Every finding on record at Haven Manor Health Care Center, LLC

Based on observation, record review, and interview, the facility failed to maintain the residents' right to a safe, clean, and comfortable environment. This was evident on the 6th Floor. Specifically, observation on the 6th Floor include but is not limited to stained ceiling tiles in some of residents' rooms, radiators were rusted and the base had cracks, window blinds had stains, bedside tables were dirty. The findings are:The facility's policy and procedure titled Maintenance Services with a reviewed date 01/2026 documented the Environmental Services Department is responsible for managing the maintenance function in the most cost-effective manner possible while maximizing the useful life of equipment, rooms, and properties while striving to provide the best service to our residents.Observations were conducted from 01/15/2025 at 10:00 AM to 01/23/2026 at 12:30 PM and the following were observed on the 6th Floor:1. The hallway ceiling was observed with brown colored stains.2. room [ROOM NUMBER] had cracked tile below the sink close to the floor.3. The air/heating unit in room [ROOM NUMBER] had a crack around the bases exposing the wall with brown and grey substance.4. The ceiling tiles in room [ROOM NUMBER] had brown colored stains and had a crack around the air/heating unit.5. The window blinds in room [ROOM NUMBER]-A had brown stains.6. The male shower room had black colored substance around the perimeter. The window perimeter was covered with brown colored substance.7. There was a dirty bedside table in the hallway. 8. room [ROOM NUMBER] ceiling tiles were in disrepair, hanging off the ceiling. The window blinds had brown stains on the border. 9. The top of the air-conditioning unit in room [ROOM NUMBER] was coming off. 10. The radiator and bedside table in room [ROOM NUMBER] were dirty. 11. The bathroom in room [ROOM NUMBER] had a hole. 12. The ceiling in room [ROOM NUMBER] B had brown stains, and the floor tiles under the sink had cracks. 13. The radiator in room [ROOM NUMBER] had rust and the surrounding wall was in disrepair with black colored substance. The window blinds were discolored, and the metal surrounding the light above the sink was rusted. 14. The radiator in the residents' dining room had brownish color and had exposed sharp metals.15. The ceiling ventilation in the residents' dining room had brown stains and was dusty. On 01/23/2026 at 12:01 PM Registered Nurse #3, who was also the Nursing Supervisor for 6th Floor, was interviewed and stated they write things in need of repair in the maintenance logbook if they see that it is unsafe or may cause immediate jeopardy to the resident. On 01/23/2026 at 11:49 AM, Housekeeper #1 was interviewed and stated that their responsibility is to make sure the residents' unit is clean. They stated they notify the Maintenance Director for any repairs that need to be done. On 1/23/2026 at 12:10 PM, the Maintenance Director was interviewed and stated that the tiles are old and need to be replaced. They stated there is nothing they can do with the radiators because the stains were caused by the weather and the water that was coming from outside caused the disrepair. They stated that the window blinds look rusty because of the bleach that housekeeping use to sanitize it and it gets oxidized. On 01/23/2026 at 12:30 PM, the Administrator was interviewed and stated they are not sure what repairs are needed. They stated the Maintenance Department makes daily rounds to see if there are any needed repairs and they also have a consultant who comes in and makes rounds in the unit. They stated there is a maintenance logbook in each unit where needed repairs are logged. 10 NYCRR 415.5(h)(2)

Based on observation, record review, and interview conducted during the Recertification Survey from 01/15/2026 to 01/23/2026, the facility did not ensure residents had a right to make choices regarding aspects of their life for two (2) of two (2) residents out of 38 residents reviewed for smoking. Specifically, the facility did not allow the residents to go out and smoke and did not offer a smoking cessation program for Resident # 103 and Resident #102, who were known smokers at the time of admission. The findings are:The policy and procedure titled 'Safe Smoking Program' reviewed 01/26 documented the facility will permit smoking in a designated area, at a designated time for those residents who choose to smoke while ensuring the safety of all other residents, staff and visitors. Residents who desire or request assistance with smoking cessation will be assisted through the Activities, Nursing and Social Service Departments. The policy also documented that smoking will be permitted only in the designated patio area at the designated time as weather permits.On 01/20/2026 at 1:37 PM, observation of safe smoking did not occur. During an interview the Recreation Director stated it is cold outside, and smoking is only done when the weather permits residents to go outside. 1. Resident #103 was admitted to the facility with diagnosis that included Anxiety Disorder, Depression, and Schizophrenia.The Annual Minimum Data Set assessment dated [DATE] documented Resident #103 was cognitively intact.The Comprehensive Care Plan titled 'Smoking/Use of Electronic Cigarettes' documented Smoking: Psychosocial history reveals Resident #103 is a known smoker. Potential for safety hazard due to resident choosing to smoke. Allow resident to smoke in designated smoking area with supervision as needed, provide assistance when smoking in the designated area.During an interview on 01/21/2026 at 10:39 AM, Resident #103 stated it has been more than a month since they were permitted to smoke, and they did not know why they had not been allowed to out and smoke. Review of Progress Notes dated 12/03/2025 through 12/09/2025 revealed no documented evidence Resident #103 engaged in unsafe smoking behaviors.There was no documented evidence Resident #103 was given a choice to smoke cigarettes during cold weather or was offered a smoking cessation program such as a nicotine replacement option when the facility implemented a policy to prohibit smoking to cold weather. 2. Resident #21 was admitted to the facility with diagnoses which included Non-Alzheimer's Dementia and Schizophrenia. The Quarterly Minimum Data Set 3.0 assessment dated [DATE] documented Resident #21 was cognitively intact.The Comprehensive Care Plan titled 'Smoking/Use of Electronic Cigarettes' documented Resident will smoke safely within the designated smoking area. Allow resident to smoke in designated smoking area with supervision as needed and provide assistance when smoking in the designated area.Review of Progress Notes dated 12/01/2025 through 12/31/2025 revealed no documented evidence Resident #21 engaged in unsafe smoking behaviors.There was no documented evidence Resident #21 was given a choice to smoke cigarettes during cold weather or was offered a smoking cessation program such as a nicotine replacement option when the facility implemented a policy to prohibit smoking due to cold weather.On 01/21/2026 at 09:34 AM, Resident #21 was interviewed and stated they have not been allowed to smoke for more than three (3) weeks and has no issue with going out to smoke in the cold weather if they wear a hat and coat. Resident #21 also stated they were told they cannot go out to smoke due to the cold weather.Review of a Resident Who Smoke List and Smoking Schedule documented there are 38 residents who smoke, and the designated smoking times are 08:30 - 09:30 AM, every day, weather permitting and designated smoking location is on the patio.On 01/20/2026 at 01:37 PM, the Recreation Director was interviewed and stated it is cold outside, and residents can only go out to smoke when weather permits. The Recreation Director also stated smoking occurs once a day and the schedule was changed from 8:30 AM in the morning to 2:00 PM. The Recreation Director further stated during the COVID-19 pandemic residents did not go out to smoke and since then the facility changed from a non-smoking facility and made smoking weather-permitting instead. The Recreation Director stated if residents come down to smoke and it is cold outside, they are not allowed to go outside and smoke. The Recreation Director also stated residents are not allowed to have any smoking cessation aids such as nicotine gum or a patch while they are identified as known smokers.On 01/20/2026 at 01:50 PM, the Director of Nursing was interviewed and stated the Director of Recreation does the assessment for the smokers, and residents can go out to smoke if the weather permits. The Director of Nursing also stated the weather has been fluctuating in the past couple of months, and smoking privileges were revised to meet to meet resident's needs and safety, which we go by first. The Director of Nursing stated residents are informed on admission that smoking is once per day and weather permitting, and when the residents come down to the Recreation room, they are informed then whether smoking will be permitted that day. The Director of Nursing also stated the last time residents were allowed to smoke was on 01/09/2026, and the residents cannot have any gum or nicotine offered as a smoking cessation. The Director of Nursing further stated if a resident asked to go and smoke today, they cannot because they are bonded by the contract that documents residents can only smoke when the weather permits. On 01/22/2026 at 03:14 PM, Medical Doctor #1 was interviewed and stated they did not know residents were not being allowed to go out and smoke and had not smoked in three (3) weeks. Medical Doctor #1 stated if residents have not smoked for a while, the facility has a smoking cessation protocol, such as the nicotine patch, which can be offered to residents. Medical Doctor #1 stated they observed residents going down to smoke today. On 01/22/2026 at 05:07 PM, the Medical Director was interviewed and stated smoking is a privilege for the residents and the facility has the right to change the time and the amount of cigarettes the resident smoke. The Medical Director also stated there is a schedule for smoking, and no residents have spoken to them about not being permitted to smoke. The Medical Director also stated smoking cessation aids are not necessary as residents are only permitted to smoke one cigarette once a day. On 01/23/2026 at 09:50 AM, the Assistant Administrator was interviewed and stated residents were not allowed to go out and smoke because Department of Health regulations stated that if it is below 40 degrees the resident should not be outside, and if they go outside, they should wear a hat and gloves. The Assistant Administrator also stated they were not sure when the notice was distributed but knows that the information came from the Department of Health. 10 NYCRR 415.5(f)(2)

