Every finding on record at Heritage Park Rehab & Skilled Nursing

Based on observations, interviews, and record review conducted during survey, the facility failed to ensure that the residents' environment remained as free of accidents as possible, and that each resident receives adequate supervision and assistance devices to prevent accidents for one (1) (Resident #21) of four (4) residents reviewed for accidents. Specifically, on 03/11/2026, the facility failed to assist Resident #21 when they were reheating liquid in the microwave oven, resulting in Resident #21 sustaining an 8.5 centimeter by 5-centimeter second degree burn (damage to both the outer (epidermis) and underlying (dermis) layers of skin, causing blisters, pain, and a shiny moist appearance) to their left upper hand. Additionally, the facility failed to develop the care plan to include Resident #21's history of burning self after heating items in the microwave oven. This resulted in actual harm to Resident #21 that was not immediate jeopardy.The findings include: The facility policy titled Food Safety Requirements, with a review date of 04/12/2024 documented education on safe food handling will be provided to all staff, family, residents, resident council, visitors and community groups who may provide foods or fluids to residents of the facility. Leftovers will be reheated to 165 degrees Fahrenheit. The facility was unable to provide a policy or protocol for safe microwave oven operation. The facility policy titled Formation of the Resident Care Plan, with a revised date of 05/23/2018 documented the objective is to maintain an individualized resident-centered plan of care. Resident #21 had diagnoses including Parkinson's disease (tremors and rigidity of movement), hypertension (high blood pressure), and epilepsy (seizure disorder). The Minimum Data Set (a resident assessment tool) dated 02/11/2026 documented the resident was cognitively intact and was independent with activities of daily living (eating dressing, toileting, grooming). The current Comprehensive Care Plan dated 02/11/2026 did not document Resident #21's history of burning self after using the microwave nor inventions related to the use of the microwave oven. During intermittent observations between 04/26/2026 to 04/29/2026, between 7:30 AM and 2:30 PM, there was a microwave oven located on a counter in the First Floor Dining Room. During an observation on 04/26/2026 at 12:49 PM, Resident #21 was observed with a reddened area, approximately 7.0 centimeters by 4.5 centimeters, on their upper left hand. The Resident Incident Form dated 12/02/2025 documented Resident #21 had a fluid filled sac (blister) on the top of the left ring finger from hot water. The resident was heating boil in the bag rice in a bowl in the microwave. The incident form documented Resident #21 had a history of burning self while using the microwave. The resident was educated to ask for staff assistance with kitchen tasks. The Resident Incident Form dated 03/11/2026 documented Resident #21 had an 8.5 centimeter by 5-centimeter blistered area on the top of their left hand. Resident #21 stated they were taking soup out of the microwave when the soup splashed onto their hand. The resident was educated to ask for assistance with hot food from the microwave. The incident report documented that the physician and the family were notified. Review of the Treatment Administration Record dated 03/2026 documented an order dated 03/12/2026 to cleanse the resident's left anterior (top) hand with normal saline, apply Neosporin ointment (over the counter antibiotic) and cover with a nonstick dressing once daily. This treatment was discontinued on 03/14/2026. On 03/14/2026 a new order was obtained to cleanse the resident's left anterior hand with normal saline apply Silvadene (prescription cream used to prevent and treat infections in second- and third-degree burns) topical cream daily for a left-hand burn and cover with a dry dressing. This treatment continued until 04/16/2026. During an interview on 04/29/2026 at 9:15 AM, Resident #21 stated they were taking soup out of the microwave oven when the handle slipped and the hot liquid sloshed on to the top of their left hand. The resident stated the facility had educated them to request for staff assistance when using the microwave oven, but there's only one problem with that, there is no staff to assist so they usually use the microwave by themselves. During an interview on 04/29/2026 at 9:36 AM, Certified Nurse Aide #5 stated Resident #21 used the microwave oven daily, and they have never heard the resident ask for help. During an interview on 04/29/2026 at 9:49 AM, Licensed Practical Nurse #2 stated Resident #21 uses the microwave all the time, and once in a blue moon will ask for staff assistance. During an interview on 04/29/2026 at 9:55 AM, the Director of Nursing stated they would consider the 03/11/2026 incident an avoidable accident that caused Resident #21 harm. During an interview on 04/29/2026, the Acting Administrator stated the facility did not have a policy on safe microwave operation, and apparently Resident #21 had been using the microwave without staff assistance all along and they would consider the burn an avoidable accident that caused Resident #21 harm. During a telephone interview on 04/29/2026 at 2:10 PM, the Medical Director stated Resident #21 had two burns within three months and would want the resident to ask the staff for assistance when using the microwave oven. They stated it was not an appropriate placement to have the microwave oven in the dining room where any resident had access to the microwave oven. Additionally, they stated Resident #21 did not experience permanent harm related to the second degree burn but did experience temporary harm from the blister and associated pain. 10 New York Code Rules Regulations (NYCRR) 415.12(h)(2)

Based on observations, interviews and record review conducted during survey, the facility failed to ensure sufficient nursing staff to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident for three (First floor, Second floor, Third floor) resident care units. Specifically, the facility did not ensure they met their minimum staffing numbers for each shift and there was a lack of sufficient nursing staff to provide timely care to meet the needs of the residents. This involves Resident's #4, #8, #9, #20, #21, #27, #30, #42, #43, #50, #51 #55, #63, #92, #96, #104, #106 and #119. The findings include: Refer to F 677 Activities of Daily Living Care for Dependent Residents, Scope and Severity = D Refer to F 684 Quality of Care, Scope and Severity = D Refer to F 689 Free of Accident Hazards, Scope and Severity = G The facility policy and procedure titled Emergency Staffing with a review date of October 2025 documented when the facility was at a crisis level impeding resident care, the supervisor will notify the Administrator and Director of Nursing regarding emergency needs. All staff on duty would be asked to remain on duty until emergency staffing is resolved. The supervisor or designee would contact off duty nursing personnel to enlist their services. The Administrator or designee would arrange for a loan of nursing personnel from other Heritage facilities, as well as any contracted staffing agency. The Facility assessment dated [DATE] documented the assessment was required to identify and analyze the facility's resident population and identify the personnel, physical plant, environmental and emergency response resources needed to competently care for the residents during the day-to-day operations and emergencies, including nights and weekends. The facility was licensed for 146 beds with an average daily census of 134. The facility will ensure that there was sufficient and competent staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The facility will make decisions on required staffing based on resident census, resident acuity/needs, facility odors, complaints, call lights, and staff's ability to complete assignments. The Facility Assessment documented the following total number or range of nursing staff needed: - Licensed nurses providing direct care 2.5 to 8 - Nurse Aides 4.5 to 17 Review of the Payroll Based Journal Staffing Data Report Fiscal Year Quarter 1 (October 1 -December 31) 2026 revealed the facility had a one-star rating for staffing and triggered for low staffing levels on weekends. The facility resident census at the time of survey entrance on 04/26/2026 was 115. 1.During an interview on 04/29/2026 at 11:03 AM, the Acting Administrator stated the bare minimum staffing needed to provide care to the residents based on the daily average census of 114 was as follows: Licensed Nurses: Day Shift: 7:00 AM - 3:00 PM - one (1) for each unit Evening shift: 3:00 PM -11:00 PM total of three (3) Night shift: 11:00 PM - 7:00 AM total of three (3) Certified Nurse Aides: Day shift: two (2) for each unit Evening shift: total of (eight). Night shift: total of (eight). Further interview on 04/30/2026 at 1:20 PM, the Administrator clarified the minimum number of certified nurse aides on the night shift would be one per unit total of three (3). Review of the facility's nursing daily staffing sheets dated 03/25/2026 - 04/25/2026 revealed the facility did not meet their stated minimum staffing numbers of certified nurse aides on the following dates: -03/25/2026 3:00 PM - 11:00 PM shift - 5 (down 1) -03/27/2026 3:00 PM - 11:00 PM shift - 4 (down 2) -03/28/2026 3:00 PM - 11:00 PM shift - 4 (down 2)-03/29/2026 3:00 PM - 11:00 PM shift - 5 (down 1)-03/30/2026 3:00 PM - 11:00 PM shift - 5 (down 1) -03/31/2026 3:00 PM - 11:00 PM shift - 5 (down 1)-04/02/2026 11:00 PM - 7:00 AM shift - 2 (down 0.5 after 3 AM)-04/06/2026 3:00 PM - 11:00 PM shift - 4.5 (down 1.5)-04/07/2026 3:00 PM - 11:00 PM shift - 5 (down 1)-04/09/2026 11:00 PM - 7:00 AM shift - 2.5 (down 0.5)-04/11/2026 3:00 PM - 11:00 PM shift - 5 (down 1)-04/16/2026 3:00 PM - 11:00 PM shift - 4 (down 2)-04/22/2026 3:00 PM - 11:00PM shift - 4 (down 2)-04/24/2026 3:00 PM - 11:00PM shift - 3.5 (down 2.5) The facility census for these dates was between 113 and 116 residents. Review of the facility's nursing daily staffing sheets dated 03/25/2026 - 04/25/2026 revealed the facility did not meet their stated minimum staffing numbers for the night shift of one nurse per unit on the following dates: -03/26/2026 11:00 PM - 7:00 AM shift - 2 (down 1)-03/31/2026 11:00 PM - 7:00 AM shift - 2.5 (down 0.5 after 3 AM) -04/01/2026 11:00 PM - 7:00 AM shift - 2 (down 1)-04/04/2026 11:00 PM - 7:00 AM shift - 2 (down 1) -04/05/2026 11:00 PM - 7:00 AM shift - 2.5 (down 0.5 after 3 AM) -04/06/2026 11:00 PM - 7:00 AM shift - 2.5 (down 0.5 after 3 AM)-04/07/2026 11:00 PM - 7:00 AM shift - 2 after 3 AM (down 0.5 after 3 AM) -04/10/2026 11:00 PM - 7:00 AM shift - 2 after 3 AM (down 0.5 after 3 AM)-04/18/2026 11:00 PM - 7:00 AM shift - 2 (down 1)-04/20/2026 11:00 PM - 7:00 AM shift - 2 (down 1) -04/25/2026 11:00 PM - 7:00 AM shift - 2.5 (down 0.5 after 3 AM)The facility census for these dates was between 113 and 116. During