stated they did not know the process by which the methadone is delivered to the facility. They stated that the methadone dosage is determined by the methadone clinic. They stated the methadone clinic sends a report to the facility indicating the dosage and frequency for each resident, and the nurse enters it in the electronic medical record under physician's order. The Medical Director stated they electronically sign the orders without looking at the report and that their only responsibility is to assess the residents and renew the orders. During a follow-up interview with the Medical Director on 02/13/2026 at 2:51 PM, they indicated that the lack of established processes and communication between the facility and the methadone clinic represents a system failure. 10 New York Codes, Rules, and Regulations 415.15 (a)

Based on observation, record review, and interviews conducted during the survey, the facility failed to ensure medications were administered in accordance with physician's orders. This was evident for 10 (Residents #2, 16, 28, 49, 50, 53, 114, 142, 146, 177) of 23 residents on methadone (a long-acting opioid medication that is used to reduce withdrawal symptoms in people addicted to heroin or other narcotic drug) maintenance therapy. Specifically, the facility administered methadone doses that differed from the physician ordered dose resulting in significant medication errors. See F-755.The findings are:The undated facility policy titled Medication Administration Policy Documentation-General, documented that medication administration and documentation shall occur in a timely and accurate manner. The electronic administration record shall serve as the source from which all medications are poured and administered and on which medication doses are charted. The licensed nurse assures the five rights: compares the medication name, strength, route and dosage schedule on the medication administration record against the prescription label and to always check three times prior to administration of medication.A review of methadone administration records identified 10 of 23 residents were administered methadone with discrepancies between the physician's orders and the labeled dose on the medication bottle. 1. Resident #2 had diagnoses of endocarditis (inflammation of the inner lining of your heart valves) and opioid use disorder (a complex illness characterized by compulsive and harmful use of opioid drugs despite negative consequences). The Minimum Data Set (a resident assessment tool) dated 01/27/2026 documented that the resident had intact cognition and required partial assistance for activities of daily living.A physician's order dated 01/27/2026 documented methadone 60 milligrams daily. The methadone bottle was labeled 70 milligrams daily. The electronic Medication Administration Record from 01/27/2026 to 02/11/2026 documented 60 milligrams of methadone was administered daily. 2. Resident #16 had diagnoses of heart failure (a long-term condition that affects the heart's ability to pump blood well), anemia (a condition in which the number of red blood cells concentration is lower than normal) and opioid use disorder. The Minimum Data Set, dated [DATE] documented that the resident had intact cognition and required supervision with activities of daily living.A physician's order dated 01/18/2026 documented methadone 115 milligrams daily. The methadone bottle was labeled 125 milligrams daily. The electronic Medication Administration Record from 01/18/2026 to 02/11/2026 documented 115 milligrams of methadone was administered daily. 3. Resident #28 had diagnoses of anemia, asthma (a persistent respiratory condition, narrows airways, causing breathlessness and difficulty breathing) and opioid use disorder. The Minimum Data Set, dated [DATE] documented that the resident had intact cognition and required partial to moderate assistance for activities of daily living. A physician's order dated 01/23/2026 documented methadone 80 milligrams daily. The methadone bottle was labeled 90 milligrams daily. The electronic Medication Administration Record from 01/23/2026 to 02/11/2026 documented 80 milligrams of methadone was administered daily. 4. Resident #49 had diagnoses of anxiety disorder (an intense, excessive and persistent worry and fear about everyday situations), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and opioid use disorder. The Minimum Data Set, dated [DATE] documented that the resident had intact cognition and was independent with activities of daily living.A physician's order dated 02/05/2026 documented Methadone 40 milligrams daily. The methadone bottle was labeled 30 milligrams daily. The electronic Medication Administration Record from 10/01/2024 to 02/11/2026 documented 40 milligrams of methadone was administered daily. 5. Resident #50 had diagnoses of diabetes mellitus (a condition that affects blood sugar levels), Hypertension (commonly known as high blood pressure) and opioid use disorder. The Minimum Data Set, dated [DATE] documented that the resident had intact cognition and required partial to moderate assistance with activities of daily living.A physician's order dated 06/26/2025 with a renewal date of 02/01/2026 documented methadone 95 milligrams daily. The methadone bottle was labeled 85 milligrams daily. The electronic Medication Administration Record from 06/26/2025 to 02/11/2026 documented 95 milligrams of methadone was administered daily. 6. Resident #53 had diagnoses of coronary artery disease (general term for plaque buildup in the arteries), hypertension, and opioid use disorder. The Minimum Data Set, dated [DATE] documented that the resident had intact cognition and required partial to moderate assistance with activities of daily living.A physician's order dated 01/08/2026 documented methadone 30 milligrams daily. The methadone bottle was labeled 24 milligrams daily. The electronic Medication Administration Record from 01/28/2026 to 02/11/2026 documented 30 milligrams of methadone was administered daily. 7. Resident #114 had diagnoses of cerebral infarction (a medical condition where an area of brain tissue dies due to a lack of blood supply), schizophrenia (a serious brain disorder that causes people to interpret reality abnormally) and opioid use disorder. The Minimum Data Set, dated [DATE] documented that the resident had severely impaired cognition and was dependent on activities of daily living.A physician's order dated 11/18/2025 documented methadone 20 milligrams daily. The methadone bottle was labeled 30 milligrams daily. The electronic Medication Administration Record from 11/18/2025 to 02/10/2026 documented 20 milligrams of methadone was administered daily. 8. Resident #142 had diagnoses of anemia, benign prostatic hypertrophy (an enlarged prostate), and opioid use disorder. The Minimum Data Set, dated [DATE] documented that the resident had intact cognition and required substantial assistance for activities of daily living.A physician's order dated 11/06/2025 documented methadone 120 milligrams daily. The methadone bottle was labeled 130 milligrams daily. The electronic Medication Administration Record from 11/07/2025 to 02/11/2026 documented 120 milligrams of methadone was administered daily. 9. Resident #146 had diagnoses of hypertension, viral hepatitis (enlargement of the liver caused by a few specific viruses that primarily attack the liver), and opioid use disorder. The Minimum Data Set, dated [DATE] documented that the resident had intact cognition and was independent for activities of daily living.A physician's order dated 11/20/2023, with a renewal date of 02/01/2026 documented Methadone 280 milligrams daily. The methadone bottle was labeled 295 milligrams daily. The electronic Medication Administration Record from 11/20/2023 to 02/11/2026 documented 280 milligrams of methadone was administered daily. 10. Resident #177 had diagnoses of coronary artery disease, heart failure and opioid use disorder. The Minimum Data Set, dated [DATE] documented that the resident had intact cognition and was dependent on activities of daily living.A physician's order dated 07/06/2022 with a renewal date of 02/01/2026 documented methadone 90 milligrams daily. The methadone bottle was labeled 80 milligrams daily. The electronic Medication Administration Record from 07/06/2022 to 02/12/2026 documented 90 milligrams of methadone was administered daily. During an interview on 02/13/2026 at 11:03 AM, Licensed Practical Nurse #4 stated when administering methadone to the residents, they first check the physician's order in the electronic medical record and then administer the methadone labeled with the resident's name. They stated they do not cross-check the dosage listed on the methadone bottle against the physician's order. Licensed Practical Nurse #4 stated they had not noticed the discrepancies between the physician's order and the dosage documented on the methadone bottle. Licensed Practical Nurse #4 stated they just realized that Residents #50 and #177's physician's order does not match the dosage on the methadone bottles. They stated they should have paid more attention. During an interview on 02/11/2026 at 10:34 AM, Registered Nurse #2 stated when administering methadone to the residents, they only check the resident's name on the bottle. They stated they do not check the physician's order and the dosage listed on the bottle because they are familiar with the residents. Registered Nurse #2 stated they were aware they were supposed to ensure that the dosage on the methadone bottle matches the physician's order to prevent medication error. During an interview on 02/13/2026 at 11:15 AM, Registered Nurse #10 stated they administered 30 milligrams of methadone to Resident #114 as stated on the bottle. They stated they only followed the dosage on the bottle and had not noticed that it was different from the physician's order. During an interview on 02/13/2026 at 11:35 AM, Registered Nurse #11 stated when administering methadone to the residents, they only followed the dosage on the bottle. They stated they had not noticed that the dosage on the methadone bottle differed from the physician's order. They stated they would have notified the nursing supervisor if they noticed the discrepancy. During an interview on 02/12/2026 at 11:33 AM, Attending Physician #1 stated the methadone clinic prescribes the dosage and frequency of methadone. They stated they do not receive any physical or electronic orders from the methadone clinic. Attending Physician #1 stated the licensed nurses enter the order from the label on the methadone bottles received from the clinic into the electronic medical record and they then sign the orders. They stated they are unsure what methadone dosage each resident is supposed to receive. However, the residents must receive the dosage indicated on the methadone bottle. Attending Physician #1 further stated that the physician's order and the dosage labeled on the methadone bottle do not necessarily need to match for the nurse to administer the medication. During an interview on 02/12/2026 at 10:11 AM, the Director of Nursing stated the methadone clinic determines the methadone dosage and frequency for the residents. They stated the resident is escorted to the methadone clinic to pick up the medication. When they return, they hand the medication over to the unit nurse. The unit nurse calls the attending physician with the dosage then enters the order in the electronic medical record. The Director of Nursing stated there is no receipt or other paperwork received from the clinic. During an interview on 02/11/2026 at 1:00 PM, the Medical Director stated they have residents in the facility that are on a methadone maintenance program. They stated they do not know the process by which the methadone is delivered to the facility. They stated that the methadone dosage is determined by the methadone clinic. They stated the methadone clinic sends a report to the facility indicating the dosage and frequency for each resident, and the nurse enters it in the electronic medical record under physician's order. The Medical Director stated they electronically sign the orders without looking at the report. They stated their only responsibility is to assess the residents and renew the orders. During a follow-up interview with the Medical Director on 02/13/2026 at 2:51 PM, they indicated that the lack of established processes and communication between the facility and the methadone clinic represents a system failure. 10 New York Codes, Rules, and Regulations 415.12 (m)(2)

Based on observation, record review, and interviews during the surveythe facility failed to ensure timely assessment and evaluation of a resident's change in condition. This was evident for one (1) (Resident #7) of three (3) residents reviewed. Specifically, Resident #7 had a bruise on top of their left eyebrow extending towards the temple that was not identified, assessed, or documented until observed by the State Surveyor. The resident was identified as high risk for falls and was receiving aspirin therapy, which increases the risk for bleeding complications. The facility failed to conduct and document a skin assessment, evaluate for possible head injury, initiate monitoring, or notify the physician in accordance with professional standards of practice. This resulted in no actual harm with a potential for serious harm that is Immediate Jeopardy to all residents' health and safety.The findings include: The facility policy titled Skin Assessment dated 01/2026 documented it is the policy of this facility to ensure that each resident receives skin assessment on an ongoing basis to identify alterations in skin integrity and ensure appropriate interventions are implemented. The purpose is to ensure timely identification, monitoring, and documentation of skin integrity in accordance with regulatory requirements and accepted standards of nursing practice. The assessment will include identification and documentation of skin condition and the presence or absence of wounds or abnormalities. Licensed nursing staff will assess and document skin integrity for residents identified as at risk, upon change in condition, following a fall or injury, and as clinically indicated. The physician will be notified of new skin breakdown or significant change in skin condition. Notification will be documented in the medical record. Residents identified with skin integrity issues will have appropriate interventions implemented and reflected in the resident's care plan. Skin assessments and related findings will be documented in the medical record. Resident #7 had diagnoses of dementia (loss of memory), diabetes mellitus (a condition affecting how the body regulates blood sugar), and atherosclerotic heart disease (narrowed or blocked arteries). The quarterly Minimum Data Set (a resident assessment tool) dated 12/30/2025 documented Resident #7 had severely impaired cognition and required substantial or maximal assistance with activities of daily living, transfers, and ambulation. A care plan titled Fall was initiated on 04/26/2025 and was last updated on 01/14/2026. The facility interventions included providing required assistance with activities of daily living and half hourly checks for safety. The physician's orders dated 01/13/2026 documented Aspirin 81 milligram chewable tablet give one (1) tablet by oral route once daily for atherosclerotic heart disease.A care plan titled at risk for easy bruising related to the use of aspirin was initiated for Resident #7 on 04/26/2025 and was last updated on 01/14/2026. The facility interventions included to observe for bruising. On 02/09/2026 at approximately 12:55 PM, Resident #7 was observed in the unit dining room sitting in a wheelchair, with a greenish bruise on top of their left eyebrow extending towards the left temple. The resident was also observed with a red thin linear bruise under their left eye that was about half an inch long. A review of Resident #7's medical record revealed no documented assessment of the bruise, no investigation for a possible fall or injury, no neurological assessment or monitoring, and no physician notification. Additionally, there was no care plan update related to the injury. On 02/09/2026 at 