Number of residents sampled: 3Number of residents cited: 1 Based on record review and interviews, the facility did not ensure that a resident or their designated representative was provided appropriate notification at the termination of Medicare Part A benefits. This was evident for one (1) resident (Resident #216) of three (3) residents reviewed for Beneficiary Notification. Specifically, there is no documented evidence that the Notice of Medicare Non-Coverage form was mailed to Resident #216's designated representative on the same day the telephone notification was made.The findings are:The facility provided no policy and procedure on the delivery of the Notice of Medicare Non-Coverage and Skilled Nursing Facility Advanced Beneficiary Notice.Resident #216 was discharged from skilled services on 01/14/2026 with 93 benefit days of Medicare Part A remaining and remained in the facility. The Notice of Medicare Non-Coverage and Skilled Nursing Facility Advanced Beneficiary Notice were completed. The Notice of Medicare Non-Coverage documented Resident # 216's representative was contacted on 1/12/2026 at 12:20 PM. A Certified Mail Receipt documented postage was not postmarked until 01/15/2026.There was no documented evidence that the form was mailed to Resident #216's Representative on the date that telephone notification was made.On 01/23/2026 at 1:58 PM, Registered Nurse #1, who is also the Minimum Data Set Coordinator, stated when skilled services are going to be discontinued, they prepare the letter and give it to the Social Worker to issue to the family. Registered Nurse #1 also stated once the letters have been signed, they prepare the envelope and give it to the secretary to mail. Registered Nurse #1 further stated mail is usually sent the next day because we are only going to the post office once a day. Registered Nurse #1 stated they usually follow-up with the secretary but did not do so in this case. 10 NYCRR 415.3(g)(2)(i)

Based on observation, record review and interviews, the facility failed to ensure residents' rights to privacy and confidentiality were maintained. This was evident for one (1) (2nd Floor) of two (2) units observed for medication administration. Specifically, Licensed Practical Nurse #3 walked away from the medication cart without locking the laptop computer exposing Resident #136's medical record. The findings include: The facility's policy titled Resident Privacy, Confidentiality, and Resident Records with a last reviewed date of 01/2026 documented that the facility will protect each resident's right to privacy and will maintain confidentiality and security of all residents' records. On 01/16/2026 at 9:30 AM, during medication pass observation on the 2nd Floor unit, Licensed Practical Nurse #3 left the medication cart with the computer laptop open and walked towards room [ROOM NUMBER]. The computer screen displayed Resident #136's medical record. There were two (2) housekeeping staff in the hallway directly across the medication cart. On 01/16/2026 at 9:33 AM, Licensed Practical Nurse #3 was interviewed and stated they were supposed to close the computer laptop screen before leaving the medication cart. On 01/23/2026 at 9:13 AM, the Director of Nursing was interviewed and stated that computer laptop monitor must be closed or locked when leaving the medication cart so that others do not gain access to the resident's medical record. 10 NYCRR 415.3(e)(1)