an interview on 04/30/2026 at 9:24 AM, the Facility Scheduler stated there was no written policy that documented the minimum amount of staffing needed for each shift. They stated they followed the guidelines provided by administration for minimum staffing which included four (4) licensed nurses on the day and evening shifts, and a total of three (3) licensed nurses on the night shift. The Facility Scheduler stated the certified nurse aide minimum staffing included eight (8) for day and evening shifts and four (4) certified nurse aids for the overnight shift. They stated when staffing fell below the minimum numbers they would notify the Director of Nursing, Administrator, and the Nursing Supervisor. The Facility Scheduler stated in the last 30 days there were a few days when the minimum staffing numbers were not met. They stated the evening shift was the most difficult to staff and the overnight shift fell below minimum at times because some staff only worked until 3:00 AM which created a gap in coverage. They stated the schedule would be staffed adequately but then call offs happened. The Facility Scheuler stated it was important to meet or exceed the minimum staffing to ensure residents received good care. During a Resident Council meeting held on 04/27/2026 at 10:30 AM six (6) residents (Resident #21, #27, #50, #63, #96, #119) participated, residents stated staffing was an issue during the evening and night shifts with only one certified nurse aide for each hallway. They stated their call bell wait times could go longer than an hour before staff responded. At times staff would enter their room, turn off the call light and say they would return but never come back. They stated call lights were not always left within reach, there were not enough staff to properly assist residents with meals specifically, staff would feed the residents too fast, and meal carts would sit on the unit up to 30 minutes before being delivered. 3. Observation and interviews with residents, Ombudsman, and family members and revealed the following: a.During observations and interviews on the third floor on 04/26/2026 at 10:11 AM, Resident #30 was in bed wearing a night gown and they had their call light on; it was sounding an illuminated. Resident #30 at this time stated they needed their brief to be changed. Licensed Practical Nurse #1 was at their medication cart and stated they had about 38 residents on the floor and staffing for the floor consisted of themselves along with two certified nurse aides. Licensed Practical Nurse #1 stated that it was normal staffing for the day shift. Further observation at 10:17 AM, revealed the third floor had two call lights luminated and sounding (Resident #30's bell light along with Resident #92's).The call light system monitor that was placed on top of the nursing station desk displayed two rooms and call light times were: Resident #30's light had been on for 18 minutes and Resident #92 for 34 minutes. A continuous observation was started, and the following was observed: -at 10:25 AM Certified Nurse Aide #1 was overheard to tell the Resident #30 they would be back to take care of them when they completed with a different resident. Resident #30 call light was no longer ringing.-at 10:26 AM the call light monitor displayed that Resident #92 call light was ringing now for 43 minutes. Resident #92 was observed to be sitting on the edge of their bed with their breakfast tray in front of them completed. Resident #92 stated they needed to be rearranged and their legs back in bed. Resident #30's call light was now back on, and the call light monitor displayed three minutes. -at 10:28 AM, Licensed Practical Nurse #1 turned off Resident #92's light and had taken care of their needs. -at 10:30 AM Certified Nurse Aide #1 entered Resident #30's room and closed their door. During an observation on 04/26/2026 at 11:20 AM, the third floor had one call light luminated and sounding (Resident #51) The call light monitor displayed Resident #51's light was on for 25 minutes. A continuous observation was started, and the following was observed: -11:23 AM Resident #51 was in their bed in a hospital gown, knitting. During an interview at this time, Resident #51 stated they had their bowel medicine, and they needed the bed pan. Resident #51 stated they usually do not get the bed pan on time and at times, it could take three to four hours before their call light was answered. -11:25 AM Licensed Practical Nurse #1 entered Resident #51's, turned off the call light and was overheard to ask the resident what they needed. Resident #51 replied they had been waiting for the bed pan. The bedroom door was closed.-11:27 AM Licensed Practical Nurse #1 exited Resident #51's room and returned at 11:28 AM with a bed pan in hand and closed the door. b. The Resident Incident Form dated 03/11/2026 documented Resident #21 had an 8.5 centimeter by 5-centimeter blistered area on the top of their left hand. Resident #21 stated they were taking soup out of the microwave when the soup splashed onto their hand. The resident was educated to ask for assistance with hot food from the microwave. During an interview on 04/29/2026 at 9:15 AM, Resident #21 stated they were taking soup out of the microwave oven when the handle slipped and the hot liquid sloshed on to the top of their left hand. The resident stated the facility had educated them to request for staff assistance when using the microwave oven, but there's only one problem with that, there is no staff to assist so they usually use the microwave by themselves. c. During an observation on 04/26/2026 at 10:51 AM Resident #4 was seated in a wheelchair with a dressing (ace wrap) noted on their right shin dated 04/24/2026. During an interview on 04/26/2026 at 10:51 AM at the time of the observation, Resident #4 stated their dressing (treatment) had not been changed yet today and it was not changed the day prior (4/25/2026). They stated one licensed practical nurse consistently completed the dressing changes/treatment but when that nurse was off, the treatment was often not completed. During an interview on 04/29/2026 at 9:26 AM, Licensed Practical Nurse #2 they stated they had noticed Resident #4's daily dressing/treatment was not always completed on their right shin, as ordered. Resident #4 never refused care. They stated they felt the staff were too busy to complete because not all staff were able to complete their work by the end of their shift. During an interview on 04/26/2026 at 12:37 PM, Resident #106 stated staffing on the 3:00 PM - 11:00 PM shift was the worst, meal carts would sit on the unit for 30 minutes before any staff member touched it. They stated dinners were served cold. d. During an interview on 04/26/2026 at 12:50 PM, Resident #42's family member stated the facility was slipping with resident care because they were always short staffed. They stated the nursing staff were wonderful but can only do what they can do, the facility needs more help. During an interview on 04/26/2026 at 12:56 PM, Resident #9 stated staffing was worse on the 3:00 PM - 11:00PM shift, they stated it took forever to get their dinner trays passed and for staff to answer their call light when they needed assistance. During an interview on 04/26/2026 at 1:31 PM, Resident #20's family member stated the facility did not have enough staff, they stated that was why staff would sometimes double brief the resident instead of offering to toilet them. During an interview on 04/27/2026 at 9:46 AM, Resident #30 was in bed dressed in a personal night gown. Resident #30 stated they do not get out of bed because once they get out of bed staff keep them up. Because once you are up you are up. Resident #30 stated there were not enough staff on the overnight shift and on all shifts their call bell goes unanswered for long periods of time. During an interview on 04/27/2026 at 10:19 AM, Resident #8 stated once the day shift staff leaves for the evening, there were not enough staff working the rest of the evening and into the night. They stated they wait a long time for their call bell to be answered and to be toileted. During a telephone interview on 04/27/2026 at 10:37 AM, the Ombudsman stated that one of the facility's biggest challenges was they were consistently short of staff and extremely short staffed on weekends. They stated they would receive complaints from the residents/family members that residents tend to be left in bed for more than 24-hours, catheter bags go unemptied, and colostomy bags explode all due to low staffing. The Ombudsman also stated that residents had complaints about long wait times to answer calls bells, and meeting their toileting needs. During an interview on 04/28/2026 at 8:54 AM, Resident #51 stated when there were only two (2) certified nurse aides on the floor they would have trouble getting staff to assist them on and off the bedpan and to be repositioned in bed for meals. Resident #51 stated they did not get out of bed very often because they required a mechanical lift for transfers and if when there were only two certified nurse aides working staff could not get them out of bed. During an interview on 04/28/2026 at 1:43 PM, Resident #55's family member stated the facility did not have enough staff. They have witnessed residents during activities ask to go to the bathroom and wait for over 30 minutes for a certified nurse aide to take them. During a continuous observation on 04/28/2026 from 8:18 AM until 2:00 PM Resident's #43 and #104 were up dressed and seated in the dining room. The residents were not offered, encouraged, or provided with toileting and/or incontinent care. Both residents were noted to have been incontinent during follow up care observations. During an interview on 04/28/2026 at 1:48 PM, Certified Nurse Aide #1 stated residents who were incontinent should be checked and changed every two hours. They stated they work about twice a week with only a second aide, and it was not possible to toilet every resident every two hours in a shift. They stated both residents should have been provided with care as planned. 