3:21 PM, Certified Nursing Assistant #1 who provided activity of daily living care for Resident #7 on 02/04/2026 at 7:00 AM - 3:00 PM shift, 02/05/2026 to 02/06/2026 at 7:00 AM - 3:00 PM and 3:00 PM - 11:00 PM shift; and on 02/08/2026 to 02/09/2026 at 3:00 PM - 11:00 PM shift, was interviewed and stated they were not aware Resident #7 had facial bruises until the State Surveyor questioned them. Certified Nursing Assistant #1 also stated they were unaware of any falls or injury Resident #7 may have sustained during their shifts.On 02/09/2026 at 3:22 PM, Registered Nurse #1 who administered morning medications to Resident #7 on 02/08/2026 and 02/09/2026 was interviewed and stated Resident #7 has a slight discoloration on their forehead and that it was not a bruise, although they did notice a slight difference of skin color on the resident's forehead. Registered Nurse #1 stated they first noticed it when the State Surveyor inquired about it. Registered Nurse #1 also stated they were not notified by staff that Resident #7 had a fall or a facial bruise either.On 02/09/2026 at 3:24 PM, Licensed Practical Nurse #1, who administered medications to Resident #7 for the 3:00 pm - 11:00 pm shift on 02/04/2026 to 02/06/2026 and 02/09/2026, was interviewed and stated they had only noticed the bruise on Resident #7's forehead when the State Surveyor questioned them. They stated they were not aware of how Resident #7 sustained the facial bruise and were not aware of any falls or injury Resident #7 may have sustained during their shifts. On 02/10/2026 at 3:03 PM, the Attending Physician was interviewed and stated they had not received reports from the staff about Resident #7 having an injury or facial bruise. They stated as with any injury to the head; they would have ordered neurological checks or computed tomography (an imaging test that uses a series of x-rays and a computer to create detailed images of your bones and soft tissues). On 02/10/2026 at 4:08 PM, the Director of Nursing was interviewed and stated the bruise on Resident #7's forehead was not reported to them; therefore, it was not investigated. The Director of Nursing stated they only found out about the bruise on 02/10/2026 when the nursing supervisor asked for documents related to it.On 02/24/2026 at 2:24 PM, the Administrator was interviewed and stated the staff are to notify the nurse if they observe any bruise or any discoloration during care. The nurse should assess the resident and notify nursing leadership so the injury can be investigated. Immediate Jeopardy was identified, and the Director of Nursing was notified on 02/12/2026 at 5:03 PM. An acceptable immediate corrective action plan from the facility was received on 02/13/2026 at 3:32 PM. Immediate Jeopardy was removed prior to the survey exit of 02/24/2026 based on the following corrective actions taken by the facility:The Director of Nursing conducted a full investigation of Resident #7's forehead bruise on 02/12/2026 which included staff statements and the Administrator was notified at 5:00 PM. The investigation concluded there was no cause to believe any alleged resident abuse, mistreatment, or neglect regarding this resident had occurred. This was reported to the Department of Health on 02/12/2026 at 7:26 PM, Complaint #2743051.The Director of Nursing completed Resident #7's head to toe and pain assessment on 02/12/2026 with no concerns noted. The attending physician was notified on 02/12/2026 and ordered x-rays of left eye orbit and skull left temporal region; x-ray results were received on 02/13/2026 indicating negative for fractures. The resident's next of kin was notified on 02/12/2026. Record review revealed neurological checks were initiated for Resident #7 as per physician orders and were completed on 02/15/2026 with no concerns. A care plan related to risk of injury was initiated on 02/12/2026. The facility interventions included monitoring Resident #7 for anticoagulation-related bleeding risk if injury occurs, to assess and monitor resident for fall risk, and skin assessment each shift for any change of condition. A care plan related to aspirin use was updated on 02/16/2026. The facility added interventions for certified nursing assistants to observe Resident #7 for any bleeding or skin discoloration and to immediately report to the nurse. A review of five (5) sampled resident's medical records revealed that information about whether a resident is at high risk for skin breakdown, such as residents at risk for falls or on anti-coagulant, was included in the certified nursing assistants' accountability records along with instructions to promptly report any changes in skin condition to the nurse. Full body assessments of all residents were completed on 02/24/2026. The State Surveyor reviewed body assessments of all residents with the Director of Nursing with no concerns identified. An in-service education on quality of care was conducted from 02/12/2026 - 02/24/2026. The lesson plan included education on identifying changes in condition, new skin impairment/injury identification, reporting, assessment and investigation, and escalation requirements so that necessary care and follow-up can be provided. 100% of clinical staff and certified nursing assistants received the in-service education. Staff interviews confirmed they received in-services on injury identification and reporting. 10 New York Codes, Rules, and Regulations 415.12

Based on observation, record review, and interviews the facility failed to ensure all alleged violations involving injury of unknown source were reported immediately, but not later than two (2) hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury to the State Survey Agency. This was evident for one (1) (Resident #7) of four (4) sampled residents. Specifically, on 09/13/2025 Resident #7 was unable to stand on their left leg and was transferred to the hospital. The resident was readmitted to the facility on [DATE] with diagnoses of left femur (thigh bone) fracture (break in the bone). Resident #7 was severely impaired in cognition and was unable to explain how they sustained the fracture. The facility reported the injury of unknown source to the New York State Department of Health on 09/23/2025 at 11:53 PM, 10 days after the change in resident's condition was observed. The findings are: The facility policy titled Reporting Alleged Violations with a reviewed date of 03/2025 documented the purpose of the policy was to ensure that all alleged violations are reported immediately to the facility Administrator and other officials. The policy stated the facility must ensure all alleged violations involving abuse, neglect, exploitation or mistreatment must be reported immediately. This includes injury of unknown source and misappropriation of resident property. Resident #7 had diagnoses of Dementia (loss of memory), Type 2 Diabetes Mellitus (a condition affecting how the body regulates blood sugar), and Major Depressive Disorder (depression). The Quarterly Minimum Data Set (a resident assessment tool) dated 08/20/2025 documented Resident #7 had severely impaired cognition and required supervision or touching assist for transfers and ambulation. A nurse's progress note dated 09/13/2025 at 3:13 PM documented that Resident #7 was unable to stand on their left leg. The physician ordered to transfer the resident to the hospital. A nurse's progress note dated 09/22/2025 at 9:58 PM documented that Resident #7 was re-admitted from the hospital at about 2:20 PM. The admission diagnosis was closed left hip fracture (a break in the left hip bone that does not penetrate the skin). The facility's Summary of Investigation dated 09/23/2025 documented that on 09/13/2025 at around 1:00 PM, Certified Nursing Assistant #15 reported to Licensed Practical Nurse #1 that Resident #7 complained of left leg pain. The resident was assessed by Registered Nurse #9 with no visible injury, no redness, and no swelling. The resident was observed with weakness to the left leg and lethargic. The attending physician was notified and ordered to transfer the resident to the hospital and was admitted with diagnosis of closed left hip fracture. The summary of investigation documented that Resident #7 was unable to provide any history due to dementia, there was no reported fall or traumatic incident. The facility concluded that the hospital x-ray (a device that projects images) showed fracture of the left femur and vascular calcifications were present. The summary documented that vascular calcifications are common in the elderly and could lead to pathological fracture. There was no cause to believe that any alleged resident abuse, mistreatment or neglect had occurred. A review of Resident #7's facility and hospital medical records showed no documentation that the fracture was pathological. The Webform submission email confirmation dated 09/23/2025 at 11:55 PM documented the Nursing Home Facility Incident Report was successfully submitted on 09/23/2025 at 11:53 PM. On 12/09/2025 at 3:40 PM, the Director of Nursing was interviewed and stated Resident #7 was transferred to the hospital because they could not stand. They stated they followed up with the hospital, but the hospital would not disclose any information. The Director of Nursing stated Resident #7 returned to the facility on [DATE] but found out about the fracture the next day during the morning meeting. They stated they knew the injury has to be reported to the New York State Department of Health, but the nursing supervisor did not immediately notify them. They stated they reported the injury once they were informed. On 12/09/2025 at 3:45 PM, the Administrator was interviewed and stated they were not aware there was a delay in reporting. They stated the Quality Assurance committee will determine what caused the delay and they will conduct staff education on proper notification and will conduct audits to ensure that injuries are reported to the department heads and to the Department of Health. 10 NYCRR 415.4 (b)(2)

Based on observation, record review, and interviews, the facility failed to ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Specifically, 1.) The walk-in refrigerator contained prepared food items and defrosting meats that were unlabeled and undated. 2.) A pantry refrigerator contained expired, undated and unlabeled resident food.The findings are:The facility's policy and procedure titled Safe Defrosting and Food Labeling, with a revision date of 01/2025, documented that all potentially hazardous foods should be thawed and labeled safely to prevent foodborne illness and comply with Department of Health and regulatory requirements. All prepared, opened, or repackaged foods stored in refrigeration, freezers, or dry storage must be clearly labeled with the product name, date prepared or opened, and use-by/discard date. All frozen food items placed into the freezer must be labeled with the product name and the date frozen. When frozen items are removed from the freezer and placed into refrigeration for thawing, the item must also show the thaw date if held more than 24 hours. Any food found unlabeled, incorrectly dated or past the use-by/discard date must be immediately discarded. It is the responsibility of all food service staff to ensure food is properly labeled and dated at the time of preparation, opening, freezing, or repackaging. The Food service Director or designee will conduct routine checks (daily refrigerator/freezer round) to monitor compliance. The facility's policy and procedure titled Outside Food and Beverage with a revision date of 06/2025, documented established rules for bringing outside food and beverages into the facility in order to protect the health, safety, and dietary needs of residents. Outside food and beverages may be brought into or delivered to the facility for residents, subject to this policy. Any outside food left at the facility to be stored in the facility refrigerator for later use must be labeled with the resident's name and the date. Unlabeled or unidentified food may be discarded. The facility's undated policy and procedure titled Food Pantry Refrigerators and Temperature Logs, documented that all foods in the pantry refrigerators more than three (3) days old will be discarded. 1.) During an observation in the kitchen on 12/01/2025 at 9:20AM, the following was noted:The Walk-in Refrigerator contained:One (1) unlabeled quarter pan of cooked beans dated 11/26/2025.One (1) unlabeled, undated full pan of raw seasoned pork.Unlabeled and undated defrosting meats including: two (2) whole turkey breasts, two (2) two-pound packages of sliced ham, three (3) two-three-pound packages of sliced bologna, three (3) whole pork loins.On 12/01/2025 at 9:53 AM, the Dietary Supervisor was interviewed and stated that all items should be labeled with the product name and dated with the date opened, date prepared, date placed in refrigerator for defrost and date to be removed from defrost. All food items that are unlabeled and undated should be discarded immediately. Unused dated food items should be discarded within 72 hours, and defrosted food items should be removed from the refrigerator within 48 hours. The Food Service Supervisor also stated that they perform kitchen rounds daily as it is their responsibility to ensure compliance and that they performed kitchen rounds today which included observation of the walk-in refrigerator, but they did not see the unlabeled, undated and defrosting food items. On 12/01/2025 at 11:55 AM, a follow up interview was performed with the Dietary Supervisor who stated that they spoke with Dietary Aide #1 by telephone who was responsible for placing the unlabeled, undated meats in the refrigerator. The Dietary Supervisor stated that Dietary Aide #1 reported that they placed a paper with the date under the food items and is not sure what happened to the paper. The Dietary Supervisor further stated that the product name and dates should have been securely labeled on the food items to ensure proper and sanitary storage, use and disposal. On 12/09/2025 at 2:15 PM and 3:37 PM, a telephone interview was attempted with Dietary Aide #1. The telephone calls placed were unanswered.2.) On 12/05/2025, the following were noted during the observation of the Sixth Floor pantry refrigerator:There were two (2) plastic bags labeled with Resident #54's name. The first bag contained two (2) one-pound open packages of Swiss cheese with a sell by date of 11/25/2025; an open package of ham with a sell by date of 11/05/2025, an open container of butter with olive oil with a best buy date of 08/25/2025; an undated large bowl of peas and rice, and an undated container with soup. The second bag contained an undated bowl of seafood salad and a bowl of rice. During an interview on 12/05/2025 at 2:45 PM, Licensed Practical Nurse #1 stated that resident food contained in the pantry refrigerator should be discarded within three (3) days. The nurses check the refrigerators daily for temperatures and expired, unlabeled, undated food and beverages but sometimes the residents will not allow the staff to discard the food despite having been spoken to by supervisors. During an interview on 12/05/2025 at 2:55 PM, Registered Nurse Supervisor #3 stated that the pantry refrigerators should be checked daily by the staff for adequate temperatures and to ensure resident food items are labeled, dated and discarded timely. Registered Nurse #3 also stated that sometimes, they check to see if the staff has performed the pantry refrigerator tasks, but they have been on vacation from October to 11/25/2025 and have not followed up since their return to see if the nurses are discarding resident food within three (3) days. During an interview on 12/06/2025 at 3:51 PM, the Dietary Supervisor stated that labeled and dated resident food can remain in the pantry refrigerators for three (3) days and then the food must be discarded. The Dietary Supervisor also stated that the dietary staff places snacks and nourishments in the pantry refrigerators daily and at that time they check that the refrigerated food is dated and labeled with the resident name and room number and that the food is discarded within three (3) days. The Dietary Supervisor also stated that resident food is not discarded by the floor staff as they are told that the residents become agitated. The Dietary Supervisor further stated that this issue has to be resolved with residents and families by nursing and social work. During an interview on 12/09/2025 at 3:15 PM, the Director of Nursing stated that each unit has a certified nursing assistant assignment every shift to check the pantry refrigerators for dated, labeled resident food and to discard the food items after three (3) days. The Director of Nursing also stated that the nursing supervisor should perform rounds to ensure compliance and follow up with the resident and families if there is an issue. The Director of Nursing further stated that they also should have performed rounds but has not this week because of the survey.During an interview on 12/09/2025 at 11:33 AM, the Administrator stated all food items should be labeled and dated when received in the kitchen, when prepared or rewrapped for freezing and defrosting. If food items are not, they should be discarded. The Administrator also stated that after the Director of Food Service left the facility, they reviewed kitchen audit tools including the overall pathways from The Center from Medicare and Medicate Services with the dietary supervisor. They asked them to follow the pathways to ensure compliance. The audits were to be used as a guide for food labeling, storage dates, temperatures, food handling and receiving. The Administrator further stated that they met with the dietary supervisor last week and went through their rounding responsibility and that they also perform kitchen rounding for temperatures and storage, but they did not look for details in the walk-in refrigerator including defrosting meats. 10 NYCRR 415.14(h)