Based on observation, record review, and interview, the facility failed to ensure residents were free from any physical restraints imposed for the purposes of discipline or convenience and not required to treat the resident's medical symptoms. This was evident for two (2) residents (Resident #143 and Resident #141) of three (3) residents investigated for Physical Restraint. Specifically, 1). Resident #143 was observed wearing a seat belt in wheelchair and Resident #143 stated they did not know how to remove the seat belt, and staff had to remove it. 2). Resident #141 was observed with a lap seat belt affixed while seated in a wheelchair on multiple occasions. Resident #141 was not able to remove the seat belt on their own.The findings are: The facility policy titled 'Restraints' dated last reviewed 1/2026 stated it is the facility's policy to promote and encourage a restraint- free environment. All residents have the right to be free from physical and chemical restraints imposed for the purposes of discipline or convenience and not required to treat the resident medical symptoms. The policy also stated that before a resident is restrained, the facility must determine the presence of a specific medical symptom that will require the use of restraint. The policy further stated a Physician will order the restraints based on the Interdisciplinary Team indicating the need for the restraints, and risks and potential hazard of restraints use need to be considered prior to use. The policy listed seatbelts as an example of trunk restraints. 1.Resident #143 had diagnoses which included Paranoid Schizophrenia and muscle spasms, and constipation. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #143 was cognitively intact, required partial to moderate assistance with most activities of daily living and mobility, used a wheelchair, had no falls since the prior assessment, and did not use physical restraints or alarms. The comprehensive care plan titled 'Falls' created 12/02/2017 and revised 11/22/2025 documented interventions which included constant reinforcement of safety measures, use of the call bell, and holding bed rails. The comprehensive care plan did not document the use of a seat belt. On 01/16/2026 at 1:07 PM, Resident #143 was observed seated in a wheelchair wearing a blue colored seat belt. On 01/20/2026 at 2:46 PM, Resident #143 was observed in the day room playing dominoes with other residents, showing no signs of distress, with the seat belt on. Review of Physician orders last reviewed 1/1/2026 contained no order for a seat belt, or directions on how the seat belt was to be used or monitored. There was no documented evidence of an evaluation of the need for restraints, and the medical necessity for use of the seat belt. Review of the comprehensive care plan revealed no documented evidence a care plan was created for use of restraints. On 01/22/2026 at 9:56 AM, Certified Nursing Assistant #4 was interviewed and stated Resident #143 has been wearing a seat belt as long as they can recall. Certified Nursing Assistant #4 also stated when Resident #143 is having lunch they will release the seat belt so they can be comfortable when they eat, but they were not instructed to do so, and the seat belt is not listed in their tasks. Certified Nursing Assistant #4 stated Resident #143 thinks they are going to fall and sometimes they can remove the seat belt and at other times they are not able to do so. On 01/23/2026 at 9:57 AM, Registered Nurse #3 was interviewed and stated Resident #143 was transferred to the third floor at the end of October 2025 and has always worn a seat belt on this unit. Registered Nurse #3 also stated there are some residents who learn forward in their wheelchairs and the seat belt helps them to maintain their safety. Registered Nurse #3 further stated Resident #143 should have an order for seat belt use and they were not able to locate orders or an evaluation for the use of seat belts. State Surveyor observed Resident #143 with Registered Nurse #3 and when Registered Nurse #3 asked Resident #143 to remove the seat belt they stated they were not able to remove the seat belt because they were not good with their hands. Registered Nurse #3 stated if Resident #143 was not able to remove the seat belt this would be considered a restraint. On 01/23/2026 at 2:05 PM, Registered Nurse #1 who is also the Minimum Data Set Coordinator, was interviewed and stated they were unaware of Resident #143's daily seat belt use as there was no order or care plan. Registered Nurse #1 also stated they did not observe Resident #143 was wearing and a seat belt when they conducted their assessment. Restraints are reviewed in the Minimum Data Set process. Registered Nurse #1 further stated that if a resident cannot remove the seat belt independently, it is considered a restraint. 2. Resident #141 was admitted with diagnosis which included Non-Alzheimer's Dementia, Depression, and Schizophrenia. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #141 had severely impaired cognition, no indicators of Psychosis, and no behavioral symptoms. The Quarterly Minimum Data Set assessment also documented Resident #141 required partial/moderate assistance of one person for oral hygiene, toileting hygiene, shower/bath, upper/lower body dressing, and personal hygiene. The Quarterly Minimum Data Set assessment documented Resident #141 did not ambulate, and no restraint was used. On 01/15/2026 at 10:10 AM, Resident #141 was observed sitting in the dining area with a seat belt over their upper thigh area. Resident #141 was mumbling to themself and responded when greeted. Resident #141 appeared confused and had no response when asked if they could remove the seat belt. On 01/15/2026 at 1:56 PM, Resident #141 was observed sitting in a wheelchair with seat belt locked across upper limbs in the dining area. Resident #141 was holding hands to their head and appeared more confused than earlier. On 01/20/2026 at 9:23 AM, Resident #141 was observed sitting in the dining area in a wheelchair with a turquoise blue seat belt with button in middle to press to release seat belt. Resident #141 was unable to follow instructions to remove the seat belt. On 01/20/2026 at 2:24 PM, Resident #141 was observed with Licensed Practical Nurse #2 in the dining room. Resident #141 had seat belt fastened and did not respond when greeted. Licensed Practical Nurse #2 stated Resident #141 always has the seat belt in place. On 01/20/2026 at 2:29 PM, Resident #141 was observed with Registered Nurse Supervisor #1 sitting in the dining room. Resident #141 had a seat belt across their upper thighs and Registered Nurse Supervisor #1 stated the seat belt is to keep Resident #141 from sliding from the wheelchair. Registered Nurse Supervisor #1 also stated Resident #141 can remove the seat belt, however Resident #141 was not able to remove the seat belt when directed to do so by Registered Nurse Supervisor #1. Review of Physician orders last reviewed 1/15/2026 contained no order for a seat belt, or directions on how the seat belt was to be used or monitored. There was no documented evidence of an evaluation of the need for restraints, and the medical necessity for use of the seat belt. Review of the comprehensive care plan revealed no documented evidence a care plan was created for use of restraints. On 01/23/2026 at 9:23 AM, the Director of Nursing was interviewed and stated restraints is applied as the last measure and is only implemented when there is an assessment and documentation by staff. The Director of Nursing also stated the facility have monthly restraints meetings before and after a restraint is initiated, and it is discussed in Quality Assurance and Performance Improvement meeting. The Director of Nursing further stated staff must monitor the resident, observed for triggers/tolerance when the restraint is implemented. The Director of Nursing stated they do not know how the facility missed Resident #141's seat belt as Resident #141 may have inherited a wheelchair with a seat belt and staff used it on the resident. The Director of Nursing stated the lack of a physician's order for Resident #141 should have been a red flag, and it was also not included on the Certified Nursing Assistant plan of care. On 01/20/2026 at 2:25 PM, Registered Nurse Supervisor #1 was interviewed and stated restraints include such items as side rails, mittens, seatbelts, and abdominal binders. Registered Nurse Supervisor #1 also stated if a restraint is in place it must be released, and the seat belt monitored, it is discussed in the restraint committee meetings if the resident needs it or it can be discontinued. Registered Nurse Supervisor #1 further stated the seat belt needs a physician order for the seat belt and could not locate an order in the electronic medical record. Registered Nurse Supervisor #1 stated the seat belt had been in place for a long time, and they could not locate a consent, assessment or any documentation related to the restraint in the electronic medical record. On 01/22/2026 at 3:20 PM, Certified Nursing Assistant #2 stated Resident #141 has had the seat belt in place for almost two years, and they are not sure why it was in place. On 01/20/2026 at 2:17 PM, Licensed Practical Nurse #2 was interviewed and stated Resident #141 is confused, needs one-person physical assist with dressing and lately needs encouragement to eat, as they yell at times and will throw their tray. Licensed Practical Nurse #2 also stated the seat belt was always in place as Resident #141 attempts to get up from the wheelchair and needs the seat belt to prevent them from getting up. On 01/20/2026 at 11:06 AM, Certified Nursing Assistant #1 was interviewed and stated when Resident #141 is placed in the wheelchair and taken to the dining area for activities put the seat belt on and once the seat belt is on Resident #141 is unable to remove and makes no attempts to remove the seat belt. Certified Nursing Assistant #1 also stated the seat belt stay in place throughout the day. Certified Nursing Assistant #1 stated Resident #141 has not exhibited any behaviors, and they put the seat belt on whenever taking Resident #141 out of bed to prevent falls. 10 NYCRR 415.4(a)(2-7)

Based on observation, record review, and interviews, the facility failed to ensure that a copy of the discharge notice was sent to a representative of the Office of the State Long-Term Care Ombudsman. This was evident for one (1) of one (1) resident (Resident #214) reviewed for Discharge. Specifically, there was no documented evidence that a copy of Resident #214's discharge notice was sent to the Office of the State Long-Term Care Ombudsman.The findings are:The facility's policy and procedure titled Discharge Planning with a revision date of 09/2025 documented that when a resident's discharge plan has been determined, a Notice of Discharge is prepared, and a copy of the notice will be sent to the Long-Term Care Ombudsman, and a copy is retained by the facility in the resident record.Resident #214 was admitted to the facility on [DATE] with diagnosis including Kidney Failure, DM, Metabolic Encephalopathy, and borderline personality disorder.The discharge Minimum Data Set assessment dated [DATE] documented Resident #215 was cognitively intact.Resident #214's discharge and instruction summary form documented they were being discharged to the community with family.A discharge care plan dated 10/30/2025 documented Resident #214 will be discharged to the community with family members.There was no documentation in Resident #214's medical record that the Long-Term Care Ombudsman office was notified of the discharge in writing. On 01/22/2026 at 12:35 PM, Social Worker #1 was interviewed and stated that they were not present at the time of the resident's discharge. They stated that a copy of the notice should have been sent to the Ombudsman.01/22/2026 at 12:40 PM, the Director of Nursing was interviewed and stated that a copy of Resident #214's discharge notice should have been emailed to the Ombudsman. However, the Director of Nursing was not able to provide evidence that a copy has been sent. They stated during a subsequent interview at 4:00 PM that they cannot find proof that the discharge notice has been sent. 10 NYCRR 415.3