4. Interviews with Facility Staff: During an interview on 04/28/2026 at 10:05 AM, Certified Nurse Aide #8 stated they worked the 7:00 AM to 3:00 PM shift and at times there would only be two (2) aides working for the whole shift. They stated if there were two certified nurse aides they would each be assigned 18 to 20 residents each. Certified Nurse Aide #8 stated they sometimes stayed over after their shift to complete their assessment, but they were not always able to get resident showers done. During an interview on 04/28/2026 at 10:30 AM, Licensed Practical Nurse #6 stated they worked the 7:00 AM to 3:00 PM shift, they were the only medication nurse for the floor and usually worked with two (2) certified nurse aides. They stated it was a struggle with only two (2) aides on the floor and would assist them the best they could. Licensed Practical Nurse #6 stated at times the certified nurse aides would not be able to make beds, give showers. Toileting and incontinent care would be left for the next shift to be completed because of staffing. During an interview on 04/27/2026 at 4:05 PM, Licensed Practical Nurse #3, stated they worked the 3:00 PM to 11:00 PM shift and were the only nurse for the floor. They stated they were able to pass all medications and complete their treatments but stayed over their shift to finish charting. Licensed Practical Nurse #3 stated they usually worked with two (2) certified nurse aides and at times would only have one certified nurse aide for the entire shift. They stated that when they were short staffed, they prioritized the best they could, but residents often had to wait long periods for care to be provided. At times residents were not toileted or put to bed until the next shift arrived. During an interview on 04/27/2026 at 4:16 PM, Licensed Practical Nurse #7 stated they worked 7:00 AM to 7:00 PM and usual staffing was one (1) to two (2) nurses for their floor and two (2) certified nurse aides. They stated staffing levels were bad, there were not always enough staff to get residents to the dining room timely for meals. They stated they were able to assist those residents that required help with eating but would take a long time to complete. During an interview on 04/28/2026 at 12:42 PM, Certified Nurse Aide #2 stated they currently work the 7:00 AM to 3:00 PM and staffing could be from two (2) to four (4) certified nurse aides. They stated when there were only two (2) aides on the floor they did their best to toilet and provide incontinent care to each resident twice during their shift but were not always able to get to all residents twice. They stated they would give report to the next shift to let them know what residents needed assistance first. During an interview on 04/28/2026 at 4:52 PM, Certified Nurse Aide #12 stated they worked the 3:00P PM to 11:00 PM shift and staffing was usually just two (2) certified nurse aides but stated they have worked as the only aide on the floor before. They stated the nurse sometimes would assist with resident care including transfers and toileting. Certified Nurse Aide #12 stated they did the best they could but were unable to complete showers and some residents would be left up until the 11:00 PM to 7:00 AM shift arrived to assist them to bed. During an interview on 04/29/2026 at 4:34 PM, Certified Nurse Aide #3 stated they work the 3:00 PM to 11:00 PM shift and on average they work with just another aide. They added at times they may work alone with no other aides. They stated when they work alone or with just a second aide do not do resident showers, toilet an incontinent resident every two (2) hours and sometimes they have to leave a resident in their wheelchair until the overnight shift comes in to put them to bed. During an interview on 04/30/2026 at 10:40 AM, Licensed Practical Nurse #8 stated they worked the 3:00 PM to 3:00 AM. They stated staffing on the 3:00 PM to 11:00 PM shift consisted of one (1) nurse and usually two (2) certified nurse aides unless there were call ins and then would only have one (1) certified nurse aide for the evening shift. Licensed Practical Nurse #8 stated it was hard to get resident care done with one (1) to two (2) aides on the floor and would assist with transfers and toileting after they completed their medication pass. They stated there were unit assistants on the floor that helped pass and collect meal trays but could not feed the residents. Licensed Practical Nurse #8 stated there were about five (5) residents on their floor that required total assistance with eating, they would go around the table and assist multiple residents until everyone was fed. Licensed Practical Nurse #8 stated evening shift was not always able to complete timely incontinent care and residents would be left up in the wheelchairs until the night shift arrived. They stated that when their shift ended at 3:00 AM, the nursing supervisor on the night shift (11:00 PM to 7:00 AM) took over for them because they were short staffed. During an interview on 4/30/2026 at 10:48 AM, Registered Nurse Supervisor #3 stated staffing on the 11:00 PM to 7:00 AM shift was not great, and we were lucky to have one certified nurse aide on each floor. They stated some nurses only worked until 3:00 AM and they would have to take over the unit when they left. Registered Nurse Supervisor #3 stated on weekends they often covered two (2) floors and supervised the building; it was just them and one other nurse for the building. They stated not having a nurse on every floor was not safe because there were not enough staff to monitor residents and prevent falls. Registered Nurse Supervisor #3 stated that when there were no aides on the floor the nurse would try to answer the call lights and provide incontinent care to the residents that were heavily soiled but not everyone could get changed. They stated there needed to be more staff for safety reasons. During an interview on 04/30/2026 at 11:02 AM, Certified Nurse Aide #11 stated staffing on the evening shift (3:00 PM to 11:00 PM) was horrible and often worked as the only aide on the floor. They stated they could not get all their work done and only some nurses helped. Certified Nurse Aide #11 stated they tried to get done what they could but were not able to toilet all residents per their care plan. They stated they would check the residents as soon as they could, if a resident was visibly soiled, they would get an aide from a different floor to help provide care If the residents were not visibly soiled, they would have to wait until the next shift to be changed. Certified Nurse Aide #11 stated it was difficult to assist residents with feeding when short staffed, took about an hour to get everyone fed; showers were not completed, and residents that transferred with a mechanical lift were left up in their wheelchair until the next shift came in. Certified Nurse Aide #11 stated the facility staffing was not safe. During an interview on 04/30/2026 at 11:18 AM, Licensed Practical Nurse #9 stated staffing on the 11:00 PM to 7:00 AM shift was one nurse and one aide. They stated at times they have worked with no aide on the floor for four (4) hours because of short staffing. Licensed Practical Nurse #9 stated having only one staff member on the floor was not safe, residents that required two (2) staff members for assistance had to wait longer for care, they could not answer call lights timely and residents could fall. During an interview on 04/30/2026 at 11:31 AM, Certified Nurse Aide #9 stated they worked 11:00 PM to 7:00 AM and often had to float between floors because there were not always enough aides in the building due to call offs. They stated the facility needed more staff to ensure residents were safe and received proper care. During an interview on 04/30/2026 at 1:08 PM, the Director of Nursing stated the minimum staffing numbers were based on the current census of 115 and consisted of one (1) nurse and two (2) certified nurse aides for each floor for both the day shift (7:00 AM - 3:00 PM) and evening shift (3:00 PM - 11:00 PM) and one (1) nurse and one (1) certified nurse aide on every floor for the night shit (11:00 PM - 7:00 AM). The Director of Nursing stated that any time staffing fell below those numbers they would not be meeting their minimum staffing. They stated they reviewed the schedule every day to ensure staffing was adequate, however the biggest issue was the call offs which created critical staffing levels. The Director of Nursing stated one aide on a unit for evening shift and one nurse covering multiple floors on night shift was not ideal staffing. Staff would not be able to provide proper and timely care for the residents. During an interview on 04/30/2026 at 1:29 PM, the Acting Administrator stated they were made aware of staffing concerns by the Director of Nursing and the Facility Scheduler. They stated when they were informed of low staffing levels and call-offs, they would offer bonuses to staff, offer schedule changes, or reach out to the other Heritage facility to see if there were staff available to work to cover any open shifts. They stated they made significant strides to staff all shifts but were aware they were not making the minimums every day. The Acting Administrator stated they would expect to have at least one (1) nurse on every floor and two (2) certified nurse aides each floor. They stated nothing less was not feasible and would be below their minimum staffing level. They stated adequate staffing was important to provide the appropriate level of care for the residents. 10 New York Codes Rules Regulations 415.13 (b) (1) (i-ii)

Based on observation, interview, and record review completed during survey, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for four (4) (Residents #20, 35, 40, and #55) of four (4) residents reviewed. Specifically, comprehensive care plans that did not accurately reflect resident's current Advanced Directives, including their code status (a medical order indicating a patient's preferences for life-saving interventions to guide staff on whether to perform resuscitation- full code (all efforts) or Do Not Resuscitate (DNR)). The findings include: The facility policy and procedure titled Formation of the Resident Care Plan, dated [DATE] documented the comprehensive care plan will be developed within seven (7) days after the comprehensive assessment and will be prepared by an interdisciplinary team that includes, but was not limited to: Attending Physician, a Registered Nurse with responsibility for the resident, and the resident or resident representative, as practicable. Each care plan was reviewed by the committee at least quarterly. The nurse manager was responsible for presenting current information on a resident's condition, noting any changes since last review. The social work policy and procedure manual titled Do Not Resuscitate (DNR), dated [DATE], documented A Do Not Resuscitate (DNR) Order in the resident's medical record instructs the medical staff not to try to revive the resident if breathing or heartbeat has stopped. This means physicians, nurses and others will not initiate such emergency procedures as mouth-to-mouth resuscitation, external chest compression, electric shock, insertion of a tube to open the resident's airway, injection of medication into the heart or open chest heart massage. A do not resuscitate order, written by the attending physician instructs the staff not to perform emergency resuscitation and not to transfer the patient to a hospital only for such procedures. The purpose of the do not resuscitate order was to allow residents or their surrogates to express their wishes regarding the level of therapeutic effort to be expanded in the event of cardiac or respiratory arrest. 