Based on observation, record review, and interviews, the facility failed to ensure a qualified dietitian or another clinically qualified nutrition professional, including a director of food and nutrition services, was employed part-time, full-time, or as a consultant. Specifically, the facility has employed a non-registered dietician as their full-time dietician and food service director without the oversight of a registered dietician or certified food service director since September 2025.The findings are:The undated facility policy, titled Food Service Management, documented that the food and nutrition services department head must meet New York State Department of Health requirements for food service manager, and plans, organizes, supervises, and directs all administrative and operational activities of the Food and Nutrition Services Department.A review of the Facility Survey Report, New York State Department of Health Form 1550, revealed it was signed by the facility operator and principal partner and dated 12/01/2025. The report lists the license number of the previous registered dietician (Facility Dietician #1) and designates them as the Registered Dietician and Food Service Director. The report does not list any other staff as the designated dietician or food service director.During an interview on 12/03/2025 at 2:30 PM, Facility Dietician #2 stated that they are not a registered dietician, but they had been employed at the facility since 2022 on a per diem basis and worked two (2) days a week. They stated that they were currently hired to work part to full time, because there has not been a full-time registered dietician or food service director in the facility since September 2025. Facility Dietician #2 further stated that they perform all tasks related to residents, such as dietary assessments, assess for allergies, diet recommendations, and weight monitoring. However, they do not perform any administrative duties such as meetings, supervision of staff or review of policies and procedures.During an interview on 12/04/2025 at 3:01 PM, the Medical Director stated that they were told the registered dietician was terminated in October 2025, and that they were expecting an immediate replacement for the position. The Medical Director also stated that they have discussed the issue with the facility Administrator and the Director of Nursing but have not been provided with any details on when the position will be filled. The Medical Director further stated that they review residents' weights, prescribed diets, care plans and they attend the monthly weight meetings to ensure that residents' nutritional needs are met, and significant weight changes are addressed.During an interview on 12/09/2025 at 11:33 AM, the Administrator stated that currently, they do not have a registered dietician employed at the facility. The previous food service director was also the registered dietician, and they resigned at the end of September 2025. Since that time, the facility has not employed another registered dietician. The Administrator stated they had contracted with a nutrition consultant who was able to find a registered dietician for the facility to hire, However, they were told the person would be able to start later this week. The Administrator stated that they intend to hire a new food service director within two (2) weeks. The facility will then have a full time and part time registered dietician. The Administrator further stated that the current facility dietician, who is not registered, has been employed at the facility per diem since 2020.10 NYCRR 415.14(a)(1)(2)

Based on record review, observation, and interviews conducted during an abbreviated survey (NY00373346), the facility did not ensure a comprehensive clinical assessment was done to identify changes in a resident's condition. The facility did not ensure residents receive treatment and care in accordance with professional standards of practice. This was evident in one (1) out of four (4) residents sampled (Resident #1). Specifically, on [DATE], Resident #1 was observed with stuffy nose, low grade fever of 100.5-degree Fahrenheit, and restlessness. There was no documented evidence that the medical doctor was informed of the resident's change in condition. Additionally, there was no documented evidence that the resident was assessed after the acetaminophen was administered. Resident #1expired on [DATE]/2025 at 9:49 AM due to cardiac arrest secondary to coronary artery disease. This resulted in actual harm to Resident #1 with the potential for serious injury, serious harm, serious impairment, or death that was not Immediate Jeopardy. The findings are: The facility's Policy and Procedure titled Change in Resident Condition dated ,d+[DATE], documented it is the facility's purpose to ensure timely identification, documentation, and appropriate response to any significant change in a resident's condition to maintain safety and quality of care. The resident will be monitored closely, and additional assessments will be conducted as needed. Resident #1 was admitted to the facility with diagnoses of Non-Alzheimer's Dementia, Schizophrenia (chronic mental illness characterized by disruptions in thought, perception, emotion, and behavior), Traumatic Brain Injury with Epilepsy, and Urinary/Fecal incontinence and Constipation. The Minimum Data Set (a resident assessment tool) dated [DATE], documented Resident #1 was severely cognitively impaired. Licensed Practical Nurse #2 documented in a nursing note dated [DATE] at 6:51 AM, Resident #1's vital signs were not done due to Resident #1 being restless. Registered Nurse Supervisor #2 was notified and assessed Resident #1 for restlessness in bed. Their body temperature was normal, but they were unable to check vital signs secondary to restlessness. A nursing note written by Licensed Practical Nurse #1 dated [DATE] at 10:25 PM, documented Resident #1 was restless in bed, and had increased temperature of 100.5-degree Fahrenheit. Registered Nurse Supervisor #1 was notified, and Resident #1 was given acetaminophen ordered as needed for fever. There was no documented evidence that the Medical Doctor was notified of Resident #1's elevated temperature and restlessness in bed. A nursing note written by Licensed Practical Nurse #3 dated [DATE] at 2:42 PM documented, around 8:53 AM, Licensed Practical Nurse #3 went in the day room to administer medication and observed Resident #1 sitting in recliner wheelchair with face down and arms flex down. Resident #1 was not moving, unable to palpate a pulse and pupils (black hole in the center of the eye) of the eye not moving. Resident #1 had an advance directive for a full code. Code Blue (an emergency alert system) was announced, and Resident #1 was taken to their room and Cardiopulmonary Resuscitation was initiated until the fire department and 911 (emergency medical number) arrived and took over. Resident #1 was pronounced expired on [DATE] at 9:49 AM, by Emergency Medical Services. During an interview on [DATE] at 9:14 AM, Resident #1's family (the complainant) stated an autopsy was requested because the facility did not provide details leading to Resident #1's death. During an interview on [DATE] at 11:06 AM, Medical Doctor #1 stated they were called on [DATE] approximately at 10:00 AM and notified that Resident #1 expired. Medical Doctor #1 stated Resident #1 expired due to cardiac arrest secondary to coronary artery disease. The Medical Doctor #1 further stated, they were not notified when Resident #1 had an increased temperature or was experiencing restlessness. During an interview on [DATE] at 11:56 AM, Certified Nursing Assistant #1 stated they worked on [DATE] during the 3:00 PM-11:00 PM shift and observed Resident #1 looked weaker and notified Licensed Practical Nurse #1. Certified Nursing Assistant #1 stated Resident #1 moved their bowel a small amount. During an interview on [DATE] at 4:40 PM, Licensed Practical Nurse #1 who worked on [DATE] during the 3:00 PM-11:00 PM shift, stated Resident #1 was observed with a stuffy nose and restlessness in bed. The Registered Nurse Supervisor #1 was notified. The COVID -19 rapid test was done, and the result was negative. Acetaminophen was given because Resident #1 had low grade fever of 100.5-degree Fahrenheit. During an interview on [DATE] at 9:01 AM, Registered Nurse Supervisor #1 stated they conducted assessment on Resident #1 but does not remember if they documented it in the medical record. Registered Nurse Supervisor #1 stated they tried to call the Medical Doctor but was unsuccessful. During an interview on [DATE] at 10:23 AM, Director of Nursing stated the nurses must notify the doctor and family when Resident #1 had fever and was restless. The Director of Nursing stated once acetaminophen was administered, there should have been a follow up assessment an hour after the medication was given. 10 NYCRR 415.12

Based on observations, interviews, and record review conducted during the Abbreviated Survey and Partial Extended Survey (Complaint NY00362627, NY00363035, NY00363415, and NY00358811), the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition. This was evident in 5 of 5 resident units Specifically, the facility failed to routinely maintain their boiler equipment. This resulted in the facility's heating system malfunctioning, causing temperatures in residents' rooms and common areas to fall below the required range. This resulted in no actual harm with likelihood for more than minimal harm that is Immediate Jeopardy and substandard quality of care to resident health and safety, in accordance with 42 CFR Part 483 and 10 NYCRR: 415.29 The findings are: A review of the facility's boiler service contracts revealed the annual service contract to maintain the boiler system expired on [DATE], the facility currently had no service contract in place. A service quote dated [DATE] for a total of $48,776 documented the vendor proposed to remove the objections for the 14 boilers identified in a previous inspection by another vendor. The facility did not act on this recommendation. On [DATE], the vendor sent a proposal to provide quarterly annual maintenance services on the boilers, which the facility did not act on. Review of Boiler Vendor #1, quote no. 136, dated [DATE], revealed a proposal to remove the boiler objections identified on a previous inspection on 14 boilers for a total of $48,776. The facility failed to address the recommendations. Review of Boiler Vendor #1, quote no. 139, dated [DATE], revealed a proposal to provide quarterly annual services. The facility failed to address the recommendations. Review of Vendor #1 Invoice no. 2024800 for a service visit on [DATE], revealed the Director of Maintenance had requested an assessment of the boilers that provide heating and hot water, in preparation for winter. Review of Vendor #1 Invoice no. 20241186 for a service visit on [DATE], revealed the facility had reported insufficient heat. The vendor identified 5 of the 13 boilers in working order. Review of Vendor #1 Invoice no. 20241204, for a service call on [DATE], revealed boiler #6 had to be turned off which left 5 of 13 boilers functioning again. Review of Vendor #1 invoice no. 20241225 for service calls from [DATE] through [DATE], revealed there was insufficient heat in the building. On [DATE]the vendor billed for a mechanic and an assistant for 4 hours during the day to service PTAC units on the 6th Floor and noted there was an insufficient amount of hot water, due to some of the boilers not working. An additional service call was made on [DATE] when the facility placed a night call for lack of heat throughout the building. A Saturday call was made to the vendor on [DATE] when the facility again reported a lack of heat throughout the building. The invoice states boilers need to be serviced as soon as possible, as lack of heat is attributed to an insufficient number of boilers working. A service call was made on [DATE] to service PTAC units on the 6th Floor. There was no documented evidence the facility's heating system equipment, including the boilers and Packaged Terminal Air Conditioners, was being inspected and maintained by facility staff. Observations during the initial tour of the facility on [DATE] from 9:00 AM to 11:30 AM revealed temperatures in resident rooms, corridors, and stairwells were below State and Federal required ranges. Temperatures were observed between ,d+[DATE] degrees Fahrenheit. The East, North, and South Stairwells were measured at 40 degrees Fahrenheit. The resident rooms located closest to the stairwells had the lowest temperature readings. On [DATE] at 1:15 PM, the Director of Maintenance was interviewed and stated the Packaged Terminal Air Conditioner units were not blowing hot air because they were connected incorrectly. The Director of Maintenance stated they made the Administrator aware of the issue. On [DATE] at 1:30 PM, the Administrator was interviewed and stated they were not aware there was loss of heat in the building or that resident room temperatures were below regulatory ranges. They were not aware temperatures in some rooms had dropped below 60 degrees Fahrenheit. The Administrator stated the Packaged Terminal Air Conditioner units were not necessary because the boiler provides heat. The Administrator stated they were not aware the boiler was also not providing heat. During an interview on [DATE] at 1:15 PM, Vendor #1, stated they serviced the boilers at the facility in [DATE] for an issue of no hot water. The vendor stated the boilers had several problems that stemmed from a lack of maintenance and were operating at about 40%. This contributed to the hot water not getting hot enough to provide hot water or heating for the building. The vendor stated several proposals were sent to the Administrator and the Director of Maintenance via email. The Vendor further stated they had serviced the boilers at the facility in previous years but had stopped because of unpaid bills. For them to return in [DATE], they were given a check for a past-due balance. On [DATE] at 1:00 PM, during a subsequent interview, the former Director of Maintenance stated that in the 6 months they were employed at the facility, they attempted to get the boilers serviced. They stated they called the vendor to schedule the services, but they would not come in because of overdue unpaid balances. The Director of Maintenance stated they referred those calls to the Administrator. The Director of Maintenance stated they were not allowed to order materials or services without prior approval from the Administrator. Immediate Jeopardy was identified, and the Administrator was notified on [DATE] at 7:25 PM. An acceptable immediate corrective action plan from the facility was received on[DATE], at 11:32 PM Immediate Jeopardy was removed prior to survey exit on [DATE] based on the following corrective actions taken by the facility: 1. Packaged Terminal Air Conditioner units were deployed to all affected areas. Residents were relocated to warmer areas of the facility and twice daily temperature checks of all residents' rooms were conducted by the facility. A review of the temperature logs from [DATE] to [DATE] revealed temperatures within acceptable ranges. 2. Extra blankets and clothing were distributed to the residents by Housekeeping and Activities staff, hot beverages were provided, and residents had the option of staying in the warmer common areas. 3. The Administrator provided a vendor contract for annual boiler maintenance and the maintenance of Packaged Terminal Air Conditioner units. 4. The facility completed staff training on identifying and addressing temperature-related issues, procedures for reporting problems, deploying emergency measures, and ensuring resident comfort. 100% of staff received the in-service. 5. A Quality Assurance meeting was held on [DATE] to discuss the findings of the Immediate Jeopardy. Wall thermometers have been installed in residents' rooms and staff were given in-service education on reading the thermometers. 6. The Emergency Preparedness plan for Loss of Heat was revised to include immediate deployment of portable units and proactive monitoring and escalation processes for heating issues. 10 NYCRR 415.29(b)