Based on observation, record review, and interviews, the facility failed to ensure that a comprehensive person-centered care plan for each resident was developed and implemented, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. This was evident for two (2) of 4 (four) (Residents #141 and #143) residents observed for restraints. Specifically, Residents #141 and #143 was observed on multiple occasions wearing seatbelts. There was no care plan developed for both residents to address ongoing use of restraints.Cross Reference F-tag 604: Right to be Free from Physical Restraints The findings include: The facility's policy titled Comprehensive Care Plan with a last reviewed date of 01/2026 documented that it is the facility purpose to ensure that each resident is provided with individualized, goal-directed care, which is reasonable, measurable, and based on resident needs. The policy further documented the Comprehensive Care Plan should include measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs as identified in the comprehensive assessment. The objectives will be used to monitor the residents' progress and alternative interventions will be documented as needed. 1. Resident #141 was admitted to the facility with diagnoses that included Cancer, Anemia, and Schizophrenia. On 01/15/2026 at 10:10 AM, Resident #141 was observed sitting in the dining area with seat belt over the upper thigh area. On 01/15/2026 at 1:56 PM, Resident #141 was observed sitting in a wheelchair with seat belt locked across upper limbs in the dining area. On 01/20/2026 at 9:23 AM, Resident #141 was observed sitting in the dining area in a wheelchair with a seatbelt that has a button in middle for release. 01/20/2026 at 2:24 PM, Resident #141 was observed in the dining room sitting on a wheelchair with a seatbelt. Licensed Practical Nurse #2, who was present during the observation, stated that Resident #141 was always wearing a seatbelt. On 01/20/2026 at 2:29 PM, Resident #141 was observed in the dining room sitting on a wheelchair with a seatbelt across their upper thighs. Registered Nurse Supervisor #1 stated that Resident #141 wears a seatbelt to keep them from sliding from the wheelchair. A review of Resident #141's medical record revealed that a care plan was not developed to address ongoing use of restraint. On 01/22/2026 at 2:30 PM, Registered Nurse Supervisor #1 was interviewed and stated they are responsible for assessing residents and initiating care plans. They stated that the Certified Nursing Assistants placed the seatbelt for Resident #141's safety without physician's order. On 01/23/2026 at 9:23 AM, the Director of Nursing was interviewed and stated that the licensed nurse is responsible for initiating care Plans. The Director of Nursing stated that a care plan for restraint was not developed because the staff did not report using a seatbelt for Resident #141. 2. Resident #143 had diagnoses which included Paranoid Schizophrenia and muscle spasms, and constipation. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #143 was cognitively intact, required partial to moderate assistance with most activities of daily living and mobility, used a wheelchair, had no falls since the prior assessment, and did not use physical restraints or alarms. On 01/16/2026 at 1:07 PM, Resident #143 was observed seated in a wheelchair wearing a blue colored seat belt. On 01/20/2026 at 2:46 PM, Resident #143 was observed in the day room playing dominoes with other residents, showing no signs of distress, with the seat belt on. There was no documented evidence that a comprehensive care plan had been created to address use of a seat belt for Resident #143. On 01/23/2026 at 9:57 AM, Registered Nurse #3 was interviewed and stated Resident #143 was transferred to the third floor at the end of October 2025 and has always worn a seat belt on this unit. Registered Nurse #3 also stated there are some residents who learn forward in their wheelchairs and the seat belt helps them to maintain their safety. State Surveyor observed Resident #143 with Registered Nurse #3 and when Registered Nurse #3 asked Resident #143 to remove the seat belt they stated they were not able to remove the seat belt because they were not good with their hands. Registered Nurse #3 stated if Resident #143 was not able to remove the seat belt this would be considered a restraint. Registered Nurse #3 stated they are responsible for creating care plans and a care plan should have been created for the seat belt which may have been missed. 10 NYCRR 415.11(c)(1)

Based on observation, record review, and interviews, the facility failed to ensure that a resident who was administered enteral tube feedings received the appropriate treatment and services to prevent complications. This was evident in two (2) of two (2) (Residents #10 and #12) residents reviewed for tube feeding out of 38 total sampled residents. Specifically, Residents #10 and #12's enteral tube feeding formula and water bag were not labeled with the resident's name, the date and start time of the administration.The findings include:The facility's policy and procedure titled Enteral Feedings with a last revised date of 01/2026 documented that the formula containers will be labeled with resident's name, date, rate and time container was started. 1. Resident #10 was admitted with diagnoses that included Anemia, Parkinson's Disease, Malnutrition, Gastrostomy status.The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #10 had severe impairment in cognition and required total dependence of staff for all activities of daily living. The Minimum Data Set also documented that Resident #10 is on feeding tube, proportion of total calories the resident received through parenteral, or tube feeding is 51% or more; and the average fluid intake per day was 501 cubic centimeter per day or more.The Comprehensive Care Plan for feeding tubes dated 07/08/2025 documented Resident #10 was on enteral feeding related to Dysphagia; Failure to thrive, percutaneous endoscopic gastrostomy tube placement on 06/28/2025, and was at high risk for aspiration pneumonia. The facility interventions include aspiration precautions; to check feeding pump (if in use) before each feeding; and to check gastric residuals before each feeding & document amount.A physician's order dated 01/15/2026 documented: Tube Feeding - Continuous using pump kit, Formula: Peptamen 1.5, 1000 cubic centimeter/day at 50 cubic centimeter /hour, start at: 4:00 PM over 20 hours if not interrupted; Total Formula Volume: 1000 cubic centimeter.On 01/15/2026 at 10:16 AM, Resident #10 was observed with tube feeding running at 50 milliliters/hour. The enteral feeding bag was not labeled with resident's name, date, rate and the time the feeding started.On 01/16/2026 at 8:50 AM, Resident #10 was observed with tube feeding running at 50 milliliters/hour. The enteral feeding bag was not labeled with resident's name, date, rate, and the time the feeding started. 2. Resident #12 was admitted with diagnoses that included Hypertension, Malnutrition, and Adult failure to thrive.The Significant Change in Status Minimum Data Set assessment dated [DATE] documented that Resident #12 had severe impairment in cognition and required total dependence of staff for most activities of daily living. The Minimum Data Set also documented that Resident #12 was on feeding tube, proportion of total calories the resident received through parenteral, or tube feeding is 51% or more; and the average fluid intake per day was 501 cubic centimeter/day or more. The Comprehensive Care Plan for feeding tubes dated 12/08/2025 and was last updated on 01/06/2026 documented that Resident was placed on gastrostomy tube on 12/05/2025 due to refusal to eat/decreased oral intake. A Physician's order dated 01/06/2026 documented: Tube Feeding - Continuous using pump kit, Formula: TwoCal-HN 1000 milliliter at 50 milliliter /hour, start at 4:00 PM until volume infused.On 01/15/2026 at 10:30 AM, Resident #12 was observed in bed, on ongoing tube feeding. The feeding bottle was not labeled with resident's name, date, rate and time feeding was started.On 01/16/2026 at 8:53 AM, Resident #12 was observed in bed with tube feeding infusing at 50 milliliters per hour, amount left in bottle was approximately 200 milliliters. The enteral feeding bottle was not labeled with resident's name, date, rate and time container was started.On 01/22/2026 at 9:16 AM, Licensed Practical Nurse #1 was interviewed and stated that the 3:00 PM to 11:00 PM nurse hangs the feeding, and they are expected to document the start date and time when the feeding started. On 01/22/2026 at 9:23 AM, Registered Nurse Supervisor #1 was interviewed and stated that the nurses who starts the tube feeding at 4:00 PM are supposed to label and date the enteral feeding bottle and water bag. Registered Nurse Supervisor #1 stated that they usually label them when they are making rounds and noted that the feeding bottle and irrigation were not labeled. Registered Nurse Supervisor #1 further stated that they were asked to work on the evening shift on those days because there was shortage of nurses, and they did not realize that the feeding bottles were not properly labeled.On 01/22/2026 at 2:40 PM, the Director of Nursing was interviewed and stated that resident's enteral feeding bottle must be labeled with the resident's name, date, and time as per facility protocol by the nurse who hangs and initiates the feeding. 10 NYCRR 415.12(g)(2)