1. Resident #35 had diagnoses that included chronic obstructive pulmonary disease (a progressive lung disease) chronic respiratory failure, and diabetes mellitus. The Minimum Data Set, dated [DATE] documented Resident #35 had moderate cognitive impairment, was usually understood and usually understands. The comprehensive care plan initiated on [DATE], documented interventions that included Resident #35 had a Health Care Proxy; Do Not Resuscitate- see Medical Orders for Life-Sustaining Treatment for details; Full Code- see Medical Orders for Life-Sustaining Treatment for details. Review of Resident #35's Medical Orders for Life-Sustaining Treatment (MOLST) last reviewed and signed by the provider on [DATE] documented Resident #35's had orders for a Do Not Resuscitate status. During an interview on [DATE] at 8:01 AM, Registered Nurse Unit Manager #1 stated they were responsible for updating care plans with any changes. They stated the resident's advanced directives were documented on their Medical Orders for Life-Sustaining Treatment (MOLST) form in the medical record, the care plan, and there would be a blue dot outside the resident's door next to their name that indicated if a resident had a full Code status. Registered Nurse Unit Manager #1 stated if there was a change in residents' code status the care plan would need to be updated to ensure their wishes were followed. Registered Nurse Unit Manager #1 reviewed Resident #35's care plan and stated their advanced directive section indicated both a Do Not Resuscitate and a Full code status. They stated on admission all approaches for advanced directives automatically populated to the care plan and the admitting nurse or nurse manager were to adjust the care plan to match the residents Medical Orders for Life-Sustaining Treatment (MOLST). Registered Nurse Unit Manager #1 stated Resident #35's care plan needed to be updated, and the full code status needed to be removed. 2. Resident #20 had diagnoses including dementia and type II diabetes The Minimum Data Set (a resident assessment tool) dated [DATE], documented that they were severely cognitively impaired, usually understood and usually understand others. The comprehensive care plan initiated on [DATE] documented care plan interventions that included Resident #20 had a Health Care Proxy; Do Not Resuscitate- see Medical Orders for Life-Sustaining Treatment for details; Full Code- see Medical Orders for Life-Sustaining Treatment for details. Resident #20's Medical Orders for Life-Sustaining Treatment (MOLST) signed [DATE], documented Resident #20's representative consented to the Advanced Directives, Do Not Resuscitate and Do Not Intubate. 3. Resident #40 had diagnoses including dementia, type II diabetes, and adult failure to thrive (a combination of symptoms that cause a decline in physical, mental, and social functioning). The Minimum Data Set, dated [DATE], documented they were severely cognitively impaired, sometimes understood and sometimes understand others. The comprehensive care plan initiated [DATE] documented interventions that included Resident #40 had a Health Care Proxy; Do Not Resuscitate- see Medical Orders for Life-Sustaining Treatment for details; Full Code- see Medical Orders for Life-Sustaining Treatment for details. Resident #40's Medical Orders for Life-Sustaining Treatment (MOLST) signed [DATE], documented Resident #40's representative consented to the Advanced Directives, Do Not Resuscitate and Do Not Intubate. 4. Resident #55 had diagnoses including dementia, a personal history of breast cancer, and difficulty walking. The Minimum Data Set, dated [DATE], documented they were severely cognitively impaired, sometimes understood and sometimes understand others. The comprehensive care plan initiated [DATE] documented interventions that included Resident #55 had a Health Care Proxy; Do Not Resuscitate- see Medical Orders for Life-Sustaining Treatment for details; Full Code- see Medical Orders for Life-Sustaining Treatment for details. Resident #55's Medical Orders for Life-Sustaining Treatment (MOLST) signed [DATE], documented Resident #55's representative consented to the Advanced Directives, Do Not Resuscitate and Do Not Intubate. During an interview on [DATE] at 8:53 AM, Registered Nurse Unit Manager #2 stated the unit managers were responsible for updating the comprehensive care plans. The residents' care plans should be accurate and show how to care for them. They stated, if the resident's code status was do not resuscitate, the care plan should document that alone. Registered Nurse #2 stated they would review and update the care plans for Residents #20, #40, and #55, and check the accuracy of the rest of the residents on the second floor. Registered Nurse Unit Manager #2 stated further stated the care plan auto populates information and it was the managers responsibility to make sure the care plans were accurate. During an interview on [DATE] at 5:02 PM, Licensed Practical Nurse #3 stated they checked the residents' Medical Orders for Life-Sustaining Treatment (MOLST) to verify if they were a Full Code or Do Not Resuscitate status. Licensed Practical Nurse #3 stated it was the unit managers' responsibility to update care plans and were unsure if the resident's code status was documented on the care plan. During an interview on [DATE] at 1:01 PM, the Director of Nursing stated the nurse managers were responsible for updating resident care plans and expected the care plans to accurately reflect the residents' care needs and preferences including advanced directives. They stated advanced directives were to be documented on the care plan according to the residents' Medical Orders for Life Sustaining Treatment (MOLST) and would expect the care plan to be updated if a change in advanced directives occurred. The Director of Nursing stated they would have expected the care plan to match the Medical Orders for Life Sustaining Treatment (MOLST) to ensure the residents' wishes were followed and the appropriate treatment was provided. 10 New York Codes, Rules, and Regulations 415.11 (c)(2) (ii-iii)

Based on observations, record reviews, and interviews conducted during the survey, the facility failed to store food in accordance with professional standards for food service safety for one (1) of one (1) kitchen and two (2) (second and third floors) of three (3) resident floors reviewed. Specifically, in the kitchen there were various sticky food spills and sticky residue on the floor, the ceiling tile grid had a visible layer of black dust and there were dirty ceiling tiles, water damaged floor tiles near the ice machine, a broken faucet in the 3-bay sink, flies in the dishwasher and food preparation areas, and a damaged ceiling light cover held together by duct tape. Additionally, the kitchen, unit dining rooms, and activity room coolers/refrigerators/freezers were dirty with liquid spills and contained multiple undated, unlabeled food items. The findings include:The facility policy Food Safety Requirements revision/review date 04/12/2024 documented it is the policy of this facility to provide safe and sanitary storage, handling, and consumption of all food including food and fluids brought to residents by family or other visitors. Additionally, the facility procures food from sources approved or considered satisfactory by federal, state or local authorities. This included storage, preparation, distribution, and serving food in accordance with professional standards for food service safety. Education on safe food handling will be provided to all staff, family, residents, resident council, visitors and community groups who may provide foods or fluids to residents of the facility. The education included: requirements for covered containers or secure wrapping; proper labeling and dating of each item; and leftover foods will be used within 3 days or discarded. Foods requiring refrigeration will be received by the facility designee (activity department, food and nutrition department, charge nurse, etc.) for proper and immediate storage including labeling and dating.1a. Observation in the third floor Dining Room on 04/26/2026 at 9:51 AM revealed the refrigerator contained an unopened 8-ounce container of thickened dairy drink. The manufacturer's stamp on it read Best if Used by 02Apr2026. The refrigerator also contained an opened bag of shredded cheese, about half full, that was not labeled with the date it was opened. The inside of the refrigerator had sticky red and orange beverage spills on the door shelf and one (1) hair in the refrigerator and one (1) hair in the freezer.1b. Observation in the second floor Dining Room on 04/26/2026 at 10:12 AM revealed the refrigerator contained a sandwich on a plate wrapped in clear plastic wrap labeled Turkey and Cheese, with no date. The inside of the freezer had frozen spills and food crumbs throughout the bottom.During an observation in the second floor Dining Room and interview with the Food Service Director on 04/29/2026 at 2:25 PM, a lidded container of mashed potatoes and a lidded container of cooked vegetables were in the refrigerator and were not labeled with a name or date. There was also one 5.3-ounce yogurt container with a manufacturer's stamp that read, Apr24 2026. The Food Service Director stated the mashed potatoes, and cooked vegetables probably came off of a resident's meal tray and should have been labeled by whoever placed them in the refrigerator, using the stickers provided. They stated because the manufacturer's stamp on the yogurt did not specify whether the date was a use by, sell by, or expiration date, it should have been thrown out on the stamped date. Also at this time, the Food Service Director stated the freezer in the second floor Dining Room could use cleaning.1c. Observation in the second floor Activities Room on 04/26/2026 at 10:23 AM revealed the refrigerator contained three (3) 5.3-ounce yogurt cups that were labeled with a resident name and room number. The manufacturer's stamp on each read, Feb22 2026. The refrigerator also contained one (1) 6-ounce yogurt cup with a manufacturer's stamp that read, Sell by 3/29/26. There was also a pitcher of thickened beverage, approximately 2 cups, that was not dated. In the freezer, there was a small plastic leftover container with ice cream and toppings. There was a layer of thick frost over the ice cream, and it was not labeled with a resident's name or date. Additionally, there were at least six (6) hairs inside the refrigerator.Further observation on 4/29/26 at 2:58 PM, revealed signs were posted on the third floor Dining Room refrigerator, second floor Dining Room refrigerator, and the Activities Room refrigerator. One (1) sign read, Attention: Family members may bring in items for their loved ones. However please make sure these items are labeled! The label must include the resident it is for, the date it was opened/ placed in the refrigerator, and the expiration date (4 days including date it was opened/ placed in the refrigerator). Anything without a label will be disposed of. Another sign read, All food for residents must be labeled with resident name and dated per Department of Health regulations. Protein based food can be kept for 3 days. All other food can be kept for 5 days then it will be disposed of.During an interview on 04/26/2026 at 10:23 AM, Activities Aide #1 stated Activities staff checked the refrigerator in the Activities Room