Based on observation, record review, and interviews conducted during the Abbreviated Survey and Partial Extended Survey (Complaint NY00362627, NY00363035, NY00363415, and NY00358811), the facility failed to ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the Administrator failed to provide effective leadership and oversight to ensure that comfortable and safe temperature levels were maintained in residents' rooms and common areas. In addition, the Administrator failed to have an effective system in place to ensure the boiler room equipment was maintained in safe operating condition. This resulted in no actual harm with the likelihood of more than minimal harm to all residents in the facility, which was Immediate Jeopardy. The findings are: 1. Cross refer to F584. Six resident grievances were filed between 12/02/2024 and 12/06/2024 concerning the lack of heat in their rooms. During an observation on 12/06/2024 from approximately 9:30 AM to 11:30 AM and from 8:00 PM to 9:00 PM, temperature readings in corridors, stairwells, and 59 out of 59 sampled rooms were below the State and Federal required ranges. The Administrator denied being aware that there was loss of heat in the building. 2. Cross refer to F908. There was no documented evidence the boiler room equipment and the Packaged Terminal Air Conditioner units were routinely maintained. During an interview on 12/06/2024 at 1:15 PM, the Director of Maintenance was interviewed and stated the Packaged Terminal Air Conditioner units were incorrectly connected and were not blowing hot air. During a subsequent interview on 12/26/2024 at 1:00 PM, the Director of Maintenance stated in the 6 months they were employed at the facility, they attempted to get the boilers serviced. They stated they called the vendor to schedule the services, but they would not come in because of overdue unpaid balances. The Director of Maintenance stated they referred those calls to the Administrator. The Director of Maintenance stated they were not allowed to order materials or services without prior approval from the Administrator. During an interview on 12/06/2024 at 1:30 PM, the Administrator stated they were not aware there was loss of heat in the building. The Administrator stated Packaged Terminal Air Conditioner units were not needed to provide heat in residents' rooms because the facility has boilers. The Administrator stated they were not aware the boilers were also not working. During an interview on 12/13/2024 at 1:15 PM, Vendor #1, stated they serviced the boilers at the facility in June 2024, for an issue of no hot water. The vendor stated the boilers had several problems that stemmed from a lack of maintenance and were operating at about 40%. This contributed to the hot water not getting hot enough to provide hot water or heating for the building. The vendor stated several proposals were sent to the Administrator and the Director of Maintenance via email. The Vendor further stated they had serviced the boilers at the facility in previous years but had stopped because of unpaid bills. They stated that they only returned in June 2024, because the facility submitted a check for their past-due balance. On 12/26/2024 at 1:00 PM, the former Director of Maintenance stated that he had received invoices and proposals from Boiler Vendor #1 via email and that the Administrator was on the same emails. During an interview on 12/17/2024, at 12:40 PM, the Administrator stated their emails are reviewed at least once per day. The Administrator denied receiving any invoices, proposals, or recommendations from any vendors. Immediate Jeopardy was identified, and the Administrator was notified on 12/12/2024 at 7:25 PM. An acceptable immediate corrective action plan from the facility was received on 12/12/2024 at 11:32 PM. Immediate Jeopardy was removed prior to survey exit on 12/19/2024 based on the following corrective actions taken by the facility: 1. The Administrator is conducting end-of-day and weekly meetings with department heads to review any issues. 2. 100% of staff have been in-serviced (except those on vacation), a policy was created on how agency staff will also be in-serviced. 3. Morning meetings attended by all department heads are being conducted. 4. Resident council meeting was rescheduled to Friday 12/20/2024. 5. The Administrator provided documentation of regular rounds. 6. Observation of a binder created of Vendor Documents and placed at the Security Desk by the elevators. 7. Emergency Preparedness plan for loss of heating was revised, and discussed at the QAPI meeting, the Administrator is the Acting Director of Maintenance 10 NYCRR 415.26

Based on observations, record review, and interviews conducted during the Abbreviated Survey and Partial Extended Survey (Complaint NY00362627, NY00363035, NY00363415, NY00358811) beginning [DATE], it was determined that this Special Focus Facility failed to maintain safe and comfortable temperature levels. This was evident on five of five resident floors, where 59 out of 59 rooms sampled had temperatures below the Federal and State requirements in accordance with 42 CFR Part 483 and 10 NYCRR: 415.29. Specifically, four complaints were submitted to the State Agency regarding loss of heat in the facility from [DATE] through [DATE], naming six residents affected. An additional six residents filed grievances at the facility on the loss of heat in their rooms from [DATE] through [DATE]. The facility did not have documented evidence they had identified resident room temperatures were at safe and comfortable ranges. This resulted in no actual harm with likelihood for more than minimal harm to all residents in the facility, which was Immediate Jeopardy and Substandard Quality of Care. The findings are: Observations during the initial tour of the facility on [DATE], from 9:00 AM to 9:00 PM included temperatures in resident rooms, corridors, and stairwells below State and Federal required ranges. Temperatures were observed between (,d+[DATE] degrees Fahrenheit). East, North, and South Stairwells were measured at 40 degrees Fahrenheit. The resident rooms located closest to the stairwells had the lowest temperature readings, as low as 53 degrees Fahrenheit. On [DATE], from 11:00 AM to 12:00 PM, a review of the Maintenance Logbooks located at the Nurse's Stations, on 5 of 5 resident floors, had entries stating that the heating was not working. These entries were made from [DATE] through [DATE] and identified 23 resident rooms that were very cold. On [DATE] at 1:30 PM, the Administrator was interviewed and stated they were not aware there was a loss of heat in the building or that resident rooms were below regulatory ranges. They were not aware that temperatures in some rooms had dropped below 60 degrees Fahrenheit. The Administrator stated the Packaged Terminal Air Conditioner (PTAC) units (self-contained heating and air conditioning system), were not necessary because the boiler provides heat. The Administrator further stated they were not aware the boiler was also not providing heat. The Administrator stated they were in the facility on Sunday, [DATE], just to ensure everything in the building was going well. A review of the Grievance Book revealed that from [DATE] to [DATE], six residents complained that their rooms have been cold. In an interview on [DATE] at 10:45 AM, the Director of Social Services stated that these grievances had been discussed at two Morning Meetings and at a Resident Council Meeting. A review of the facility's policy on Heating/Cooling, revised on ,d+[DATE] and ,d+[DATE], reveals that it is the facility policy to maintain indoor temperatures within the range of ,d+[DATE] degrees Fahrenheit. The policy also states that the Administrator is responsible for maintaining service contracts for routine and emergency maintenance of heating and cooling systems. A review of the Daily Room Temperature Log Readings for [DATE] to [DATE], revealed that hallway and resident room temperatures on resident floors ranged from 67- 70 degrees Fahrenheit, one resident room was listed at 71 degrees Fahrenheit. The resident room number were not indicated on the log, nor which corridor was measured. The temperature logs listed one temperature reading, once per day. Maintenance Staff #1 stated that temperatures were taken at a random location on each floor. Review of an annual service contract dated [DATE], revealed the service contract expired on [DATE]. A review of the annual service contract with Vendor #2 to maintain the boiler system, dated [DATE], revealed there was no service contract in place from February 2024 through [DATE] for preventive maintenance. Review of Boiler Vendor #1, quote no. 136, dated [DATE], revealed a proposal to remove the boiler objections of a previous report on 14 boilers for a total of $48,776. The facility failed to address the recommendations. Review of Boiler Vendor #1, quote no. 139, dated [DATE], revealed a proposal to provide quarterly services for 12 months. The facility failed to address the recommendations. Review of Vendor #1 Invoice no. 2024800 for a service visit on [DATE], revealed the Director of Maintenance had requested an assessment of the boilers that provide heating and hot water, in preparation for winter. Review of Vendor #1 Invoice no. 20241186 for a service visit on [DATE], revealed the facility had reported insufficient heat. The vendor identified 5 of the 13 boilers in working order. Review of Vendor #1 Invoice no. 20241204, for a service call on [DATE], revealed boiler #6 had to be turned off which left 5 of 13 boilers functioning again. Review of Vendor #1 invoice no. 20241225 for service calls from [DATE] through [DATE], revealed there was insufficient heat in the building. On [DATE] the vendor billed for a mechanic and an assistant for 4 hours during the day to service PTAC units on the 6th Floor and noted there was an insufficient amount of hot water due to some of the boilers not working. An additional service call was made on [DATE] when the facility placed a night call for lack of heat throughout the building. A Saturday call to the vendor was made on [DATE] when the facility again reported a lack of heat throughout the building. The invoice states boilers need to be serviced as soon as possible, as lack of heat is attributed to an insufficient number of boilers working. A service call was made on [DATE] to service PTAC units on the 6th Floor. During an interview on [DATE] at 1:15 PM, Vendor #1, stated they serviced the boilers at the facility in [DATE], for an issue of no hot water. The vendor stated the boilers had several problems that stemmed from a lack of maintenance and were operating at about 40%. This contributed to the hot water not getting hot enough to provide hot water or heating for the building. The vendor stated several proposals were sent to the Administrator and the Director of Maintenance via email. The Vendor further stated they had serviced the boilers at the facility in previous years but had stopped because of unpaid bills. For them to return in [DATE], they were given a check for a past due balance. During an interview on [DATE], at 12:40 PM, the Administrator stated their emails are reviewed at least once per day. The Administrator denied receiving any invoices, proposals, or recommendations from any vendors. During an interview on [DATE], at approximately 12:00 PM, Activities Staff #1 and #2, stated they had been called into work on Sunday, [DATE], to distribute hot drinks because of the heating issue. Record review of Nursing In-services, revealed cold weather/cold temperature in-servicing started on [DATE]. Record review of the Grievance log, revealed that from [DATE] to [DATE], six residents complained it was too cold in their rooms. During an interview with the Medical Director on [DATE] at approximately 4:00 PM, the Medical Director stated they were not aware of any heat-related issues in the building. The Medical Director stated if the room temperatures fell below 50 degrees Fahrenheit and remained there for an extended period then residents may develop hypothermia. It is all based on how long the residents were exposed to cold temperatures. Immediate Jeopardy was identified, and the Administrator was notified on [DATE] at 7:25 PM. An acceptable immediate corrective action plan from the facility was received on [DATE] at 11:32 PM Immediate Jeopardy was removed prior to survey exit on [DATE] based on the following corrective actions taken by the facility: 1. Packaged Terminal Air Conditioner units were deployed to all affected areas. Residents were relocated to warmer areas of the facility and twice daily temperature checks of all residents' rooms were conducted by the facility. A review of the temperature logs from [DATE] to [DATE] revealed temperatures within acceptable ranges. 2. Extra blankets and clothing were distributed to the residents by Housekeeping and Activities staff, hot beverages were provided, and residents had the option of staying in the warmer common areas. 3. The Administrator provided a vendor contract to provide annual maintenance to boilers, and for the maintenance of Packaged Terminal Air Conditioner units. 4. The facility completed staff training on identifying and addressing temperature related issues, procedures for reporting issues, deploying emergency measures, and ensuring resident comfort. 100% of staff received the in-service. 5. A Quality Assurance meeting was held on [DATE] to discuss the findings of the Immediate Jeopardy. Wall thermometers have been installed in residents' rooms and staff were given in-service education on reading the temperature. 6. The Emergency Preparedness plan for Loss of Heat was revised to include immediate deployment of portable units and proactive monitoring and escalation processes for heating issues. 10 NYCRR: 415.29