Based on observation, record review, and interview, the facility did not ensure that medication and biologicals drugs were labeled in accordance with currently accepted professional principles on the Medication Cart on the 4th floor. Specifically, Residents #119 and #186's eye drops did not have the resident's name on the vial. This was evident for one (1) (4th Floor) of five (5) units reviewed for Medication Storage. The findings are:The facility's Policy titled Label/Store Drugs and biologicals dated last review January 2026 documented all medications and the biologicals must remain in original Pharmacy labeled packaging, unless administered per authorized dispensing practice. The policy further documented the required elements as applicable include the resident name if resident -specific, medication name, strength, dosage form, directions for use, prescriber name, date dispensed, expiration date, Pharmacy name and Prescription number, On 01/20/2026 at 9:08 AM, during the medication storage facility task the fourth (4th) floor medication cart was examined with Licensed Practical Nurse Number one (1). Latanoprost 0.0005% eye drop for resident number 119 and resident number 186 was observed in a dark plastic bag with label on the outside bags and both dated open 1/8/2026. There were no labels observed on the vials. Licensed Practical Nurse number one (1) stated the eye drops will expire 42 days after opening. On 01/23/2026 at 09:47 AM, a Telephone interview completed with Pharmacist form Spectrum Pharmacy refused to give full name and identify self as Pharmacist for the facility. The Pharmacist stated is responsible for labeling medications for Pharmacy. The Pharmacist stated the eye drops are labeled with the patient's name, room number, date of birth and a label is placed on the bag, the box and the bottle. Pharmacist stated if the label is not on the bottle the facility will call the Pharmacy, and the Pharmacy will resend the item new. The Pharmacist stated the facility must send pictures and describe that the label was missing. The pharmacist stated that the Pharmacist is legally required to label all medications and saw that the eye drops for the residents were last process on 1/6/2026 and stated did not get any phone call from the facility regarding the eyedrops. Pharmacists stated that they were not sure what would happen in these cases. On 01/23/2026 at 9:11 AM, The Director of Nursing stated medications must be labeled with the resident's name, the dosage, instructions and the bottle is affixed to the bottle. The Director of Nursing stated if the label is missing the nurse should report to the supervisor who in turn can call the pharmacies and or Director of Nursing and a new medication is sent or if the Pharmacist Consultant is in the building cand assist. The Director of Nursing stated Nurse do not affix labels to any medications and the nurse needs to report to the Supervisor. The Director of Nursing stated monitors by doing rounds, medication audits, and staff reporting any issues or concerns. 01/22/2026 2:53 PM Infection Control Preventionist stated it all came from the pharmacy, and the pharmacy put the labels and stated cannot label things because the facility cannot label things and do stock eye drops, and usually there is bag and bottle, and the eye drops have a bag and not sure what happened there. Infection Control Preventionist stated the nurse should make sure there is a label and if there is not, they need to reach out to the pharmacy and or let the Infection Control Preventionist Director of Nursing aware. On 01/20/2026 at 9:12 AM Licensed Practical Nurse number one (1) stated there was no label on the bottle, but the bottles are dated when opened on 1/8/2026. Licensed Practical Nurse number one (1) stated will know who the medications belong to by checking all the other eye drops to ensure each resident has their drops to make sure it is the right resident if do not see any label on the bottle. Licensed Practical Nurse number one (1) LPN gave no reason why the bottles were not labeled with the resident name and stated will make the Supervisor aware. 10 NYCRR 415.18 (d)

Based on observation, record review, and interviews, the facility failed to ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident for one (1) of three (3)(Licensed Practical Nurse #3) nurses observed during medication administration. Specifically, Licensed Practical Nurse #3 failed to sanitize the sphygmomanometer (an equipment used to take blood pressure) and the blood pressure cuff before and after use and in between residents. The findings include: The facility's policy titled Reprocessing of Reusable Resident Medical Equipment with a last reviewed date of 01/2026 documented equipment or items in the resident environment likely to have been contaminated with infections fluids or other potentially infectious matter must be handled in a manner so as to prevent transmission of infectious agent example wearing gloves for handling soiled equipment, and properly clean and disinfect or sterilize reusable equipment. The policy further documented that blood pressure machine/cuff used by nursing, medical and rehabilitation department must be cleaned before and after using with a sanitizing cloth wipe. On 01/16/2026 at 9:14 AM, during medication administration observation on the 2nd Floor. Licensed Practical #3 was observed taking Resident #102's blood pressure without sanitizing the blood pressure cuff before and after using. On 01/16/2026 at 9:30 AM, Licensed Practical Nurse #3 used the same blood pressure cuff onto Resident #136. The Licensed Practical Nurse failed to sanitize the blood pressure cuff before and after use between each resident. On 01/16/2026 at 9:33 AM, Licensed Practical Nurse #3 was interviewed and stated they were supposed to clean and sanitize the blood pressure cuff with sanitizing wipes before and after use and between each resident to prevent infection but stated that they forgot. On 01/20/2026 at 2:48 PM, Registered Nurse Supervisor #1 was interviewed and stated they are responsible for supervising Licensed Practical Nurse #3 to ensure that they properly sanitize the reusable equipment. Registered Nurse Supervisor #1 stated the blood pressure cuff must be cleaned in-between residents and the staff should use the purple top sanitizing wipes. On 01/22/2026 at 2:47 PM, the Infection Preventionist was interviewed and stated that the blood pressure machine and its cuff must be sanitized and must wait for it to dry before using it for the next resident. On 01/23/2026 at 9:11 AM, the Director of Nursing was interviewed and stated that the blood pressure cuff must be cleaned with a purple top sanitizing wipes between residents use for infection control measures. 10 NYCRR 415.19

Based on observation, record review, and interviews, the facility failed to provide a safe and comfortable environment for the staff. This was evident during physical environment observation in the laundry room on the basement and the 6th Floor nurses' station.The findings include: The facility's policy and procedure titled Maintenance Services with a reviewed date 01/2026 documented the Environmental Services Department is responsible for managing the maintenance function in the most cost-effective manner possible while maximizing the useful life of equipment, rooms, and properties while striving to provide the best service to our residents.1. On 01/16/2026 at 9:41 AM, during observation in the laundry room at the basement, the back of washing machines #3 and #4 was rusted and the gray colored panels were loose and disconnected from the machine. 2. On 01/16/2026 at 12:19 PM, the nurses' station on the 6th Floor was observed with mismatched floor tiles, there was a brown colored substance on the wall under the desk, and the desk was chipped. On 1/23/2026 at 12:10 PM, the Maintenance Director was interviewed and stated that the tiles are old and need to be replaced. On 01/23/2026 at 12:30 PM, the Administrator was interviewed and stated they are not sure what repairs are needed. They stated the Maintenance Department makes daily rounds to see if there are any needed repairs and they also have a consultant who comes in and makes rounds in the unit. They stated there is a maintenance logbook in each unit where needed repairs are logged.10 NYCRR 415.29

Based on observation, record review, and interviews, the facility failed to ensure that Minimum Data Set assessments accurately reflected the resident's status. This was evident for three (3) of 3 (three) (Residents #141, 100, and 143) reviewed for resident assessment. Specifically, 1.) Resident #141's use of restraint was not accurately documented in the Minimum Data Set assessment. 2.) Resident #100 who had a physician's order for clopidrogel (an antiplatelet drug used to prevent blood clot by preventing platelets from clumping together in the blood), was coded in the Minimum Data Set assessment as receiving anticoagulant. 3.) Resident #143's use of restraint was not accurately documented in the Minimum Data Set assessment. Cross Reference to F-tag 604: Right to be Free from Physical RestraintsThe findings include: The facility's policy titled Resident Assessment Minimum Data Set 3.0 with a last reviewed date of 01/2026 documented it is the policy of the facility to ensure a comprehensive and accurate assessment of residents. The policy stated the assessment will include direct observations, and communication with the residents, as well as communication with licensed and non-licensed direct care staff members on all shifts. 1. Resident number 141 was admitted to the facility with diagnoses that included Cancer, Anemia, and Schizophrenia. On 01/15/2026 at 10:10 AM, Resident #141 was observed sitting in the dining area with seat belt over the upper thigh area. On 01/15/2026 at 1:56 PM, Resident #141 was observed sitting in a wheelchair with seat belt locked across upper limbs in the dining area. On 01/20/2026 at 9:23 AM, Resident #141 was observed sitting in the dining area in a wheelchair with a seatbelt that has a button in middle for release. 01/20/2026 at 2:24 PM, Resident #141 was observed in the dining room sitting on a wheelchair with a seatbelt. Licensed Practical Nurse #2, who was present during the observation, stated that Resident #141 was always wearing a seatbelt. On 01/20/2026 at 2:29 PM, Resident #141 was observed in the dining room sitting on a wheelchair with a seatbelt across their upper thighs. Registered Nurse Supervisor #1 stated that Resident #141 wears a seatbelt to keep them from sliding from the wheelchair. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #141 was severely cognitively impaired. The assessment did not document the use of restraints. On 01/23/2026 at 10:24 AM, the Minimum Data Set Coordinator was interviewed and stated they do not recall seeing Resident #141 wearing a seatbelt when on a wheelchair. They stated they always see Resident #141 in bed. They stated that there was no order for Resident #141's seatbelt therefore, it cannot be coded as a restraint. 2. Resident #100 was admitted to the facility with diagnoses of Cerebrovascular Disease, Hypertension, and Hyperlipidemia. A physician's order with a last reviewed date of 01/15/2026 documented an order for clopidogrel 75 milligram give one tablet by oral route once daily which is an antiplatelet for Cerebrovascular disease. There was no physician's order for any anticoagulant. The Minimum Data Set, dated [DATE] documented that Resident #100 was receiving an anticoagulant. On 01/23/2026 at 10:11 AM, the Minimum Data Set Coordinator was interviewed and stated that clopidrogel is not an anticoagulant and that coding it as antiplatelet in the Minimum Data Set assessment was an error. 3. Resident #143 had diagnoses which included Paranoid Schizophrenia and muscle spasms, and constipation. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #143 was cognitively intact, required partial to moderate assistance with most activities of daily living and mobility, used a wheelchair, had no falls since the prior assessment, and did not use physical restraints or alarms. On 01/16/2026 at 1:07 PM, Resident #143 was observed seated in a wheelchair wearing a blue colored seat belt. On 01/20/2026 at 2:46 PM, Resident #143 was observed in the day room playing dominoes with other residents, showing no signs of distress, with the seat belt on. The Minimum Data Set assessment for Resident #143 did not accurately reflect the use of a seat belt. On 01/23/2026 at 9:57 AM, Registered Nurse #3 was interviewed and stated Resident #143 was transferred to the third floor at the end of October 2025 and has always worn a seat belt on this unit. Registered Nurse #3 also stated there are some residents who learn forward in their wheelchairs and the seat belt helps them to maintain their safety. Registered Nurse #3 further stated Resident #143 should have an order for seat belt use and they were not able to locate orders or an evaluation for the use of seat belts. State Surveyor observed Resident #143 with Registered Nurse #3 and when Registered Nurse #3 asked Resident #143 to remove the seat belt they stated they were not able to remove the seat belt because they were not good with their hands. Registered Nurse #3 stated if Resident #143 was not able to remove the seat belt this would be considered a restraint. On 01/23/2026 at 2:05 PM, Registered Nurse #1 who is also the Minimum Data Set Coordinator, was interviewed and stated they were unaware of Resident #143's daily seat belt use as there was no order or care plan. Registered Nurse #1 also stated they did not observe Resident #143 was wearing and a seat belt when they conducted their assessment. Registered Nurse #1 further stated that if a resident cannot remove the seat belt independently, it is considered a restraint and should be coded on the Minimum Data Set Assessments. 10 NYCRR 415.11 (b)