occasionally, but it was not documented. They stated the yogurts belonged to a specific resident, so they would not throw them out. They stated if they noticed an item in the refrigerator for a long time, they would usually say something about it to their supervisor, but they did not personally see that the dates on the yogurts had passed. They were not sure who placed the pitcher of thickened beverage in the Activities Room refrigerator, but it should have a date written on it. Activities Aide #1 stated they were not told that Activities staff were supposed to clean the refrigerator in the Activities Room, it was probably assigned to Dietary staff, and the hairs inside the refrigerator needed to be removed.During an observation in the second floor Activities Room and interview with the Food Service Director on 04/29/2026 at 2:30 PM, a pitcher of less than 1 cup of thickened beverage that was undated was in the refrigerator. The small plastic leftover container with ice cream and toppings remained in the freezer. The Food Service Director stated they did not know when the thickened beverage was made, therefore it should be discarded. Dietary staff should place a date on the pitcher when it was made, and thickened beverages could be kept in the refrigerator for three (3) days after opening. They also stated the leftover container of ice cream did not come from the Main Kitchen and needed to be labeled with the resident's name and date. Staff must keep their own personal food and drinks in the basement Cafe refrigerator.During an interview on 04/29/2026 at 2:15 PM, the Food Service Director stated the refrigerator in the Activities Room was maintained by Activities staff only. They stated the refrigerators in the resident unit Dining Rooms were maintained by Nursing and Dietary staff and Housekeeping staff cleaned the insides of those refrigerators. They stated most dairy products could be served three (3) to four (4) days beyond the manufacturer's best by date and could be served four (4) to five (5) days beyond the manufacturer's sell by date. The Food Service Director stated the sandwich in the second floor Dining Room refrigerator was probably taken off of a resident's tray to save for later. Stickers were provided at the refrigerators and were to be used to label and date foods at the time they were being placed in the refrigerator.2a. Observation in the Main Kitchen on 04/26/2026 at 9:46 AM included the following: - various sticky food spills on the floor- a 32-ounce plastic container of cornstarch with the lid not screwed on and a whitepowder-like substance on the tops of the canned goods on the shelf below in the dry storage room- multiple unlabeled, undated food items in stainless steel containers in the walk-in cooler- 22 unlabeled, undated gelatin cups in the walk-in cooler- uncovered, unlabeled and undated cheese block in the walk-in cooler- thick layer of frost in the upright freezer with multiple undated, unlabeled food itemsDuring an interview on 04/26/2026 at 10:00 AM, the Dietary Supervisor stated all food items should be labeled and dated.During an interview on 04/30/2026 at 9:49 AM, the Acting Administrator stated all food items need to be labeled and dated, and there should not be a thick layer of frost in the freezer.2b. Observation in the Main Kitchen on 04/26/2026 at 2:10 PM revealed the walk-in freezer was not operating, and it was being used to store dry goods. Further observation revealed an upright freezer in the Main Kitchen was empty, had its door propped open, and was defrosting.At the time of the observation, the Food Service Director stated on 06/27/2025, the walk-in freezer went down. They stated they brought in a smaller freezer to help the situation, and it was currently being defrosted. The smaller freezer was used for odds and ends frozen storage. They stated ice cream was delivered to the facility on Fridays, and it went straight to the freezers on the resident units for frozen storage. They also stated food delivery occurred each Tuesday and Friday and they planned their menu around the delivery dates, as frozen storage was very limited.During an interview on 04/26/2026 at 2:45 PM, the Corporate Director of Environmental Services stated they were aware that the walk-in freezer was out of service. They stated they tried to get a vendor to come out to provide an estimate for repair, but they had not come out yet. They stated the first step was to obtain estimates for repair and then decide if it would be a better decision to repair the walk-in freezer or replace it. They stated there was no proposed timeline for repair or replacement at this time.3. Observation in the Main Kitchen on 04/26/2026 at 2:15 PM revealed water to the three (3)-bay sink in the dishwash area could not be shut off at the faucet but had to be shut off at the valve under the sink. Also, the floor at the perimeter of the room and around stationary equipment, such as refrigerators, sinks, tables, the mixer, and the ice machine had a sticky, blackish residue. The floor tiles under the ice machine were curled from water damage. Further observation revealed a 5-gallon bucket of soy sauce was uncovered and three (3) live flies were flying around the opening. There were also about eight (8) live flies in the vicinity of the soy sauce, at the far corner of the Ansul suppression hood. There were at least four (4) live flies observed in the dishwash area, and an insect light trap was present, but not plugged in. The shelf that the soy sauce was stored on near the far corner of the Ansul suppression hood had various sticky food spills. Additional observation revealed the four (4) ceiling vents closest to the Ansul suppression hood that were white had a black discoloration, and the ceiling tiles that surrounded each had a black discoloration. One (1) ceiling light in the Main Kitchen had its cover held up with duct tape and approximately 30 percent of the ceiling tile grid in the Main Kitchen appeared dusty with a visible layer of black dust.During an interview on 04/26/2026 at 2:15 PM, the Food Service Director stated they were not aware that the water at the three (3)-bay sink needed to be shut off at the valve, and it was not like that on Friday, 04/24/2026. The Food Service Director stated the Main Kitchen floor had not been stripped and waxed in about two (2) and a half years, and Dietary staff swept and mopped the floor twice per day and tried to scrape under the equipment as much as they could. They stated it was possible that some tiles were just stained. The Food Service Director also stated they started to notice the flies recently, and it was possible that they came in with the last fruit delivery. The insect light trap worked but needed new glue paper. They stated they had already informed the Acting Administrator and requested new glue paper. The Food Service Director also stated that the shelf the soy sauce was stored on needed to be cleaned.During an interview on 04/26/2026 at 2:30 PM, the Environmental Supervisor stated the discoloration around the ceiling vents in the Main Kitchen was likely due to air discharge and could be cleaned off of the metal vents, but the surrounding ceiling tiles could not be cleaned and needed to be replaced. The Environmental Supervisor stated the Main Kitchen floor was stripped and waxed about every two (2) years and it was probably due for another strip and wax again. They stated one (1) ceiling light fixture cover in the Main Kitchen had a strip of duct tape on it, which needed a more permanent solution. The Environmental Supervisor stated they were not aware of any flies in the Main Kitchen, and the facility had a licensed exterminator who did not have regularly scheduled treatments but would come for service when needed. The licensed exterminator had not done any recent treatments in the Main Kitchen.During an interview on 04/26/2026 at 2:44 PM, the Corporate Director of Environmental Services stated the licensed exterminator provided the insect light trap in the dishwash room and the facility refilled the glue paper as needed.10 New York Code Rules Regulations (NYCRR) 415.14(h)

Based on interview and record review conducted during an Onsite Post Survey Revisit #1 completed on 06/25/2026, the facility did not ensure that the Quality Assurance Performance Improvement Program (QAPI) Committee developed and implemented appropriate plans of action to correct identified quality deficiencies and regularly reviewed, analyzed, and acted on available data to make improvements. Specifically, the facility did not maintain effective systems to maintain compliance, and there were repeated deficiencies observed from the Standard survey completed on 04/30/2026, in the areas of Right to be Free from Physical Restraints, Care Plan Timing and Revision, Food Procurement, Store/Prepare/Serve-Sanitary, Emergency Lighting, and Fire Alarm System - Testing and Maintenance. In addition, the facility did not follow their plan of correction from their Standard survey 04/03/2026 to provide education to staff in the areas of Activities of Daily Living Care Provided for Dependent Residents (F677); and Infection Control (I210). The findings include: Refer to: F 604- Right to be Free from Physical Restraints - Scope and Severity D F 657- Care Plan Timing and Revision - Scope and Severity D F 677- ADL Care Provided for Dependent Residents F 812- Food Procurement, Store/Prepare/Serve - Sanitary - Scope and Severity E K 291- Emergency Lighting - Scope and Severity E K 345- Fire Alarm System - Testing and Maintenance - Scope and Severity E I 210- Infection Control The policy and procedure tilted Quality Assurance Performance Improvement (QAPI) Program and Committee revised 2018-11-2 documented it shall be the policy of the facility to conduct an ongoing evaluation of all services provided to Residents utilizing tools and methods throughout our organization to determine root causes of problems and to establish improvements to be implemented and measured to determine progress towards excellence. The committee shall monitor items such as, but not limited to: Quality Measures, Plan of Correction Updates, Standard Measures of Professional Practice, Department of Health Reportable Events. The committee shall ensure outcomes of reviews are shared with appropriate staff to be used for the revision or development of policies and practices. Review of Summary Report of Meeting dated 06/12/2026 at 9:30 AM, documented type of meeting: Quality Assurance, presented by the Administrator. Subject covered: Plan of Correction, Audits and Scheduled Education. Review of Quality Assurance Meeting Agenda dated 06/12/2026, documented Statement of Deficiencies - Reviewed. Education provided for F604, F657, F677, F689. Education reviewed for F812. There was no documentation that the I210 was reviewed during the meeting. Review of Standard Survey Statement of Deficiencies (form 2567) issued by the New York State Department of Health with an exit date of 04/30/2026 revealed the facility was cited as follows: F 604- facility failed to ensure residents