Based on record review and interviews conducted during the Recertification and Complaint (NY00350179) from 11/13/2024 to 11/21/2024, the facility did not ensure that residents were free from abuse, neglect, and exploitation. This was evident in 2 (Resident #118 and #151) of 6 residents reviewed for Abuse. Specifically, Resident #118 who had history of stealing and being involved in physical altercations, was not provided supervision and monitoring despite the staff being aware of Resident #118's behavior. Subsequently, on 08/02/2024, Resident #118 snatched a $20 bill from Resident #151's hand while they were on the elevator. Resident #151 hit Resident #118's head with a cane. Resident #118 sustained head lacerations that required emergency medical intervention. Resident #118 had 14 staples to the wound. This resulted in actual harm to Resident #118 that was not Immediate Jeopardy. Cross Reference: F657 - Care Plan Timing and Revision The findings are: The facility's policy on Abuse Prohibition and Prevention with a reviewed date of 05/2023 documented the intent of the policy was to prevent/prohibit resident abuse. The facility has zero tolerance for abuse and must provide a safer resident environment and protect all residents. The policy defined abuse as the willful infliction of injury. Willful was defined as the individual acting deliberately to inflict injury or harm. The policy documented that abuse can be resident to resident. A Resident Occurrence Form dated 08/02/2024 documented that at 11:15 AM, Resident #118 was hit in the head with a cane by Resident #151 while they were in the basement. Resident #118 stated while getting in the elevator in the basement, a resident who was inside the elevator hit them in the head with a cane and they did not know why. Resident #118 was sent to the emergency roiagnom on [DATE] at 12:15 PM. Computed Tomography (also called a CT scan, is a type of imaging that uses X-ray techniques to create detailed images of the body) of the head was completed at the hospital with no acute findings, and no acute fractures of the facial bones. The Incident/Accident Employee Statement completed by the Registered Nurse Supervisor dated 08/02/2024 documented Resident #151 was interviewed by the nursing supervisor and stated they had an altercation with Resident #118 in the elevator at the basement. Resident #151 stated Resident #118 snatched their money. Resident #118 hit Resident #151 while trying to retrieve their money. Resident #151 stated they retaliated. The undated facility's Summary of Investigation documented that on 08/02/2024 at around 11:15 AM, Resident #118 was involved in an altercation with Resident #151 in the basement elevator. The facility investigation revealed there was cause to believe resident abuse had occurred. The documented Resident #118 insisted to ride the elevator but Resident #151 told Resident #118 that the door would not close. Resident #118 then grabbed the $20 bill from Resident #151's hand. Resident #151 hit Resident #118 with a cane. The incident was witnessed by 3 other residents who were present in the elevator . Resident #118 was sent to the hospital for follow-up care on 08/02/2024 and returned to the facility on [DATE]. Resident #118 sustained injury to the head with 14 staples to their scalp. 1.) Resident #151 was admitted to the facility with diagnoses of Chronic Kidney Disease, Opioid Abuse with withdrawal, and Chronic Obstructive Pulmonary Disease (a term for lung and airway diseases that restrict your breathing). The Minimum Data Set assessment dated [DATE] documented Resident #151 had moderate impairment in cognition and had no behavioral symptoms. A care plan for victimization was initiated for Resident #151 on 05/26/2022. The facility intervention included to redirect as needed. A care plan note by the social worker dated 08/13/2024 documented Resident #151 was reported to be involved in a physical altercation with a peer. Resident #151 stated Resident #118 stole their money. Social Worker provided counseling. There was no documented evidence the interventions on the comprehensive care plan were reviewed or evaluated after the resident-to-resident physical abuse on 08/02/2024. 2.) Resident #118 was admitted to the facility with diagnoses which included Violent Behavior, Unspecified Mood Disorder, and Parkinson's Disease. The quarterly Minimum Data Set assessment (a resident assessment and care tracking tool) dated 08/09/2024 documented Resident #118 had moderate impairment in cognition and required supervision for most activities of daily living. The Minimum Data Set did not document any behavioral symptom. A nurse's note dated 08/02/2024 at 12:52 PM documented Resident #118 was hit in the head by another resident with a cane at around 11:20 AM. Resident #118 had bleeding from the head, 911 was called and was transferred to the emergency room . A nurse's note dated 08/03/2024 at 12:50 PM documented a call was received from the physician at the emergency room who stated Resident #118 had been treated with lacerations to the head and had 14 staples. The physician stated Resident #118 was in police custody while at the emergency room . A nurse's note dated 08/04/2024 at 5:29 PM documented Resident #118 was admitted from the hospital at 4:30 PM. Resident #118 was assessed with 2 lacerations on the head, each measured 5 centimeters in length, with 14 staples. The emergency room after visit summary dated 08/04/2024 documented Resident #118's reason for visit was headache. Computed Tomography images of the brain was completed on 08/03/2024, no intracranial (within the skull) mass or bleeding, lacerations of bilateral frontal scalp, underlying calvarium (top part of skull) was intact. A medical progress note by Staff Physician #1 dated 08/05/2024 at 6:21 AM documented Resident #118 had mild pain at the wound site of the head injury. Current medications were reviewed with no changes made, to start Tylenol 1000 milligrams as needed every 8 hours. A medical wound consultant note by Nurse Practitioner #1 dated 08/05/2024 at 6:54 AM documented Resident #118 was hit in the head in an altercation. Resident had 2 lacerations on the head, 3 centimeters each, with 14 staples. Apply betadine (a topical antiseptic) and leave open to air. A care plan for victimize/victimization was initiated for Resident #118 on 06/27/2023. The facility interventions included identifying triggers for behavior, room change as appropriate, and close observation on every half hour to check for behavior and safety monitoring. The care plan notes documented on 09/01/2023, Resident #118 was accused by another resident of stealing their wallet. This resulted in Resident #118 being pushed by the other resident and falling to the floor. A care plan for mood and behavior patterns were initiated for Resident #118 on 06/27/2023 and was last reviewed on 08/09/2024. The care plan documented Resident #118 had behavior of taking multiple towels and bed sheets and attempted to snatch a candy from another resident. The facility interventions included monitoring changes in cognition, mood, and behavior and to notify the physician; encourage daily activities, and to encourage socialization with peers. The care plan notes documented Resident #118 had history of non-compliance with care and exposing their private parts while in the day room. A care plan for victimization/aggressive behavior was initiated for Resident #118 on 06/27/2023.The facility interventions included psychiatric evaluation, 1:1 monitoring, and protecting from overstimulation. The care plan notes documented Resident #118 had been involved in an altercation with another resident on 09/15/2023 and 04/21/2024. A care plan note by the social worker dated 08/28/2024 documented Resident #118 had an altercation with a peer on 08/02/2024, social worker will continue to follow up. There was no documented evidence the care plan was updated after the resident to resident physical abuse on 08/02/2024. There was no documented evidence of close observation or every half hour check and no documented evidence of 1:1 monitoring as stated in the 06/27/2023 care plan interventions. On 11/18/2024 at 11:35 AM, Certified Nursing Assistant #3 was interviewed and stated Resident #118 was alert and oriented to person, place, and time and does not follow instructions. Certified Nursing Assistant #3 stated Resident #118 had behavior issues like wandering to other units and stealing things from other residents or staff when no one was inside the room. Certified Nursing Assistant #3 stated they redirect Resident #118 when the Resident was on the unit however, they do not monitor Resident #118 when they leave the unit. On 11/20/2024 at 10:20 AM, Certified Nursing Assistant #9 was interviewed and stated they took something down to the basement on 08/02/2024 and observed Resident #151 and #118 fighting in the elevator. Certified Nursing Assistant #9 stated they tried to stop the residents from fighting and called for help. On 11/20/2024 at 10:29 AM, Licensed Practical Nurse # 2 was interviewed and stated Resident #118 liked to steal things from other residents on their unit and goes to other floors to steal things. Licensed Practical Nurse #2 stated they do not know if Resident #118 is monitored when the resident leaves the unit and goes to other floors. On 11/21/2024 at 03:06 PM, Licensed Practical Nurse #1 was interviewed and stated they would see Resident #118 on their unit (a different unit from Resident #118's unit), but they do not monitor them. On 11/20/2024 at 11:42 AM, Registered Nurse #1 was interviewed and stated they were not sure if the staff on other floors were aware of Resident # 118's behavior or if Resident #118 was monitored when they went to other floors. On 11/20/2024 at 11:48 AM, The Director of Social Services was interviewed and stated Resident #118 often steals and they were aware of the altercation Resident #118 had with Resident #151 on 08/02/2024. They stated their role was to advocate for Resident #118, but it was the nursing department's responsibility to initiate interventions and monitor Resident #118's behavior. On 11/21/2024 at 3:38 PM, the Director of Nursing was interviewed and stated they were aware of Resident #118's behavior issues such as stealing and exposing themselves. The Director of Nursing stated the nurse supervisor is responsible for updating the care plans to manage Resident #118's behavioral issues. The Director of Nursing had no response as to how Resident #118 was monitored and supervised when they leave their unit. 10 NYCRR 415.4(b)(1)(i)

Based on record review, interviews, and observations conducted during the Recertification and Complaint (NY00350179) Survey from 11/13/2024 to 11/21/2024 the facility did not ensure that comprehensive care plans were reviewed and revised periodically and after each assessment including both the comprehensive and quarterly review assessments. This was evident for 3 (Resident #84, #118, and #151) of 7 residents reviewed for Catheter Care and Abuse out of 38 total sampled residents. Specifically, 1.) Resident #84's care plan for indwelling catheter/external urinary appliance was not reviewed and revised after the Resident returned from an emergency room visit due to urinary retention and pain at the urinary catheter insertion site. Additionally, Resident #84's care plan for indwelling catheter/external urinary appliance was not reviewed and/or revised after each comprehensive and quarterly review assessments. 2.) Resident #118's care plan interventions for behavior and victimization were not reviewed and evaluated after the resident to resident physical abuse on 08/02/2024. 3.) Resident #151's care plan interventions were not reviewed and evaluated following a resident to resident physical altercation on 08/02/2024. This resulted in actual harm to Resident #118 that was not Immediate Jeopardy. Cross Reference: F600 - Free from Abuse and Neglect The findings are: The facility policy and procedure titled Comprehensive Care Plans dated 08/2024 documented it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 1.) Resident #84 was admitted to the facility with diagnoses of Benign Prostatic Hyperplasia with Lower Urinary Tract Symptom (prostate enlargement that includes urinary frequency, urgency, dribbling at the end of urination, and not being able to fully empty the bladder) and Obstructive Uropathy (a condition when urine cannot flow due to obstruction). The annual Minimum Data Set assessment (a resident assessment and care screening tool) dated 08/26/2024 documented Resident #84 was cognitively intact. The assessment documented Resident #84 had an indwelling urinary catheter. Further review of Resident #84's Minimum Data Sets revealed quarterly assessments were completed on 03/04/2024 and 06/04/2024. The quarterly assessments documented Resident #84 had an indwelling urinary catheter. On 11/14/2024 at 10:17 AM, Resident #84 was observed in their room. The Resident was interviewed, and they stated they went to the urology clinic yesterday and had their Foley catheter (a medical device that helps drain urine from your bladder) changed. Resident #84 stated their Foley catheter is changed at the urology office and the drainage bag is changed at the facility weekly. A physician's order with an original order date of 11/01/2023 and a renewal date of 11/15/2024 documented general orders for Foley catheter French #16, balloon size, 10 milliliters for Obstructive Uropathy; to change the Foley catheter monthly every 20th of the month and as needed for blockage. An order for urology follow-up for Foley catheter change in 6 weeks was entered on 11/13/2024. A care plan on indwelling catheter/external urinary appliance was initiated for Resident #84 on 11/02/2023. The facility interventions included to observe urine for sediment, cloudy, odor, blood, and amount; to observe for urinary tract infection; to change the catheter as ordered or when blocked, keep drainage bag below suprapubic level and off the floor, and to provide sterile technique when changing catheter. A nurse's progress note dated 10/12/2024 at 9:23 PM documented Resident #84 complained of abdominal pain and stated their Foley catheter was not draining enough and they would like to go to the hospital. Resident #84 was transferred to the hospital for further evaluation. The emergency room provider note dated 10/13/2024 documented Resident #84 presented with chronic indwelling Foley catheter, with complaints of urinary retention for 2 days and pain at the Foley insertion site. The bedside sonogram showed full bladder, resident with acute urinary retention. Urethral catheterization (a standard method of accessing the urinary bladder with the use of a flexible catheter to allow urine to drain) was inserted for relief of acute urinary retention. Resident was discharged from the emergency department on 10/13/2024. A medical progress note dated 10/15/2024 at 3:50 AM documented the date of service was on 10/14/2024. The medical note documented Resident #84 returned from emergency room and was seen for follow up. Resident #84 was stable, the assessment and plan documented were to monitor for any changes, to continue with monitoring of lower urinary symptoms and Foley catheter care every shift, to notify the physician if signs of infection and bleeding were noted. There was no documented evidence Resident #84's comprehensive care plan related to urinary catheter was reviewed and/or revised following the emergency room visit on 10/12/2024 due to urinary retention and pain at the urinary catheter insertion site. There was no documented evidence the same care plan was reviewed and/or revised after the quarterly assessments on 03/04/2024 and 06/04/2024, and after the annual assessment that was completed on 08/26/2024. On 11/20/2024 at 10:26 AM, Registered Nurse #1 was interviewed and stated Registered Nurses on duty are responsible for initiating the comprehensive care plans for newly admitted residents. They stated Registered Nurses are also responsible for reviewing and revising a resident's care plan quarterly and if there is a change in a resident's status. Registered Nurse #1 stated that recently it has been the external consultants the facility hired, who have been updating the residents' care plans. Registered Nurse #1 could not explain why Resident #84's care plan on indwelling catheter was not reviewed. On 11/20/2024 at 4:09 PM, the Director of Nursing was interviewed and stated the nursing supervisors are responsible for initiating the care plans on admission and for updating the care plans quarterly and as needed. The Director of Nursing stated they also assist in updating the residents' care plans. They stated Resident #84's care plan not being reviewed must have been an oversight. 