Based on record review and interviews conducted during the abbreviated survey (#2650673), the facility did not ensure each resident's right to privacy and confidentiality. This was evident for one (1) of three (3) residents (Resident #1) sampled. Specifically, photographs of Resident #1's body and private space were taken without the resident's or designated representative's written consent. The findings include:The facility policy and procedure titled 'Photographs, video surveillance and audio recordings' dated 01/2022 documented the facility is committed to ensuring that the rights of the residents to safe and secure environment, privacy, confidentiality and dignity are maintained. The policy also stated to support accurate assessment and timely clinical decisions-making, authorized healthcare providers may take photographs or video during emergency situations when necessary to document the condition of a resident. Resident #1 was admitted with diagnosis including Non-Alzheimer's Dementia and Acute kidney failure.The Minimum Data Set (a resident assessment tool) dated 09/17/2025 documented Resident #1 had severely impaired cognition, and they required partial/moderate assistance of staff for most activities of daily living.There was no documentation of resident's photo taken without consent in the medical record. in the resident's chart.On 10/27/2025, at 10:30 AM and at 2:15 PM, attempts to speak with the complainant during the onsite investigation were unsuccessful. On 10/27/2025 at 01:00 PM, the Director of Nursing was interviewed and stated staff are aware that they are not allowed to take any resident's photograph without consent. The Director of Nursing also stated they were notified that Resident #1's photograph was taken by the Medical Doctor #1 during Resident #1 assessment and when having telephone conversation with the family to get their permission to start intravenous fluid for Resident #1 prior to hospital transfer. The Director of Nursing further stated the family was verbally informed by Medical Doctor #1 during the telephone conversation before the photograph was taken and Resident #1's photograph taken was not shared with anyone other than the family just to get their consent for Resident #1's plan of care.On 10/27/2025 at 02:00 PM, Medical Doctor #1 was interviewed and stated when Resident #1 was noted with a large volume of blood-tinged vomit in August 2025, Resident #1 was immediately assessed and evaluated, and they wanted to start Resident #1 on intravenous fluid prior hospital transfer. Resident #1's family was called and notified of the plan of action, but they declined intravenous fluid and hospital transfer. Medical Doctor #1also stated a photo was taken of Resident #1's vomit and was sent to the family to convince them of the urgent need for the treatment intervention in order to get them to agree that Resident #1 be given intravenous fluid immediately and be transferred to the hospital.On 11/25/2025 at 11:50 AM, during a follow-up interview, Medical Doctor #1 stated the picture taken of Resident #1 and shown to the family was to enable them to get consent for emergency care needed by Resident #1. Medical Doctor #1 also stated they did not compromise Resident #1's protective health information, and the photograph was only shared with the resident's health care proxy to enable them to see Resident #1's condition when they were initially refusing urgent interventions needed to be given to Resident #1 to prevent their condition worsening. Medical Doctor #1 further stated the photo of Resident #1's emesis was taken during their conversation, and the family was notified when the photo was being taken, they requested to see the picture before they gave permission for the treatment, and the photograph was never sent to any social media. Medical Doctor #1 further stated they believed they have not violated any regulation by taking and sharing Resident #1's photograph with the person responsible for making decision during an emergency situation for Resident #1, and any further delay in Resident #1's treatment could have been a disaster.On 11/25/2025 at 01:20 PM, during an interview the Medical Director stated the facility is fully aware of resident's protected health information record and their staff have not been violating residents' rights for privacy. The Medical Director stated residents' care is always collaborated with the attending medical doctor every day. Medical Director also stated that the attending doctor was on the phone with Resident #1's family prior taking the photo and the doctor explained to the family on phone that resident's photograph would be taken to show the amount of emesis from Resident #1 before permission was given to provide intravenous fluid and transfer resident out for further urgent care needed. On 11/25/2025 at 02:00 PM, the Administrator was interviewed and stated the facility policy on resident's right for privacy is followed by their physicians. The Administrator also stated if the resident's situation requires emergency attention, the physician would ensure prompt action is taken. The Administrator further stated they have always included Resident #1's representative in the resident's plan of care, and if there is any issue or concern, the staff are readily available to listen to their concern. The Administrator stated they do not understand why the emergency actions taken by their physician to provide needed care for Resident #1 was an issue. 10 NYCRR 413.3(e)(1)(ii)