were free from physical restraints imposed for purposes of discipline or convenience that were not required to treat the resident's medical symptoms. The facilities Plan of Correction documented the deficiency would be corrected by 06/22/2026 and was not.F 657- the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. The facilities Plan of Correction documented the deficiency would be corrected by 06/22/202 and was not.F 812- the facility failed to store food in accordance with professional standards for food service safety. The facilities Plan of Correction documented the deficiency would be corrected by 06/22/2026 and was not.K 291- the facility failed to test battery-powered emergency lighting at least monthly for 30 seconds and annually for 90 minutes. The facilities Plan of Correction documented the deficiency would be corrected by 06/22/2026 and was not.K 345- the facility failed to maintain the fire alarm system. The facilities Plan of Correction documented the deficiency would be corrected by 06/22/2026 and was not. F 677- the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Form 2567 documented the facilities approved Plan of Correction would include that Licensed nursing staff and Certified Nurse Aides would be re-educated on: following individualized care plans; timely provision of incontinent care, feeding assistance, and hygiene support; documentation requirements; Resident dignity and quality of life expectations; and Escalation processes when resident care concerns arise or assistance is needed to meet resident needs. The facilities Plan of Correction documented the deficiency would be corrected by 06/22/2026 and staff education was not completed.I 210- the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Form 2567 documented the facilities approved Plan of Correction would include that the Environmental Supervisor, Maintenance Department, and Administrator received education regarding regulatory requirements, vendor oversight expectations, scheduling accountability, and documentation processes. The facilities Plan of Correction documented the deficiency would be corrected by 06/22/2026 and staff education was not completed. During an interview on 06/25/2026 at 1:51 PM, the [NAME] President of Skilled Nursing Operations stated the in-service and education for Legionella was completed but they were not able to locate that information. During an interview on 06/23/2026 at 1:27 PM and 1:49 PM, the Director of Nursing stated they were looking for additional signatures for education completed per the Plan of Correction. They stated education started approximately two weeks ago and was being completed by themselves, the Administrator and Day Supervisor. When interviewed on 06/24/2026 at 1:09 PM, the Director of Nursing stated the Administrative Assistant was responsible for staff education related to fire alarm pull stations. The Director of Nursing further stated the in-service education was a read and sign maintained at the Administrative Assistant's desk. The Administrative Assistant stated they did not reach out to per diem staff, and staff that were already in the building or staff that came in for in-service education signed off on the policy review. The Administrative Assistant further stated they were not present for overnight staff education, and they would return the sign off sheet to the Administrator at the end of their shift.During an interview on 06/24/2026 at 2:48 PM, the Director of Nursing stated responsibility to ensure the Plan of Correction was completed on or by 06/22/2026 rested on both the Administrator and the Director of Nursing. The Director of Nursing stated they were off last week but could not honestly say why staff education related to restraints and care plans was not fully completed. They stated the Plan of Correction should have been completed by 06/22/2026 because that was their deadline. During an interview on 06/25/2026 at 12:49 PM, the Director of Nursing stated they did not know why education was not completed for Activities of Daily Living Care for Dependent Residents per the Plan of Correction to Licensed Nurses and Certified Nursing Aides . They stated it should have been completed last week while they were out. They stated the education should have been completed on or prior to 06/22/2026 because it was their timeline. Additionally, the Director of Nursing stated the Administrator was not available to be interviewed. During an interview on 06/25/2026 at 1:51 PM, the [NAME] President of Skilled Nursing Operations stated the in-service education sign off sheets contained per diem and terminated staff, and those inaccuracies could have added to part of the problem. They stated the education sign off sheets needed to accurately reflect current staff so they could see who had been educated. The [NAME] President of Skilled Nursing Operations further stated staff that worked on the third shift should have been educated either by supervisory staff coming in early or supervisory staff on the night shift. The [NAME] President of Skilled Nursing Operations stated they did not know who educated third shift staff, but it would most likely not be assigned to an hourly employee who does not work that shift, like the Administrative Assistant, it would have been supervisory staff. Additionally, the [NAME] President of Skilled Nursing Operations stated the person assigned as responsible for completion of the corrective action should have reviewed the in-service education sign off sheets and verified accuracy. The [NAME] President of Skilled Nursing Operations stated they did not know why the Plan of Correction was not completed and stated it should have been on or prior to 06/22/2026 because that was the facility's completion date. They stated they needed to complete what they said they were going to do in the Plan of Correction. 10NYCRR 415.27(c)(3)(iv)(v)

Based on observations, interviews, and record reviews conducted during the survey, the facility failed to ensure residents were free from physical restraints imposed for purposes of discipline or convenience that were not required to treat the resident's medical symptoms, used for the least amount of time and document ongoing re-evaluation of the need for restraints for one (1) (Resident #104) of one (1) resident reviewed for physical restraints. Specifically, there were no evaluations completed to determine if Resident #104's lap tray and seat belt devices were restraints or re-evaluations to assess their continued need, staff did not release the seat belt or lap tray devices for over five (5) hours, and there were no provider orders to release the devices. The findings include: The facility policy and procedure titled Restraints and Safety Devices dated 10/07/2014 documented the objective of the policy was to maintain dignity of the resident at all times and promote greater functional independence. The policy documented that residents shall not be restrained unnecessarily or for convenience of staff. When a safety device is necessary, the least possible restrictive device shall be used. The nurse's responsibility was to consult with the physical therapist and the resident's physician prior to application of the safety device and choose the least restrictive device possible. The policy documented the physician must order the least restrictive safety device, document the specific reason for use of the device and designate the length of time the device was to be used. A treatment plan needed to be immediately developed and include removal of device to ensure exercise, ambulation and/or range of motion and change of position every two hours. Resident #104 had diagnoses that included seizures, intellectual disabilities and legal blindness. The Minimum Data Set (a resident assessment tool) dated 02/11/2026 documented Resident #104 had severe cognitive impairment, sometimes understood and rarely/never understands. The assessment tool documented Resident #104 was dependent on all activities of daily living. The comprehensive care plan dated 04/22/2026 documented Resident #104 had impaired functional status and was a dependent two assist with a full lift and full body sling to transfer to/from the bed. They used a custom tilt wheelchair that had a seat belt and padded lap tray to facilitate neutral alignment of their pelvis, trunk and head. Staff were to assist the resident back to bed if they showed signs and symptoms of discomfort. The Resident ADL/Daily Care List (a guide used by staff on how to provide care) dated 09/02/2025 documented Resident #104 was a dependent two assist with a full lift and full body sling to transfer to/from the bed; they used a custom tilt wheelchair that had a seat belt and padded lap tray to facilitate neutral alignment of their pelvis, trunk and head. Staff were to assist back to bed if showing signs and symptoms of discomfort. The care guide did not instruct to remove or release the seat belt and lap tray every two hours. The Physician's Orders dated 04/30/2026 documented an order dated 02/05/2026 for Resident #104 to use a wheelchair with chest support, a seat belt and a lap tray to facilitate neutral alignment of their pelvis, trunk (torso), and head. Staff assistance was required for the medical equipment and there was no order to release the seat belt and lap tray. The Medication Administration Records and Treatment Administration Records dated 04/2026 lacked documented evidence that the seatbelt and lap tray were released. Review of the interdisciplinary notes dated 09/02/2025 through 04/30/2026 lacked documented evidence that the restraint was released every two hours. The following was documented:- On 09/03/2025, an occupational therapy evaluation documented Resident #104's durable medical equipment/positioning was a custom tilt-in-space wheelchair from the group home. Wheelchair had a chest support, seat belt and padded lap tray to facilitate neutral alignment of pelvis, trunk and head. If patient shows signs of discomfort, please assist back to bed. -On 11/13/2025, an occupational therapy screen was completed and documented Resident #104's durable medical equipment/positioning was a custom tilt-in-space wheelchair from the group home. Wheelchair had a chest support, seat belt and padded lap tray to facilitate neutral alignment of pelvis, trunk and head. If patient shows signs of discomfort, please assist back to bed. There was no determination if the seat belt or padded lap tray were restraints. Review of the Occupational Therapy Evaluations and treatment notes dated 09/03/2025 through 10/02/2025 lacked documented evidence of an assessment for the use of a restraint. Review of the Physical Therapy Evaluations and treatment notes dated 09/03/2025 through 10/02/2025 lacked documented evidence of an assessment for the use of a restraint. During an observation on 04/26/2026 at 12:11 PM, Resident #104 was observed in the dining room in a tilt in space wheelchair (a wheelchair that can be reclined backward in a sitting position) with a padded lap tray in front of them. The lap tray attached to both arms of the wheelchair crossing in front of the resident's upper abdomen/lower chest area. During an observation on 04/27/2026 at 9:22 AM, Resident #104 was observed to be in the dining room, in their wheelchair with the padded lap tray attached to the arm rests. Resident #104 was observed to rest their head on the lap tray. During a continuous observation of Resident #104 on 04/28/2026 from 8:18 AM-2:00 PM the following was observed:-at 8:18 AM, Resident #104 was observed in their wheelchair next to a table in the dining room. Resident #104 was sitting upright and was wearing clean clothing. A padded lap tray was observed to be attached to both arms of the wheelchair and crossing in front of the resident's upper abdomen/lower chest area. There was also a seat belt buckled across the resident's thighs.