44843 2.) Resident #118 was admitted to the facility with diagnoses which included Violent Behavior, Unspecified Mood Disorder, and Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements). The quarterly Minimum Data Set assessment (a resident assessment and care tracking tool) dated 08/09/2024 documented Resident #118 had moderate impairment in cognition and required supervision for most activities of daily living. The Minimum Data Set did not document any behavioral symptom. A care plan for victimize/victimization was initiated for Resident #118 on 06/27/2023 and was last reviewed on 11/08/2024. The facility interventions include identifying triggers for behavior, room change as appropriate, and close observation on every half hour to check for behavior and safety monitoring. The care plan notes documented that on 09/01/2023, Resident #118 was accused by another resident of stealing their wallet. This resulted in Resident #118 being pushed by the other resident and falling to the floor. A nurse's note dated 08/02/2024 at 12:52 PM documented Resident #118 was hit in the head by another resident with a cane at around 11:20 AM. There was no documented evidence the care plan was updated after the 08/02/2024 incident. A care plan for mood and behavior patterns were initiated for Resident #118 on 06/27/2023 and was last reviewed on 08/09/2024. The care plan documented the Resident had behaviors of taking multiple towels and bed sheets and attempted to snatch a candy from another resident. The facility interventions included monitoring changes in cognition, mood, and behavior and to notify the physician; encourage daily activities, and to encourage socialization with peers. The care plan notes documented Resident #118 had a history of non-compliance with care and exposing their private parts while in the day room. A care plan for victimization/aggressive was initiated for Resident #118 on 06/27/2023 and was last reviewed on 08/29/2024. The facility interventions included psychiatric evaluation, 1:1 monitoring, and protecting from overstimulation. The care plan notes documented Resident #118 had been involved in an altercation with another resident on 09/15/2023 and 04/21/2024. There was no documented evidence the interventions documented on the comprehensive care plan were reviewed and evaluated after resident-to-resident physical abuse on 08/02/2024. There was no documented evidence of close observation, or every half hour checks and no documented evidence of 1:1 monitoring as stated in the care plan interventions. 3.) Resident #151 was admitted to the facility with diagnoses of Chronic Kidney Disease, Opioid Abuse with withdrawal, and Chronic Obstructive Pulmonary Disease (is a term for lung and airway diseases that restrict your breathing). The Minimum Data Set assessment dated [DATE] documented Resident #151 had moderate impairment in cognition and had no behavioral symptoms. A care plan for victimization was initiated for Resident #151 on 05/26/2022 and was last reviewed on 08/13/2024. The facility intervention included to redirect as needed. There was no documented evidence the interventions documented on the comprehensive care plan were reviewed and evaluated after resident to resident physical abuse on 08/02/2024. On 11/20/2024 at 11:48 AM, The Director of Social Services was interviewed and stated their role was to advocate for Resident #118, but it was the nursing department's responsibility to initiate interventions and monitor Resident #118's behavior. On 11/21/2024 at 3:38 PM, the Director of Nursing was interviewed and stated the nurse supervisor is responsible for updating the care plans. 10 NYCRR 415.11(c)(2)(i-iii)

Based on observation, record review, and interviews conducted during the Extended Recertification and Complaint survey (NY 383, NY 660 and NY 005) from 07/21/2022 through 08/03/2022, the facility did not ensure residents were adequately supervised to prevent smoking accidents. This was evidenced for 4 of 4 residents reviewed for Smoking. (Resident #s 196, 82, 33, and 48) Specifically, the facility failed to provide adequate supervision and interventions to address residents with unsafe smoking and smoking in their rooms. Additionally, incidents of unsafe smoking were not investigated to determine adequate interventions to prevent recurrence. This was evident for 4 (Resident #s 196, 48, 82, and 33) of 4 residents reviewed for smoking. Resident #196 was identified as a smoker when admitted on [DATE] and had a BIMS score of 12 out of 15, indicating moderately impaired cognition. A smoking safety assessment was not completed, and a smoking care plan was not developed. A Social Work (SW) note dated 5/13/2022 documented the fire alarm sounded in Resident #196's room. The room smelled of smoke, a room search was done, and a cigarette box and ashes were found. Resident #196 was reminded the facility is smoke-free, and Resident #196 denied smoking. The Fire Alarm Report documented the fire alarm was triggered in Resident #196's room due to unsafe smoking on 3/18/2022, 5/1/2022, and 6/1/2022. There was no documented evidence Resident #196 was provided a 30-day discharge notice, had increased monitoring, or care planned interventions to address the unsafe smoking. There was no documentation the incidents of unsafe smoking were investigated. A SW Note dated 07/26/2022 documented Resident #196 was observed smoking marijuana in their room. Resident #196 was educated about the smoking policy, informed the facility is non-smoking, and offered a nicotine patch and gum. The SW documented the ethics committee would meet, and a 30-day discharge notice would be provided when a placement was found. Resident #s 48, 82, and 33 also had incidents of unsafe smoking that were not investigated. There was no evidence of increased monitoring or new interventions implemented after the incidents. During observations of the stairwells conducted on 7/26/22, surveyors smelled smoke and found cigarette butts throughout the stairwells. This resulted in Substandard Quality of Care that was Immediate Jeopardy (IJ) with the likelihood for serious injury, serious harm, serious impairment, or death to all residents smoking unsafely without adequate assessment and supervision. It was identified and declared. The IJ began on 07/26/2022 and was called on 07/27/2022 at 05:12 PM The facility submitted a removal plan on 07/28/2022 at 01:42 AM. IJ was removed 08/01/2022 at 05:36 PM. The findings include but are not limited to: The facility policy titled Smoking Free Facility dated 04/2020, documented the following: -The facility initiated a smoke free policy on April 2020 due to COVID-19 Public Health Emergency and will promote smoking cessation while ensuring resident safety. -Smoking is prohibited in all areas of the facility and residents admitted after the facility became smoke-free will be notified of this policy during the admission process, and as needed. -All residents will be asked about tobacco use urges during admission, quarterly, or upon comprehensive Minimum Data Set 3.0 (MDS) assessment. 1.) Resident #196 was admitted [DATE] with diagnoses of [CONDITION(S)] and [CONDITION(S)]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #196 had mild moderately impaired cognition and required limited to extensive assistance to complete Activities of Daily Living (ADL). On 7/26/2022 at 12:25 PM, the South Stairwell (SS) alarm sounded, and Resident #196 was observed exiting the SS and entering the unit. Staff were not observed responding to the door alarm. Resident #196 was observed silencing the SS door alarm. On 07/26/2022 from 06:30 PM to 6:45 PM, observations of the SS were conducted: there was a strong odor of cigarette smoke; a burnt cigarette butt (CB) on the floor between the 5th and 6th floor; 4 CBs placed behind a fire hydrant pipe on the 5th floor landing; 3 CBs stuffed into cracks in the wall by the sprinkler pipe between the 3rd and 4th floor landings; 1 CB on the 4th floor landing; multiple CBs stuffed behind the fire standpipe risers of the 4th floor; 1 CB on the 2nd floor landing; and, 10 CBs in a space between the staircase and the wall between the 2nd and 1st floor. On 07/26/2022 at 06:48 PM, the North Stairwell (NS) 3rd floor landing was observed with 1 CB behind a fire hydrant pipe. The SW admission note dated 06/16/2021 documented Resident #196 identified themselves as a smoker, was informed of the facility smoking policy, and would be assessed for smoking. Fire Alarm Records dated 03/18/2022, 05/1/2022, and 06/1/2022 documented the fire alarm was triggered in Resident #196's room due to cigarette smoke. SW note dated 05/13/2022 documented the fire alarm sounded in the Resident #196's room. The room smelled of cigarette smoke, a room search was done, and a cigarette box and ashes were found. Resident #196 was reminded the facility is smoke-free. A SW note dated 07/26/2022 documented Resident #196 was observed smoking Marijuana in their room. Resident #196 was educated about the smoking policy, informed the facility is smoke-free, and offered a nicotine patch and gum. The ethics committee will meet, and a 30-day discharge notice will be provided to Resident #196 when a placement is found. There was no documented evidence the facility assessed Resident #196 for smoking, provided adequate supervision to prevent smoking incidents, investigated incidents of unsafe smoking, or addressed the resident's unsafe smoking with revised care plan interventions. On 07/27/2022 at 08:56 AM, the Registered Nurse (RN #2) assigned to Resident #196's unit, was interviewed and stated staff do not monitor resident use of the stairwells. Residents are not allowed to use the stairwell, but there are residents who use the stairwell when the elevator takes too long. Staff check the stairwells when the stairwell door alarms sound. 2.) Resident #82 had diagnoses of [CONDITION(S)] ([CONDITION(S)]) on Hemodialysis and Diabetes. The MDS assessment dated [DATE] documented Resident #82 was cognitively intact and required limited to extensive assist with Activities of Daily Living (ADL). On 07/21/2022 at 10:01 AM and 07/25/2022 at 11:51 AM, Resident #82 was observed in bed in their room. The room had a strong odor of stale cigarette smoke. Resident #82 was interviewed and stated they smoke in their room sometimes because the facility does not address their smoking concerns. Resident #82 could not recall being informed of the facility smoking policy. Social Work (SW) Assessments dated 05/28/2021, 01/19/2022, and 05/26/2022 documented Resident #82 reported being a smoker. There was no documented plan to address Resident #82 as a smoker. A SW note dated 6/10/2022 documented the SW met with Resident #82 on multiple occasions due to noncompliance with smoking safety regulations, but Resident #82 continued to smoke in the facility. A Nicotine patch was offered, and the Medical Doctor (MD) was made aware. The was no documented evidence the MD evaluated and assessed Resident #82 for smoking cessation or intervention. A SW note dated 7/18/2022 documented Resident #82 was observed by nursing staff smoking in the facility despite being counseled on current regulations and guidelines. Resident #82 became verbally and physically aggressive by using profanity and throwing objects at staff. There was no documented evidence the facility assessed Resident #82 for smoking, provided adequate supervision to prevent smoking incidents, investigated incidents of unsafe smoking, or addressed the resident's unsafe smoking with revised care plan interventions. On 07/25/2022 at 12:04 PM, Certified Nursing Assistant (CNA) #1 was interviewed and stated they observe Resident #82 smoking in their room all the time. When the fire alarm goes off, the security announces the location of suspected smoke/fire, and the staff conduct a search of the room. CNA #1 never found smoking materials when they searched residents' rooms. The Registered Nurses (RN) Supervisors, SW, and Administrator are aware there are constant smoking issues. On 07/25/2022 at 11:54 AM, an interview was conducted with RN Supervisor #1 who stated the facility is smoke-free, and most of the smokers don't leave the building to smoke. Some of the smoking residents smoke in their rooms, and the alarm goes off very often. RN Supervisor #1 was not aware of a facility plan to address the smoking residents. The staff reinforce with smoking residents that the facility is smoke-free. 3.) Resident #33 was admitted to the facility on [DATE] with [CONDITION(S)] due to spinal cord injury and major depressive disorder. The MDS dated [DATE] documented Resident #33 was cognitively intact and required the extensive assist of two people for bed mobility and transfers. The Baseline Comprehensive Care Plan (CCP) dated 11/24/2021 documented Resident #33's status as a smoker was a safety concern. On 07/21/2022 at 10:02 AM, Resident #33 was observed in their room and the room had strong cigarette smoke smell. The Social Work (SW) assessment dated [DATE] documented Resident #33 smokes cigarettes. The SW notes dated 04/28/2022, 5/05/2022, 5/06/2022, and 06/10/2022, documented Resident #33 was counseled on facility regulations and guidelines due to smoking in the facility. Resident #33 continued to be noncompliant, and a nicotine patch was offered. There was no documented evidence the facility assessed Resident #33 for smoking, provided adequate supervision to prevent smoking incidents, investigated incidents of unsafe smoking, or addressed the resident's unsafe smoking with revised care plan interventions. On 07/27/2022 at 10:39 AM, Housekeeper was interviewed and stated residents use the stairwell. The Housekeeper found cigarette butts in the stairwell previously and reported it to their supervisor. On 7/26/2022 at 11:12 AM, the Director of SW (DSW) was interviewed and stated the DSW informs potential residents the facility is smoke-free prior to admission by providing brochures and facility information to the hospital discharge planner. Potential residents are aware the facility is smoke-free and the DSW is not involved in approving potential residents for admission. The SWs meet with residents on the first day they are admitted to the facility and reinforces the facility is smoke-free. Residents with a history of smoking are offered nicotine gum and patches or a transfer to a facility that allows smoking. If a resident violates the smoking policy, the DSW searches their room, revokes their visitation and out-on-pass privileges, and gives them a 30-day discharge notice. The issue of unsafe smoking began in 10/2021 and, in the past, the facility issued 30-day discharge notices to 2 residents due to unsafe smoking. On 07/26/22 at 11:17AM, an interview was conducted with the Director of Nursing (DON) who stated prospective residents are informed the facility is smoke-free prior to admission. Noncompliant unsafe smoking residents receive counseling from the SW. Residents are offered smoking cessation. Resident family members were notified the facility became smoke free and not to bring in cigarettes to the residents. The unsafe smokers are having difficulty accepting the facility smoking policy. On 7/26/2022 at 11:29 AM, the Administrator was interviewed and stated residents continue to smoke despite the facility being smoke-free. Noncompliant residents are counseled, informed they may receive a 30-day discharge notice, and the family is made aware. Residents and visitors bring smoking materials into the facility. The Administrator did not identify smoking as a concern. The Administrator stated he/she did not think the unsafe smokers in the facility required assessments and care plan interventions because the facility became smoke-free, and the residents were informed of the policy upon admission. On 07/27/2022 05:12 PM, Immediate Jeopardy (IJ) was identified and declared. The facility Administrator and Director of Nursing were notified. On 07/28/2022 at 01:42 AM, the facility submitted a removal plan that was reviewed and accepted by the NYSDOH. On 08/01/2022 at 05:36 PM, the survey team declared the IJ was removed based on the following corrective actions taken by the facility: 1- For Resident #196 and Resident #82, smoking assessments, Smoking Comprehensive Care Plans (CCP), and smoking contracts were completed. Both residents were observed with one-to-one monitoring, room searches conduct every 4 hours and no further smoking safety concerns identified. All corrections completed by 7/30/2022 2- For Resident #33, a review of nurse's progress note dated 07/24/2022 documented that the resident was transferred to the hospital due to other medical related condition. 3- Resident # 48, smoking assessment was done on 7/29/2022. MD order dated 7/29/2022 at 7:29pm documented allowed to smoke per facility protocol. Smoking care plan effective 7/29/2022. Smoking contract signed 7/30/2022. 4- All residents were reviewed, and the smoking list was updated. All other residents identified as smokers were assessed for safety and smoking care plans were developed and completed as of 08/01/2022. 5- A new smoking policy was developed on 7/2022. The revised policy ensured consistency in assessing residents for smoking, care plans and supervisions. 6- In-service lesson plan and sign-in sheets were reviewed 08/01/2022 and education was provided to 90% of staff (department heads, Administration, Nursing, MDS Department, Dietary, Housekeeping/Maintenance, Recreation, Social Work, Rehabilitation Department) regarding smoking safety protocols, accident/incident reporting, and the revised smoking policy. 7- Interviews were conducted with the following staff regarding smoking safety protocols on from 7/28/2022 through 8/1/2022 the following staff were inserviced and knowledgeable re: the facility's smoking policy: RN = 7, Licensed Practical Nurse = 12, CNA = 25, Therapeutic Nursing Aide = 3 Personal Care Attendant = 1, Medical Doctor = 1, Nurse Practitioner = 1, DSW = 1, Director of Rehabilitation = 1, Certified Occupational Therapy Aide = 2, Physical Therapy Aide = 2, Recreation = 4, Maintenance/Housekeeping = 4, Security = 3, Admissions = 1, SW = 2, and the Administrator = 1. Based on observation, interview and record review conducted on 08/01/2022, the facility fully implemented the IJ Removal Plan, and the IJ was removed as of 08/01/2022 at 5:36 PM. 415.4(a)(2-7)