Based on observation, record review, and interviews conducted during an abbreviated survey (NY00333004), the facility did not ensure that all alleged violations involving abuse are reported immediately, but not later than two hours after the allegation of abuse was made, to the State Survey Agency (New York State Department of Health). This was evident in two out of four residents sampled (Residents #1 and #2). Specifically, on 02/04/24 at 1:00 am, Resident #1 informed the front desk Receptionist that Resident #2 climbed into their bed and took advantage of them. On 02/06/24 at 9:30 am, the facility reported the allegation to the New York State Department of Health, two days after the incident occurred. The findings include: The facility Policy and Procedure titled Abuse Prevention and Reporting Policy with a revised date of 04/13/23, documented that all alleged violations must be reported immediately but no later than 2 hours if the alleged violation involves abuse. The facility's Accident/Incident Report dated 02/04/24 at 1:00 am, documented that Resident #1 informed the front desk Receptionist that Resident #2 climbed into Resident #1's bed and took advantage of them. Resident #1 could not recall what happened, however Resident #1 felt pain all over. The facility concluded that abuse did not occur. Resident #1 was inconsistent with the details of the event. Resident #2 was interviewed on several occasions and during each interview, they denied having any interactions with Resident #1. Resident #1 was admitted on [DATE] to the facility with diagnoses including Bipolar Disorder (extreme mood changes) and Schizophrenia (a disorder that affected the ability to think, feel and behave clearly). The Minimum Data Set (assessment tool), dated 12/13/23, documented Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) and scored 2 out of 15 indicating severely impaired cognition. A Comprehensive Care Plan for Victimization dated 09/18/23, documented interventions to transfer resident to the emergency room for evaluation, issue a private room for lodging pending investigation and change room closer to the nurse's station for increase monitoring. Resident #2 was admitted on [DATE], to the facility with diagnoses including Schizophrenia (a disorder that affected the ability to think, feel and behave clearly) and Hypertension (high blood pressure). The Minimum Data Set (assessment tool), dated 12/08/23, documented Resident #2 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) and scored 7 out of 15 indicating severely impaired cognition. A Comprehensive Care Plan for Victimization updated 02/09/24, documented Resident #2 was involved in an alleged incident that occurred on 02/04/24 with Resident #1. Resident #2 was calm and cooperative, able to answer questions in an appropriate manner and denied having any interaction/encounter with Resident #1. During an interview on 04/10/24 at 1:28pm, Risk Manager stated the Incident occurred on 02/04/24 and was reported to the Department of Health on 02/06/24. Risk Manager stated they are aware that abuse allegations should be reported within 2 hours, however they were away and when they returned to the facility, they reported the incident. During an interview on 04/10/24 at 2:26 pm, Director of Nursing stated the Risk Manager is responsible for reporting incidents to the Department of Health after they are made aware and have informed the Assistant Administrator. Director of Nursing stated the Risk Manager was not available to report the incident to the Department of Health. During an interview on 04/10/24 at 3:52 pm, Assistant Administrator stated they were informed of the incident on 02/04/24 and the Risk Manager is responsible for reporting any incident to the Department of Health. Assistant Administrator stated they are aware that any allegation of abuse is supposed to be reported within 2 hours. 10 NYCRR 415.4(b)

Based on observation, interview, and record review conducted during the Recertification survey from 11/8/2023 to 11/15/2023, the facility did not ensure the Director of Nursing (DNS) served as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. This was evident for 1 (Unit 5) of 5 Units. Specifically, the DNS was observed working as a charge nurse and administered medication to residents. The findings are: The facility policy titled Competent Nursing Staff dated 1/1/2023 documented the facility will have sufficient nursing staff to provide nursing services. The facility census at the time of survey entrance on 11/8/2023 at 9:00 AM was 219 out of 240 available beds. On 11/14/2023 at 08:47 AM, the DNS was observed administering medication to a resident on Unit 5. On 11/15/2023 at 09:39 AM, the DNS was observed on Unit 5 administering medication to residents. The DNS was interviewed at the time of the observation and stated they need to attend to the residents' needs because the medication nurse scheduled to work did not come in and the facility was unable to get a replacement. On 11/15/2023 at 09:52 AM, an interview was conducted with the Nursing Secretary (NS) who stated the DNS worked as a medication nurse on 11/14/2023 because the scheduled nurse was coming in late and there was no other nurse to cover the unit. The medication nurse scheduled for 11/15/2023 called out, the NS could not get a replacement, and the DNS had to be on the unit to administer medications and attend to resident needs. On 11/15/2023 at 12:06 PM, the Administrator was interviewed and stated it has been difficult to staff the facility with nurses. The facility worked with staffing agencies and paid staff extra for staying overtime. The DNS has covered as the charge nurse on the unit on rare occasions. 10 NYCRR 415.13(b)(1)

Based on observation, record review, and interviews conducted during a Recertification survey from 11/8/2023 to 11/15/2023, the facility did not ensure a safe, clean, comfortable, and homelike environment was provided to residents. This was evident for 1 (Unit 2) of 5 resident units. Specifically, rusty bedframes were observed being used for Resident #372 and #152. The findings are: The facility policy titled Resident Right - Safe/Clean/Comfortable/Homelike Environment dated 11/15/2023 documented Maintenance staff were responsible for conducting environmental rounds per defined schedule of all units and other areas to identify building issues that require repair. All staff were responsible to report issues related to cleanliness and equipment. The Director of Maintenance follows up with the Administrator for any issues not addressed in a timely manner. On 11/13/2023 at 02:54 PM, observations of the Unit 2 were conducted and Resident #372 and Resident #152 were observed with rusty bedframes. On 11/14/2023 at 09:47 AM, Licensed Practical Nurse (LPN) #3 was interviewed and stated staff can document in the unit Maintenance logbook if something needs to be addressed. On 11/14/2023 at 02:52 PM [NAME] was interviewed and stated that they would let the supervisor know and then they would call the PT, and they would get the chair replaced. I did not take her out today. This is anything that PT. On 11/14/2023 at 8:31 AM and 11/14/2023 at 9:31 AM, the Director of Maintenance (DM) was interviewed and stated the Maintenance Department was responsible for conducting environmental rounds and each floor had a communication book that informs the department of identified concerns. The Maintenance Director conducts room inspections on 1 wing of 1 unit each week and made notes of any damaged beds. The DM observed the bedframes for Resident #372 and #152 during the interview and stated the bedframes should be changed or repainted because of the rust. 10 NYCRR 415.5(h)(2)

Based on observations, interview, and record review conducted during the Recertification Survey from 11/08/2023 to 11/15/2023, the facility did not ensure that residents remained free of physical restraints. This was evidenced for 2 (Resident #197, Resident #141) of 6 reviewed for Physical Restraints out of 38 total sampled residents. Specifically, 1) Resident #197 was observed with bilateral upper 1/2 siderails (SR) in place without assessment or Medical Doctor Order (MDO), and 2) Resident #141 was observed with bilateral 1/2 siderails (SR) in place without a restraint assessment or Medical Doctor Order (MDO). The findings are: The facility policy titled Restraints dated 11/13/2023 documented a physical restraint is any physical or mechanical device that the individual cannot remove easily which restricts freedom of movement, for example, side rails. The facility policy titled Side/Bed Rail dated 1/2023 documented the use of side rails is only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. The facility will assess to determine if the bed rail meets the definition of a restraint, whereby due to the resident's physical or cognitive inability to lower the bed rail independently. Resident #197 had diagnoses of acoustic neuroma and schizophrenia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #197 was severely cognitively impaired, totally dependent on 2 people for bed mobility, and did not use restraints. On 11/10/2023 at 08:34 AM and 11/13/2023 at 10:44 AM, Resident # 197 was observed in bed, alert and not responsive when greeted. Bilateral 1/2 upper SRs were in the raised position. The Comprehensive Care Plan (CCP) related to activities of daily living dated 1/31/2023 documented Resident #197 required 2 people to assist with bed mobility. The Restraint assessment dated [DATE] did not document Resident #197 required SRs. The SR assessment dated [DATE] documented Resident #197 had no factors that warranted SR use. There was no documented evidence Resident #197 was adequately assessed for SR use and a MDO for SR use was obtained. On 11/13/2023 at 10:44 AM, Certified Nursing Assistant (CNA) #2 was interviewed and stated Resident #197 had contractures and was unable to aid in bed mobility. Bilateral 1/2 upper SRs were always raised to prevent Resident #197 from slipping out of the bed. Resident #197 was unable to grab onto, raise, or lower the SRs on their own. On 11/14/2023 at 09:42 AM, Registered Nurse (RN) #2 was interviewed and stated Physical Therapy (PT) assessed Resident #197 for SR use. There was an MDO in place for Resident #197 to have SRs which are used for safety. SRs should be lowered when not in use and only used during morning care. Resident #197 was unable to move on their own and RN #2 stated Resident #197 was unable to grab onto the SRs to use them for bed mobility. RN #2 was responsible for completing the restraint assessments. On 11/14/2023 at 10:17 AM, the PT was interviewed and stated they assess residents to determine whether they can use the SR to assist in bed mobility and transferring out of bed. Resident #197 was assessed in 8/2023 and should not have a SR in use and no SRs should be raised on Resident #197's bed. 2) Resident #141 had diagnoses of catatonic disorder and systemic lupus erythematosus. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #141 was severely cognitively impaired did not use SRs and was totally dependent on 1 person for bed mobility. On 11/12/2023 at 10:44 AM, 11/13/23 at 10:45 AM, and 11/14/23 at 11:44 AM, Resident #141 was observed in bed with bilateral 1/2 upper SRs raised. The Comprehensive Care Plan (CCP) related to activities of daily living initiated 08/01/2022 documented Resident #141 required the total assistance of 1 person for bed mobility. The CCP related to restraint use initiated 6/6/2023 did not document Resident #141's SR use. The SR assessment dated [DATE] documented Resident #141 did not have factors that warranted SR use and SRs were not indicated. The Restraint assessment dated [DATE] did not document Resident #141 used SRs. There was no documented evidence SR use was indicated or there was a MDO for SR use with Resident #141. On 11/14/2023 at 02:46 PM, Certified Nursing Assistant (CNA) #2 was interviewed and stated Resident #141 cannot follow direction and required 2 people to assist with bed mobility. Resident #141 was unable to grab onto, raise, or lower the SRs independently. On 11/15/2023 at 11:57 AM, the Assistant Director of Nursing (ADNS) was interviewed and stated Registered Nurse Supervisors decided whether residents need SR upon assessment. Maintenance was responsible for installing the SRs. The SR Assessment for Resident #141 clearly documented Resident #141 did not need SRs. 10 NYCRR 415.4(a)(2-7)