-at 8:34 AM, Certified Nurse Aide #2 sat next to Resident #104 and started assisting them with their breakfast tray until 8:49 AM with the lap tray and seat belt remaining in place.-at 11:04 AM, Registered Nurse #1 wheeled Resident #104 out of the dining room to the scale and returned the resident back next to the table in the dining room within a few minutes. The lap tray and the seatbelt remained in place.-at 12:25 PM, Licensed Practical Nurse #1 sat next to Resident #104 and began assisting the resident with their lunch meal with the lap tray and seat belt remaining in place.-at 2:00 PM, the continuous observation was completed. Resident #104 was observed not to have the lap tray or seat belt released. Resident #104 was observed to move their upper body forward and backward throughout the observation; would place their head on the lap tray at times; and lean forward hugging a stuffed avocado on top of the lap tray. During an interview on 04/28/2026 at 3:02 PM, Certified Nurse Aide #1 stated they were responsible for Resident's #104 care for the day. They stated they got Resident #104 washed, dressed and into their wheelchair at 8:06 AM and had not provided any further care for the resident since then. Certified Nurse Aide #1 stated Resident #104 utilized a seat belt and lap tray when they were in their wheelchair and the resident came into the facility with those devices. Certified Nurse Aide #1 stated Resident #104 did not walk but they have seen the resident try to stand from their bed. During an interview on 04/28/2026 at 3:11 PM, Licensed Practical Nurse #1 stated Resident #104 wore a seat belt and utilized a padded lap tray while they were up in their wheelchair. They stated they did not know why Resident #104 utilized the seat belt and lap tray, but they used both since admission to the facility. Licensed Practical Nurse #1 stated Resident #104 previously lived in resource style housing and they utilized the devices there. They stated the resource style housing regulations were different and they asked the Director of Nursing about them when Resident #104 was admitted . Licensed Practical Nurse #1 stated they were not releasing the devices every two hours nor were they ever instructed to do so. During an observation and interview on 04/29/2026 at 2:52 PM, the Assistant Director of Therapy was brought to the dining room where Resident #104 was sitting in their wheelchair. Resident #104 had a seat belt that was attached to their wheelchair that was buckled closed, and the strap was across their thighs. The padded lap tray was attached to both arm rests. The Assistant Director of Therapy stated that Resident #104 could not remove those devices on command because they were deaf and blind. The Assistant Director of Therapy stated the purpose of Resident's #104 seat belt was to keep the buttocks to the back of the chair and prevent the resident from sliding out of the chair and it might be considered a restraint. The stated the purpose of Resident's #104's padded lap tray was to keep the resident in an upright position as the resident tended to roll into a hunched position and could tumble out of the chair if it was not in place. The Assistant Director of Therapy stated they had never done a restraint assessment and there was nothing put into place to ensure the devices were removed every two hours. They stated staff would only remove the devices prior to transfers. The Assistant Director of Therapy stated they attempt to do a skin check weekly on Resident #104 when time allows to make sure there was no rubbing with the lap tray or seatbelt. They stated all their documentation would be in the electronic medical record. During an interview on 04/29/2026 at 4:34 PM, Certified Nurse Aide #3 stated Resident #104 utilized a lap tray and a seat belt while in the wheelchair. They stated they are not sure why Resident #104 used the devices they are assuming the resident came to the facility with the devices. Certified Nurse Aide #3 stated Resident #104 did not walk or did not stand but they had seen the resident scoot across their bedroom floor into the hallway. Certified Nurse Aide #3 stated they believed Resident #104 would fall from their wheelchair if their lap tray was not in place and that Resident #104 was smart and could find a way to get out of their wheelchair. During a telephone interview on 04/30/2026 at 9:35 AM, Registered Nurse #1 Unit Manager stated that Resident #104 was a mechanical lift, if the resident was to stand it would be spontaneous self-positioning and the resident tended to do fast forward movements while they were in their wheelchair. Registered Nurse #1 stated they were aware Resident #104 utilized a padded lap tray and just found out they utilized a seat belt also. They stated the seat belt was utilized in the group home Resident #104 previously resided in as a safety measure to hold the resident in their chair from their spontaneous movements and from standing. Registered Nurse #1 stated that the lap tray was utilized as a sense of comfort for Resident #104 as they had sensory issues. They stated Resident #104 cannot self-release the seat belt or the lap tray and they did not think staff knew they had to release those devices every two hours. Registered Nurse #1 stated they did not feel Resident #104 needed both devices. During an interview on 04/30/2026 at 11:17 AM, the Director of Rehabilitation stated when Resident #104 was admitted to the facility, therapy would attempt to stand the resident. Resident #104 could bear some weight but needed a maximal assist of two for standing and could not follow any commands. The Director of Rehabilitation stated Resident #104 came from their group home with the tilt in space wheelchair, lap tray and seat belt. They stated that in a way those items were restricting Resident #104's movements. The Director of Rehabilitation stated Resident #104's lap tray was to help the residents positioning and the seat belt was to keep the resident in their chair. The Director of Rehabilitation stated Resident #104 did not have any restraint screens completed and that therapy did not do any restraint screening. During a telephone interview on 04/30/2026 at 1:19 PM, the Medical Director stated they were familiar with Resident #104, and they see the resident at least once a month. They stated that they were not sure if Resident #104 utilized a lap tray and seat belt, but if those items were utilized all the time, then it would be considered a restraint. The Medical Director stated Resident #104 should have had a restraint assessment completed. They stated they would expect the facility to follow the facility's policy for restraints. During an interview on 04/30/2026 at 1:51 PM, the Director of Nursing stated they could not locate any restraint evaluations for Resident #104 in the electronic medical record. They stated all they could locate was the occupational evaluation dated 09/30/2025. The Director of Nursing stated they were aware Resident #104 utilized a lap tray but was unaware they also utilized a seat belt until this week. They stated they believed the seat belt was used for positioning and they could not say if the seat belt was restricting the resident's movement because they just found out about it. The Director of Nursing stated they did not feel the lap tray was restricting the resident's movement because it was utilized for comfort and positioning due to the resident's contractures. The Director of Nursing stated that any restraints needed a medical provider order but was not sure if the facility's policy was that any restraints needed to be released in a specific time frame. 10 New York Codes, Rules, and Regulations (NYCRR) 415.4(a)(2)(iii)

Based on observations, interviews, and record reviews conducted during survey, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for two (2) (Resident #43 and #104) of eight (8) residents reviewed for activities of daily living (ADLs). Specifically, Residents #43 and #104 were not provided with timely incontinence care. The findings include: The facility policy and procedure titled Care of Incontinent Resident dated 10/07/2014 documented that providing incontinent care was to keep a resident with problems of involuntary elimination, clean and dry to promote cleanliness, comfort and to prevent skin issues. An incontinent resident in bed should be checked and change incontinence product as per care plan The facility policy and procedure titled Activities of Daily Living dated 01/14/2015 documented the nursing staff will assist the resident with any of the activities that they were unable to perform. 1. Resident #43 had diagnoses including dementia, hypertension (high blood pressure), and chronic kidney disease. The Minimum Data Set (a resident assessment tool) dated 02/11/2026 documented Resident #43 had severe cognitive impairment, understands and usually was usually understood by others. The resident assessment also documented Resident #43 was always incontinent of bladder/bowel and was dependent for toileting transfers and toileting hygiene. The comprehensive care plan dated 03/23/2026 documented Resident #43 had an impaired functional status, was dependent on two staff members assist with a full lift and full body sling to transfer to/from the bed; dependent on one staff member assist for toileting tasks completed via check and change; and to encourage toileting /incontinent care every two (2) to four (4) hours and as needed. The care plan documented Resident #43 had urinary incontinence. The Resident ADL/Daily Care List (guide used by staff to provide care) dated 07/21/2025 documented Resident #43 was a dependent two assist with a full lift and full body sling to transfer to/from the bed; a dependent one assist for toileting tasks completed via check and change; and to encourage toileting /incontinent care every two (2) to four (4) hours and as needed. The care plan documented Resident #43 had urinary incontinence. A continuous observation of Resident #43 on 04/28/2026 from 8:18 AM to 2:00 PM revealed the following: -at 8:18 AM, Resident #43 was seated in a Geri chair (a chair that reclines into a laying position and has wheels) next to a table in the dining room. Resident #43 was wearing clean day clothing, slippers and had blanket covering them.