Based on observation, interviews and record review conducted during an abbreviated survey (NY 980) and (NY 561), the facility failed to ensure that residents were free from physical abuse. This was evident in 2 out of 3 residents sampled (Resident #1 and Resident #3). Specifically, 1). On 02/28/2022, Resident #2 witnessed Licensed Practical Nurse (LPN) #1 punch Resident #1 in the face. Resident #1 was transferred to the emergency room (ER) and was diagnosed with closed fracture of the nasal bone. 2) On 03/11/2021 at approximately 5:00AM, LPN #2 sprayed an unknown disinfectant at Resident #3. Resident #3 complained of burning and redness to the eyes. Nursing Supervisor #2 assessed Resident #3 with redness to the eyes. This resulted in actual harm to Resident #1 and Resident #3 that is not Immediate Jeopardy. The findings are: Review of the facility's policy and procedure entitled Abuse, Neglect and Exploitation Program effective in 09/2018 and reviewed 03/2022 documented: It is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The facility will establish policies and procedures to investigate any such allegations and include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, reporting procedures, and Dementia management and resident abuse prevention. The facility will provide ongoing oversight and supervision of staff to assure that its policies are implemented as written. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. 1) Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #1 had a Brief Interview for Mental Status (BIMS) score of 12/15 indicating moderately impaired cognition. A Comprehensive Care Plan (CCP) titled Peer Abuse Prevention/Victimization initiated on 03/10/2020 and updated on 12/14/2021, documented interventions to allow Resident #1 to vent feelings and Social Worker to counsel the resident. A review of the facility's Summary of Investigation dated 03/01/2022 documented that on 02/28/2022 at around 6:30 AM, Nursing Supervisor #1 was paged to Resident #1's unit. Resident #1 alleged that LPN #1 punched him/her on the face. Resident #1 was bleeding from the nose. Nursing Supervisor #1 assessed Resident #1 and observed a blood stain on Resident #1's hand. There were no skin break or marks on Resident #1's face. Resident #1 declined further body assessment. The resident called 911 and was transferred to the hospital. Resident #1 returned from the hospital at 7:30 PM without any hospital paperwork. On 03/01/2022, the facility followed up with the hospital and the ER Summary was faxed to the facility. The Computed Tomography (CT) scan of the head and maxillofacial (face and jaw) showed closed fracture of the nasal bone. LPN #1 denied hitting Resident #1. LPN #1 stated that during medication pass on 02/28/2022 at 6:00 AM, Resident #1 asked LPN #1 to leave the medication on Resident #1's bedside table and LPN #1 left the room. LPN #1 stated that Resident #1 came out of the room, very aggressive, cursed LPN #1 and threw a box of milk at LPN #1. LPN #1 stated that he/she followed Resident #1 to the room to find out what was going on and Resident #1 grabbed LPN #1's mask off LPN #1's face. The surveillance camera showed Resident #1 came out of the room and threw a box of milk at LPN #1 in the hallway. LPN #1 then followed Resident #1 to the room right afterwards and closed the door. Within a few, LPN #1 came out of Resident #1's room without a face mask and went back to the medication cart. The investigation concluded that a reasonable suspicion of allegation of abuse with an injury or actual harm occurred to Resident #1. A review of a Nursing Progress Note, by Nursing Supervisor #1, dated 02/28/2022 at 7:15 AM documented that Resident #1 was observed with blood stain on the resident's hand. Resident #1 refused assessment and vital signs. A review of a Nursing Progress Note, by Nursing Supervisor #1 dated 02/28/2022 at 7:17 AM documented that Resident #1 called 911 at about 7:00 AM and requested to be transferred to the hospital for nosebleed. The Nurse Practitioner (NP) notified, and Resident #1 was transferred to the hospital. A review of a Nursing Progress Note dated 02/28/2022 at 8:03 PM documented that Resident #1 arrived back to the facility unaccompanied via ambulette. Resident #1 was welcomed back to his/her room. On assessment there was no respiratory distress. Vital signs checked and recorded. Resident #1 denied any pain. A review of the hospital After Visit Summary dated 02/28/2022 documented Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Medication given: Tylenol (Acetaminophen) last given at 8:13 AM. No scheduled appointment. Follow up with plastic surgery clinic if the resident needed it repaired. A Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Medical Progress Note, by Physician #1, dated 03/08/2022 at 12:00 PM documented Late Note: Chief Complaint (CC): Facial fracture: Resident #1 was seen today, according to Resident #1, he/she had what started as a verbal altercation with LPN #1 regarding Resident #1 taking his/her morning medications. This altercation escalated with Resident #1 apparently becoming angry and throwing his/her milk at LPN #1. As per Resident #1's report, he/she was then followed into his/her room and was struck in the face by LPN #1. In the ER a CT scan of the face revealed an acute fracture of the nasal bone. Resident #1 continues to complain of pain in the fractured area. Resident #1 denied headache. Head, Eyes, Ear, Nose and Throat (HEENT): there is a depressed nasal bone fracture with surrounding [CONDITION(S)] (superficial redness of the skin), [CONDITION(S)] (swelling), and tenderness at the bridge of the nose with surrounding ecchymosis (blood or bleeding under the skin due to trauma of any kind) on the left, just under the eye. The pupils are equally reactive to light and accommodation, normal extraocular (muscle that control the movements of the eye) eye movements. Assessment / Plan- Nasal bone fracture - Allegedly suffered at the hands of a staff member. No intervention is necessary at this time as this does not represent a displaced fracture. Continue pain management. Follow for any subsequent sequelae (a condition which is the consequence of a previous disease or injury). During an interview on 04/18/2022 at 2:30 PM, Resident #2 stated that he/she was in an adjoining room next to Resident #1's room. Resident #2 stated that they shared the same bathroom. Resident #2 stated that he/she responded to the commotion between Resident #1 and LPN #1. Resident #2 stated that he/she observed Resident #1 standing in the bathroom doorway towards Resident #2's room. Resident #2 stated that LPN #1 was also in the bathroom. Resident #2 stated that he/she saw LPN #1 punch Resident #1 in the face and that Resident #1 fell on the bathroom floor. Resident #2 stated that after Resident #1 fell , LPN #1 left the room. Resident #2 stated that Resident #1 was bleeding from the nose. Resident #2 stated there were drops of blood on the floor in the bathroom and Resident #2 wiped the blood off the floor. Resident #2 stated that the facility interviewed him/her, and he/she told the facility what happened. During an interview on 04/18/2022 at 4:08 PM, LPN #1 stated that he/she did not hit or touch Resident #1 on 02/28/2022. LPN #1 stated that he/she went to give Resident #1 medication around 6:00 AM on 02/28/2022 and Resident #1 wanted LPN #1 to leave the medication on Resident #1's bedside table. LPN #1 stated that he/she refused to leave the medication in Resident #1's room. LPN #1 stated that he/she exited Resident #1's room to continue medication administrations and Resident #1 followed him/her out of the room to the hallway yelling. LPN #1 said that Resident #1 threw a box of milk at him/her and went back to Resident #1's room. LPN #1 said that he/she followed Resident #1 to the room to talk to Resident #1. LPN #1 stated that Resident #1 suddenly punched LPN #1 in the face and pulled off LPN #1's face mask causing a scratch. LPN #1 stated that Resident #1 ran in the bathroom leading to the other room. LPN #1 stated that he/she left Resident #1's room and called the Nursing Supervisor #1. LPN #1 stated that he/she did not see Resident #2 while in he/she was in Resident #1's room. LPN #1 also stated that he/she did not observe any bleeding from Resident #1's nostril and did not see any blood on the floor in Resident #1's room. During an interview on 04/19/2022 at 10:05 AM, Nursing Supervisor #1 stated that he/she responded to the unit on 02/28/2022 around 6:00 AM. Nursing Supervisor #1 stated that LPN #1 reported that Resident #1 was aggressive towards LPN #1. Supervisor #1 stated that Resident #1 was alert and verbally responsive. Nursing Supervisor #1 stated that Resident #1 was holding Resident #1's nose and there was a small amount of blood on Resident #1's hand. Nursing Supervisor #1 stated that he/she did not see any blood on the room and bathroom floors. Nursing Supervisor #1 stated that Resident #1 did not say that he/she fell or had pain. Nursing Supervisor #1 stated that Resident #1 was uncooperative with assessment. Nursing Supervisor #1 said that Resident #1 had called 911 and they responded while he/she was on the unit. Nursing Supervisor #1 said that he/she observed milk splashed on the floor near Resident #1's room. During the subsequent interview conducted with Nursing Supervisor #1 on 05/20/2022 at 3:10PM. Nursing Supervisor #1 stated that he/she did not check LPN #1's hands for blood or injury. Nursing Supervisor #1 also stated that he/she did not observe any scratch mark on LPN #1's face. During an interview on 04/19/2022 at 10:55 AM, through language bank interpreter, Resident #1 stated that the nurse (LPN #1) went into his/her room and slammed the door. Resident #1 stated that LPN #1 then punched him/her in the face and fractured his/her nose. During an interview on 05/13/2022 at 12:25 PM, Physician #1 stated that he/she worked at the facility for about two to three months and was Resident #1's Primary Physician. Physician #1 stated that he/she recalled that he/she saw Resident #1 a few days after the incident. Physician #1 stated that Resident #1 reported that Resident #1 was punched in the face by the nurse (LPN #1). Physician #1 stated that he/she examined Resident #1 and Resident #1 had a closed non-displaced Nasal Bone Fracture with bruising and tenderness to the nose and surrounding area under one of the eyes. Physician #1 stated that the medical management was for the nasal fracture to heal by secondary intention, since the fracture was closed. Physician #1 stated that they ensured that Resident #1's vision was not affected and Resident #1's pain was controlled. Physician #1 stated that Resident #1's pain was mild, and it was controlled with Tylenol tablets. During an interview on 05/12/2022 at 11:17 AM, the Director of Nursing (DON) stated that the facility concluded that there was cause to believe that Resident Abuse occurred because of the Nasal Fracture injury that Resident #1 sustained. The DON stated that Resident #1 stated that LPN #1 punched him/her in the face. The DON stated that Resident #2 also reported that he/she witnessed LPN #1 punch Resident #1 in Resident #1's face. Subsequent interview was conducted with the DON on 05/20/2022 at 3:45 PM. The DON stated that LPN #1 was already sent home when 911 and the Police responded on 02/28/2022. The DON stated that there was a follow up phone call to the Police on 03/01/2022 but does not know if LPN #1 was arrested. The DON stated that he/she does not know the exact length of time LPN #1 was in Resident #1's room but it was for a short time. 2) Resident #3 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #3 had a Brief Interview for Mental Status (BIMS) score 12/15 indicating moderately impaired cognition. A Comprehensive Care Plan (CCP) titled Peer Abuse Prevention initiated on 01/03/2020 and updated on 02/23/2021 documented interventions to allow Resident #3 to vent feelings, counsel by Social Worker and family involvement if needed. A Facility Investigation Summary dated 03/12/2021 documented that on 03/11/2021 at approximately 5:00 AM, Resident #3 reported to the Nursing Supervisor #2 that while Resident #3 was at the nurses station asking about another staff member from Activities, LPN #2 appeared upset about something and started spraying a disinfectant spray on the countertop and up in the air spraying in the direction of Resident #3's face. Resident #3 stated that it hurt his/her eyes. Nursing Supervisor #2 immediately assessed Resident #3's eyes and noted slight redness in both eyes. Resident #3 was directed to the eye wash station and rinsed both eyes. After completing the rinse, the Nursing Supervisor #2 stated that both eye redness subsided within minutes. Physician #2 was informed, and staff were ordered to monitor the resident for further adverse reactions. An interview was conducted with LPN #2 who stated that Resident #3 kept coming to the nurse's station without a mask despite redirection. LPN #2 stated that he/she brought his/her own spray because of COVID. Based on camera footage, LPN #2 sprayed an unknown aerosol towards the direction of Resident #3 and Resident #3 sustained redness to both eyes. LPN #2 was suspended immediately and was eventually terminated. Resident #3 was seen by Physician #2 and Optometry Consult with impression of DM, [CONDITION(S)], [CONDITION(S)]. The facility concluded that there was probable cause to believe Abuse, Neglect or Mistreatment occurred. A review of a Nursing Progress Note, by Nursing Supervisor #2, dated 03/18/2021 at 6:08 AM documented that Resident #3 complained of burning sensation to his/her eyes and face and reported that LPN #2 sprayed disinfectant on his/her eyes and face. Wash with a lot of soap and water. A review of a Nursing Progress Note, by Nursing Supervisor #2, dated 03/18/2021 at 6:09 AM documented above incident happened 03/11/2021 at 5AM. The facility's surveillance recording video was reviewed on 04/20/2022 at 1:50 PM with the Administrator: On 03/11/2021 at 5:55 AM, Resident #3 was seen walking towards the nurse's station. At 5:55 AM, LPN #2 and CNA #1 were seated behind the desk in the nurse's station. At 5: 55:13 AM, Resident #3 approached the nurse's station. LPN #2 started spraying a liquid in a bottle on the desk. At 5:55:18 AM, Resident #3 was seen standing directly in front of the desk at the nurse's station. At 5:55:22 AM, LPN #2 was seen pointing the spray bottle and spraying in the direction of Resident #1. At 5:55:28 AM, CNA #1 was seen handing Resident #2 a face mask and Resident #2 walked away from the nurse's station. This surveyor made several attempts to contact LPN #2 but was unsuccessful. A certified mail was sent out with no response to date. During an interview on 05/10/2022 at 1:10 PM, Nursing Supervisor #2 stated that on 03/11/2021 at around 6:00 AM, Resident #3 reported that LPN #2 sprayed disinfectant in Resident #3's eyes. Nursing Supervisor #2 stated that Resident #3 said that his/her eyes were burning. Nursing Supervisor #2 stated that he/she assessed Resident #3's eyes and observed slight redness to both eyes. Nursing Supervisor #2 stated that he/she washed Resident #3 's eyes with water and informed the DON. During an interview on 05/12/2022 at 11:12 AM, the DON stated that as per the surveillance video review of the incident involving Resident #3 and LPN #2, there was cause to believe that staff to resident abuse occurred. The DON stated that the video showed that LPN #2 pointed the disinfectant spray at Resident #3. The DON stated that LPN #2 had prior Inservice on Abuse and LPN #2 was terminated from employment. 415.4(b)(1)(i)