Based on record review and interview conducted during the recertification survey from 11/8/2023 to 11/15/2023, the facility did not ensure accuracy of resident assessments. This was evident for 2 (Resident #110 and Resident #184) of 38 total sampled residents. Specifically, 1) the Minimum Data Set 3.0 (MDS) assessment for Resident #110 did not accurately reflect the resident's diagnoses, and 2) the MDS assessment for Resident #184 did not include the resident's use of a Wander Alert Device (WAD). The findings are: An undated facility policy titled Resident Assessment - MDS documented an accurate assessment of residents will be completed. 1). Resident #110 was diagnosed with schizophrenia and depression. The MDS assessments dated 7/27/2023 and 10/25/2023 documented Resident #110 was severely cognitively impaired. The MDS assessments did not document Resident #110 was diagnosed with schizophrenia, bipolar disorder, or depression. The Comprehensive Care Plan (CCP) related to psychotropic drug use initiated 7/19/2022 documented Resident #110 had diagnoses of schizoaffective disorder and depression. A CCP related to mood stated initiated 7/22/2022 documented Resident #110 had a diagnosis of depression. The Medical Progress Noted dated 10/19/2023 documented Resident #110 was diagnosed with bipolar disorder, depression, and schizoaffective disorder. The Psychiatry Consult dated 09/07/2023 documented Resident #110 had diagnoses of schizoaffective disorder. There is no documented evidence that the MDS dated [DATE] and 7/27/2023 documented Resident #110's diagnoses of schizophrenia, depression, and bipolar disorder. An interview was conducted on 11/13/2023 at 1:48 PM with the MDS Coordinator who stated they were responsible for completing the MDS assessments. Diagnoses for residents was gathered using the progress notes and doctor orders. The missing diagnoses from Resident #110's MDS assessments was an error. An interview was conducted on 11/13/2023 at 2:04 PM with the Director of Nursing Services (DNS) who stated an MDS Consultant reviews the work of the MDS Coordinator quarterly. The DNS was not aware of any concerns with the MDS accuracy. 44472 2. Resident #184 had diagnoses of bipolar disorder and non-Alzheimer's dementia. The MDS assessment dated [DATE] documented Resident #184 was severely cognitively impaired and did not use a WAD. A comprehensive care plan (CCP) related to WAD use dated 7/15/2023 documented Resident #184 had a WAD in place as a result of exit-seeking. A Physician's Order dated 08/22/2023 documented Resident #184 had a WAD on their left arm. An Elopement Risk assessment dated [DATE] documented Resident #184 was at high risk for elopement and a WAD had been in place since their admission to the facility. Nursing Notes dated 08/22/2023 documented Resident #184 had a WAD on their left wrist. There was no documented evidence the MDS assessment dated [DATE] documented Resident #184's WAD to their left wrist. On 11/15/2023 at 01:34 PM, the MDS Coordinator was interviewed and stated they missed coding the WAD for Resident #184 on their MDS assessment and would make a correction immediately. On 11/15/2023 at 01:37 PM, Director of Nursing (DNS) was interviewed stated the MDS Coordinator made an errors and sometimes there were computer glitches that caused the MDS assessments to have inaccuracies. 10 NYCRR 415.11

Based on record review and interviews conducted during the Recertification survey from 11/08/2023 to 11/15/2023, the facility did not ensure that each resident was screened for a mental disorder (MD) or intellectual disability (ID) prior to admission to the facility. This was evident for 1 (Resident #472) of 38 total sampled residents. Specifically, Resident #472 did not have a Preadmission Screening and Resident Review (PASARR) completed prior to their admission to the facility. The findings are: The facility policy titled Admission Screening Procedures dated 1/2022 documented the Screen was reviewed to determine if the could meet the applicant's needs. Resident #472 was admitted to the facility on [DATE] with diagnoses of osteoarthritis and dementia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #472 was severely cognitively impaired. There was no documented evidence that a PASARR was completed for Resident #472 prior to their admission to the facility. On 11/15/2023 at 02:59 PM, an interview was conducted with the Director of Social Work who stated they were unable to locate a copy of the PASARR for Resident #472. The PASARR was not available for review prior to Resident #472's admission to the facility. 10 NYCRR 415.11(e)

Based on observation, record review, and interviews conducted during the Recertification survey from 11/8/2023 to 11/15/2023, the facility did not ensure comprehensive care plans (CCP) were reviewed and revised after each assessment. This was evident for 1 (Resident #110) of 38 total sampled residents. Specifically, the CCPs related to Activities of Daily Living (ADL) and psychotropic drug use were not reviewed and revised upon quarterly Minimum Data Set 3.0 (MDS) assessment. The findings are: An undated facility policy titled CCP documented goals, objectives, and interventions are reviewed and/or revised by the Interdisciplinary Team (IDT) at least quarterly and after each scheduled MDS assessment. Resident #110 had diagnoses of non-Alzheimer's dementia and diabetes mellitus. The MDS assessment dated [DATE] documented Resident #110 was severely cognitively impaired, required limited assistance for dressing, toilet use and personal hygiene, and required supervision for eating. The MDS assessment dated [DATE] documented Resident #110 was severely cognitively impaired, required partial assistance with dressing, toilet use, and personal hygiene, and was independent with eating. A CCP related to ADLs initiated 7/19/2022 and last reviewed 8/8/2023 documented Resident #110 required limited assistance with dressing, toilet use, and personal hygiene. Resident #110 was independent with eating. A CCP related to psychotropic drug use initiated 7/19/2022 and last reviewed 9/7/2023 documented Resident #110 had a diagnosis of psychosis, depressive disorder, and schizoaffective disorder and was prescribed Olanzapine, Haldol, Depakote ER, and Trazodone. There was no documented evidence the CCPs related to ADLs and psychotropic drug use were reviewed and revised upon the 10/25/2023 MDS assessment. On 11/13/2023 at 1:48 PM, an interview was conducted with the MDS Coordinator who stated that CCPs are reviewed by the nursing supervisors upon a resident's significant change, annual and quarterly MDS assessment. The MDS Coordinator assisted the nursing supervisors in reviewing CCPs when they were short of staff and checked the CCPs during the CCP meetings so the review and revision of the CCPs followed the MDS schedule. The MDS Coordinator stated Resident #110's CCPs were not reviewed timely when the MDS assessment was done 10/25/2023 and they were currently in the process of reviewing the resident's CCPs. On 11/13/2023 at 2:04 PM, an interview was conducted with the Director of Nursing Services (DNS) who stated the IDT and nursing supervisors review and update the CCPs according to the MDS assessment schedule. An MDS Consultant also reviews the CCPs monthly as part of quality assurance and the DNS is not aware of any CCP review issues. 10 NYCRR 415.11(c)(2)