Based on observations, interviews and record review conducted during an abbreviated survey (NY 166) on 11/03/2021, the facility did not have physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Specifically, Resident #1 was admitted from the hospital to the facility on [DATE] with discharge orders for [MEDICATION(S)] ([CONDITION(S)] medication). The [MEDICATION(S)] was not ordered, and Resident #1 did not receive the medication. Resident #1 had a [CONDITION(S)] on 10/11/2021 and was transferred to the emergency room (ER). On 10/12/2021, Resident #1 was transferred back to the facility with discharged orders from the ER for [MEDICATION(S)] ([MEDICATION(S)]) Syrup 1125 mg every 12 hours. The [MEDICATION(S)] Syrup was not ordered in the facility, and Resident #1 suffered another [CONDITION(S)] on 10/17/2021 and was transferred to the ER. Resident #1 missed 16 days (32 dosages) of [CONDITION(S)] medication, suffered Seizures and two hospital transfers before facility staff became aware that the hospital and emergency room Discharge Orders, for the [MEDICATION(S)], were not implemented. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy. The findings are: Review of the facility's policy and procedure entitled Admissions, Transfers and Discharges last revised in April 2019 documented: The facility will admit only those residents whose, medical and nursing care needs can be met. Prior to or at the time of admission, the resident's Attending Physician must provide the facility with information needed for the immediate care of the resident, including orders covering at least: type of diet, medication orders and routine care orders. A facility Summary of Investigation dated 10/26/2021 documented that there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #1 that was missed on the initial admission on 10/01/2021. Resident #1 was transferred to the hospital on 10/11/2021 for evaluation of seizures. Resident #1 returned from Hospital on 10/12/2021 with recommendations to start [MEDICATION(S)], Registered Nurse (RN) #1 did not review the emergency room (ER) Discharge Paperwork and the Physician did not follow up on Resident #1's ER Discharge recommendations. The facility concluded that both the Nursing Supervisor and Resident #1's Attending Physician failed to locate the emergency room Discharge Summary upon Resident #1's return to the facility on [DATE]. The hospital recommendation for Resident #1 to start [MEDICATION(S)] was not followed. Resident #1 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 10/08/2021 documented that Resident #1 had intact long/short-term memory and had severely impaired decision-making ability. Resident #1 previously resided in a Group Home prior to his/her hospitalization and admission to the facility. A Hospital Inpatient Discharge Summary dated 09/26/2021 documented: Reason for Admission: Small Bowel Obstruction, Septic Shock, and Pneumonia. History included Autism, [CONDITION(S)] Disorder, History of Aspiration Pneumonia, and Mental Disability ([CONDITION(S)]). The Active Medication List included [MEDICATION(S)] 500 mg in [MEDICATION(S)] 5% 50ml IVPB (intravenous piggyback), 500 mg 50/ml/hr. IV Q6H. (Home medications included Valproate 1125mg every 12 hours). A Nursing Correction Progress Note dated 10/01/2021 at 10:15 PM documented that Resident #1 was admitted from the hospital at about 8:55 PM accompanied by 2 Emergency Medical Service (EMS). Resident #1 had Past Medical History (PMHX) of Autism, [CONDITION(S)], History of Aspiration, Mental Disability, [CONDITION(S)], Dysphagia, Non-Alcoholic Fatty Liver Disease (NAFLD) and Raynaud's Disease. On assessment Resident #1 was non-verbal, confused, and disoriented. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Neurological Function with Risk for [CONDITION(S)] related to [CONDITION(S)] Disorder Care Plan was initiated on 10/02/2021. The interventions included administer medications as ordered, observed for side effects, effectiveness, and observe for change in mental status. A Medical Correction Comprehensive Physician Admission Note dated 10/02/2021 at 7:34 AM documented that Resident #1 was discharged from hospital on 10/01/2021. All hospital paperwork reviewed. Medications included Lorazepam 2mg, give 2 tabs (4mg) by PEG every 6 hours for 15 days as needed for Anxiety, [MEDICATION(S)] 0.5mg tablet, give 1 tablet by Percutaneous Endoscopic Gastrostomy (PEG) 2 times a day for 14 days as needed for anxiety. Listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no mention of [MEDICATION(S)] for [CONDITION(S)] Disorder. A Nursing Progress Note dated 10/11/2021 at 9:35 PM documented that Resident #1 was observed with [CONDITION(S)] activity twice. The seizures lasted 2 to 3 minutes. The Physician was notified and ordered that Resident #1 be transferred to the hospital. Resident #1 left the facility via Emergency Medical Service (EMS) at 9:00 PM. The emergency room Discharge Summary (ERDS) dated 10/12/2021 documented Valproate Level collected on 10/11/2021 at 10:50 PM. The result documented that Resident #1's [MEDICATION(S)] level was <20.0ug/ml (reference range 50.0-140.0ug/ml). The discharge summary documented Patient was supposed to be on [MEDICATION(S)] Syrup 1125mg every 12 hours, however this was not listed in the Nursing Home medications. Resident #1 presented to the Emergency Department (ED) on 10/11/ with two witnessed convulsive seizures at the nursing home. The [MEDICATION(S)] level found to be subtherapeutic. It was likely that the resident was not getting the scheduled doses at the Nursing Home. Resident #1 was observed to have myoclonic jerks on presentation to the ED. Restart [MEDICATION(S)] 1125mg two times a day ([MEDICATION(S)] syrup through the PEG tube). A Nursing Progress Note dated 10/12/2021 at 7:16 PM documented that Resident #1 had returned from the hospital at 5:00 PM. Resident #1 was in stable condition. The tube feeding was completed, and medication given via gastrostomy (GT). There was no documentation that the physician was notified of Resident #1's return to the facility. There was no documentation that the discharge summary was reviewed and there was no mention of [MEDICATION(S)]. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician's Progress Note dated 10/15/2021 at 6:32 AM documented that Resident #1 was seen at the bedside. Chief Complaint (CC): follow up of Infection. The physician's progress note did not mention the hospital recommendation to start Resident #1 on [MEDICATION(S)] for [CONDITION(S)] Disorder. A Nursing Progress Note dated 10/17/2021 documented that at about 5:20 AM, Resident #1 was observed by private caregiver with [CONDITION(S)] activity. The caregiver described it as sudden, jerky and shaking movement which lasted about 1 minute. On assessment, Resident #1 was back to baseline. The Physician was notified and recommended transfer to the hospital for evaluation. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nursing Progress Note dated 10/17/2021 at 3:24 PM documented that Resident #1 returned from hospital at approximately 1:12 PM via stretcher accompanied by 2 Emergency Medical Technicians. The resident was alert and responsive, in no distress. New order for [MEDICATION(S)] 1,125mg ordered. The Physician was notified, and the medication transcribed in Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] A Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nursing Progress Note (late entry for 10/12/2021) dated 10/20/2021 at 4:47 PM documented no new medical order received by writer upon Resident #1's return from the hospital. A Physician's Progress Note dated 10/20/2021 at 6:19 AM documented that Resident #1 was seen at the bedside. There was no documentation of the discharge summary or the [CONDITION(S)] medication. An Activities of Daily Living (ADL) Functional Rehab Potential with Focus Cardiac Function secondary to [CONDITION(S)] Disorder, Care Plan updated on 11/02/2021 documented interventions to provide [CONDITION(S)] medications as per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 11/03/2021 at 1:30 PM, the Mental Hygiene Nurse Program Coordinator from New York State Developmental Disabilities Office stated that on 10/17/2021, he/she received a call from the Hospital Physician regarding Resident #1. The Hospital Physician informed the Nurse Program Coordinator that Resident #1 was in the emergency room and the level of Resident #1's [CONDITION(S)] medication was zero. The Nurse Program Coordinator further stated that he/she assigned a Group Home Registered Nurse (GHRN) to go to the facility to see Resident #1. The Nurse Program Coordinator added that the GHRN stated that he/she observed Resident #1's hospital discharge papers on the bedside table in Resident #1's room. The Nurse Program Coordinator added that he/she request a meeting and a plan of correction from the facility. During an interview on 11/03/2021 at 1:40 PM, the GHRN stated that he/she went to the facility on [DATE] to reconcile Resident #1's medications around 3:00 PM. The GHRN stated that he/she requested a printout of Resident #1's medications from the charge nurse. The printout showed that Resident #1's medications did not include [MEDICATION(S)]. The GHRN went to Resident #1's room and observed the hospital discharge papers dated 10/12/2021 on Resident #1's bedside table. The GHRN stated that a companion was with Resident #1 in the room and stated that the discharge papers were in Resident #1's room. The GHRN stated that he/she went to the nurse and alerted him/her about the finding of the hospital discharge summary. The GHRN added that the facility entered the [MEDICATION(S)] medication order for Resident #1 after 3:00 PM on 10/17/2021, while he/she was onsite at the facility. During an interview on 11/03/2021 and 11/18/2021, Resident #1's Attending Physician stated that he/she was the Physician who admitted Resident #1 on 10/01/2021. The Attending Physician stated that he/she reviewed the Patient Review Instrument (PRI), Resident #1's history and the Hospital Discharge Summary the same night of Resident #1's admission. The Attending Physician verbalized that he/she missed the order for the [MEDICATION(S)] when he/she reviewed Resident #1's hospital discharge summary on 10/01/2021. The Attending Physician stated that he/she was aware that Resident #1's had [CONDITION(S)] Disorder diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Attending Physician said that he/she was informed that Resident #1 had Seizures on 10/11/2021 and ordered Resident #1 to be transferred to the ER for evaluation. The Attending Physician said that he/she did not find the Hospital Discharge Summary for 10/12/2021 after Resident #1 returned to the facility. The Attending Physician stated that he/she asked the unit nurse and the nursing supervisor for Resident #1's hospital Discharge Summary and instructed them to call the hospital for the discharge summary. The Attending Physician was unable to state the names of the staff who he/she asked for Resident #1's Hospital Discharge Summary. The Attending Physician also said that he/she called the hospital for Resident #1's Discharge Summary on 10/12/2021 but he/she did not get to speak to anyone. The Attending Physician stated that he/she did not speak to the Medical Director or to the Director of Nursing (DON) regarding Resident #1's missing Hospital Discharge Summary for 10/12/2021. During an interview on 11/03/2021 and 11/19/2021, RN #1 stated that he/she worked as the Nursing Supervisor when Resident #1 was transferred to the hospital on 10/11/2021 and when Resident #1 returned from the hospital on 10/12/2021. RN #1 said that he/she checked Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #1 verbalized that when he/she worked as a Nursing Supervisor, his/her responsibility included checking Resident #1's Hospital Discharge Summary or emergency room Discharge Summary to see if there were any new orders and to notify the Physician. RN #1 said that he/she asked Resident #1's companion about the hospital discharge papers but the companion told RN #1 that Resident #1 had no discharge papers. RN #1 also said that he/she called the hospital but did not reach anyone. RN #1 further stated he/she did not ask the incoming shift to follow up with the hospital and that he/she did not notify the DON. During an interview on 11/04/2021 at 1:50 PM, Registered Nurse Supervisor #1 (RNS #1) stated that he/she was the Nursing Supervisor for the night shift on 10/01/2021 and performed Resident #1's admission assessment. RNS #1 said that he/she reviewed the PRI and entered the orders in the Electronic Medical Record (EMR) then notified the Physician. RNS #1 said that he/she was not sure if there was a Hospital Discharge Summary for Resident #1 on 10/01/2021 and that there was no order for [MEDICATION(S)]. RNS #1 verbalized that he/she reviewed Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/12/2021 at 11:22 AM, the Director of Nursing (DON) stated that the facility's protocol for admissions is for the Registered Nurse Supervisors to obtain the PRI and Hospital Discharge Summary on a resident's admission to the facility. The RNS should review the PRI and Hospital Discharge Summary and inform and verify the discharge orders and recommendations with the Physician. The RNS then places the orders in the Sigma system. The DON said that RNS #1 placed Resident #1's orders in the Sigma but it was incomplete. The DON said that the Physicians are supposed to follow up in the morning after a resident's admission to the facility. The PRI is scanned in Sigma and the Discharge Summary is placed in the Nursing Office or on the unit where the resident is admitted . The DON stated that he/she did not know where Resident #1's Hospital Discharge Summary was placed. The DON verbalized that RN #1 should have informed the following shift about the emergency room Discharge Summary of 10/12/2021. The Physician should have spoken to the supervisor, follow up and should have insisted on getting Resident #1's emergency room Discharge Summary of 10/12/2021 since Resident #1 had seizures. The DON added that there was a breakdown in communication. The DON further added that he/she was not aware that the emergency room Discharge Summary was found in Resident #1's room until 10/26/2021 during a meeting with the Group Home. During an interview on 11/19/2021 at 1:00 PM, the Medical Director stated that around 10/20/2021, he/she became aware that Resident #1's Hospital Discharge order for [MEDICATION(S)] was not ordered by Resident #1's Attending Physician and that Resident #1 was transferred to the hospital with seizures. The Medical Director said that the admission procedure that Resident #1's Attending Physicians should have followed was to review the Hospital Discharge Summary and Instructions then reconciled the orders with the Registered Nurse. 415.11