-at 8:24 AM Resident #43 had their breakfast tray on the table in front of them-at 8:47 AM Registered Nurse #1 sat next to Resident #43 and started assisting Resident #43 with their breakfast meal. At 8:49 AM Certified Nurse Aide #2 replaced Registered Nurse #1 to finish assisting Resident #43 with their breakfast. -at 12:02 PM Resident #43's family member was in the facility and was visiting with the resident who had remained in the dining rom. -at 12:20 PM Resident #43 was served their lunch tray. Certified Nurse #1 and Registered Nurse #1 boosted Resident #43 in the Geri chair and placed the resident in an upright position. Resident #43's family member assisted the resident with their lunch meal. -at 12:55 PM Resident #43 completed their lunch meal and the resident's family member then pushed the resident into their room.-at 2:00 PM the continuous observation was completed. Resident #43 was not removed from the dining room and/or provided with any additional care during this time, including toileting or checking for incontinence. During an interview on 04/28/2026 at 1:48 PM, Certified Nurse Aide #1 stated they started their shift at 7:00 AM and they finish work at 3:00 PM. They stated they got Resident #43 washed, dressed and out of bed at 7:40 AM. They stated Resident #43 was incontinent and they resident should be checked and changed every two (2) hours. Certified Nurse Aide #1 stated they had not provided any incontinent care for Resident #43 since they were gotten out of bed because there were other residents they had to get up and did not check on. Certified Nurse Aide #1 stated they were working with only one other aide, and it was not possible to provided incontinent care to all their assigned residents every two (2) hours. They stated they usually can only provide incontinent care once a shift, sometimes twice, when there were only two aides on the unit. During a care observation on 04/28/2026 at 2:35 PM, Resident #43 was placed into bed via a mechanical lift by Registered Nurse #1 and Certified Nurse Aide #1. When Resident #43's brief was unfasted the brief was visibly wet with urine and soiled with feces (bowel). 2. Resident #104 had diagnoses that included seizures, intellectual disabilities and legal blindness. The Minimum Data Set, dated [DATE] documented Resident #104 had severe cognitive impairment, sometimes understood and rarely/never understands. The resident assessment tool documented Resident #104 was always incontinent with bladder and bowel and was dependent on all activities of daily living. The comprehensive care plan dated 04/22/2026 documented Resident #104 had impaired functional status and was dependent on two staff members assist with a full transfer lift for to/from bed for check and change; dependent for peri-care and clothing management; and to encourage toileting/incontinent care every two (2) to four (4) hours and as needed. The care plan documented Resident #104 had urinary incontinence. The Resident ADL/Daily Care List dated 09/02/2025 documented Resident #104 was dependent on two staff members assist with a full transfer lift for to/from bed for check and change; dependent for peri-care and clothing management; and to encourage toileting /incontinent care every two (2) to four (4) hours and as needed. The care plan documented Resident #104 had urinary incontinence. A continuous observation of Resident #104 on 04/28/2026 from 8:18 AM to 2:00 PM revealed the following: -at 8:18 AM, Resident #104 was seated in a tilt in space wheelchair (a wheelchair that can be reclined backward in a sitting position) next to a table in the dining room. Resident #104 was sitting upright and was wearing clean day clothing.-at 8:24 AM Resident #104 had their breakfast tray on the table in front of them-at 8:34 AM Certified Nurse Aide #2 sat next to Resident #104 and started assisting them with their breakfast tray until 8:49 AM.-at 11:04 AM Registered Nurse Unit Manager #1 wheeled Resident #104 out of the dining room to the scale and returned the resident back next to the table in the dining room within a few minutes. -at 12:20 PM Resident #104's lunch tray was placed in front of them on the table. -at 12:25 PM Licensed Practical Nurse #1 sat next to Resident #104 and began assisting the resident with their lunch meal. -at 2:00 PM the continuous observation was completed. Resident #104 was not provided with any additional care during the observation including toileting and/or checking for incontinence. During a further interview on 04/28/2026 at 3:02 PM, Certified Nurse Aide #1 stated they were also responsible for Resident's #104 care for the day. They stated they got Resident #104 washed, dressed and into their wheelchair at 8:06 AM. Certified Nurse Aide #1 stated they had not provided any further incontinent care for Resident #104 after getting them out of bed. They stated Resident #104 was an incontinent resident and should have been toileted every two (2) hours. They stated they could not provide the care due to staffing. Certified Nurse Aide #1 stated that if they could not get to a resident prior to the end of their shift they would notify the oncoming shift to make sure the oncoming shift made that resident a priority. Certified Nurse Aide #1 stated the importance of timely incontinent care, so the residents did not get any sores or skin breakdown. Additionally, it was a resident right to use the bathroom in a timely manner. During a care observation on 04/28/2026 at 3:37 PM, Resident #104 was placed into bed via a mechanical lift and incontinent care was provided by Certified Nurse Aide #3 and Certified Nurse Aide #4. As Resident #104 was being lifted out of their wheelchair a strong odor of urine was noted and when Resident 104's brief was unfasted the brief was visibly wet. During an interview on 04/28/2026 at 3:11 PM, Licensed Practical Nurse #1 stated an incontinent residents should be toileted every two (2) to four (4) hours. They stated that Resident #43 and Resident #104 were both incontinent and Resident #43's family preferred the resident to be back into bed after lunch daily. Licensed Practical Nurse #1 stated Resident #43 not having incontinent care provided until from 7:40 AM - 2:30 PM and Resident #104 not having incontinent care provided to them from 8:05 AM to the end of the day shift was not appropriate and it was due to staffing. During an interview on 04/28/2026 at 3:17 PM, Registered Nurse Unit Manager #1 reviewed Resident #43's care plan and stated the resident was incontinent and they were to be toileted every two (2) to four (4) hours and as needed. They stated it was also the same for Resident #104. Registered Nurse #1 stated Certified Nurse Aide #1 did tell them they could not provide incontinent care to Resident #43 until 2:30 PM but they were not told that Resident #104 was not provide care since that morning. Registered Nurse #1 stated the outgoing shift were to do a unit walk through with the oncoming shift so it was communicated which residents the outgoing staff could not provide care to timely. Registered Nurse #1 stated the care was not completed timely due to staffing concerns on the unit and both residents should have been checked and changed sooner as standards of care were to provide toileting to a resident every two (2) to four (4) hours. During an interview on 04/30/2026 at 1:51 PM, the Director of Nursing stated their expectation for toileting an incontinent resident would be every two (2) to three (3) hours. They stated they were familiar with Resident #43 and Resident #104 and both residents were incontinent. The Director of Nursing stated they were unsure why Resident #43 and Resident #104 went so many hours without incontinent care on 4/28/2026 but five (5) to seven (7) hours was untimely and not appropriate. The Director of Nursing stated the floor was staffed at bare minimum on 04/28/2026 and that could have contributed to the untimely care. The Director of Nursing stated that timely incontinent care was important for a resident's dignity, skin integrity and the residents plan of care was not followed. 10 New York Codes, Rules, and Regulations (NYCRR) 415.12(a)(3)

Based on observation, interview and record review conducted during a Complaint investigation (NY00363355-806626 and NY00359730-806683) completed on 09/12/2025, the facility did not ensure sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, the facility did not ensure there was sufficient nurse staffing to meet the needs of the resident in accordance with their preferences and plans of care.The findings are:Review of the Dear Administrator letter 23-11 dated 06/30/23 sent to the nursing home administrators informing them that starting 04/01/2022 nursing homes were required to have an average daily staffing of 3.5 hours of care per resident per day with 2.2 hours for Certified Nurse Aides and 1.1 hours for Licensed Practical Nurses or Registered Nurses.The Facility Assessment, review dated 01/30/2025, documented the assessment is required by the nursing home Requirements of Participation to identify and analyze the facility's resident population and identify the personnel, physical plant, environmental and emergency response resources needed to competently care for the residents during the day-to-day operations and emergencies, including nights and weekends. The facility is licensed for 146 beds with an average daily census of 134. The facility will ensure that there is sufficient and competent staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. Additionally, the Facility Assessment documented the following total number needed or average or range of nursing staff including days, evenings, nights, and weekends:- Licensed nurses providing direct care 2.5-8- Nurse Aides 4.5-17Review of the Direct Care Staffing report dated 08/10/2025=09/10/2025 of nursing staff directly responsible for nursing care documented the following:- 08/30/2025 - resident census 121; Licensed Practical Nurse and Registered Nurse hours 84.24 or .7 hours per resident per day; Certified Nurse Aide hours 140.93 or 1.1 hours per resident per day. Based on the census there was not the required number of Licensed Nurse or Certified Nurse Aide hours per day.- 08/31/2025 - resident census 121; Licensed Practical Nurse and Registered Nurse hours 89.95 hours or .7 hours per resident per day; Certified Nurse Aide hours 13.69 hours or 1.0 hours per resident per day. Based on the census there was not the required number of Licensed Nurse or Certified Nurse Aide hours per day.- 09/05/2025 - resident census 123; Licensed Practical Nurse and Registered Nurse hours 97.76 or .75 hours per resident per day; Certified Nurse Aide hours 110.5 hours or .7 per resident per day. Based on the census there was not the required number of Licensed Nurse or Certified Nurse Aide hours per day.The Aspen Complaints/Incidents Tracking System (ACTS) complaint #NY00359730, Internet Quality Improvement & Evaluation System (iQIES) complaint #806683, documented the complainant reported 11/05/2024 Resident #9 for three (3) days, had an incontinent brief soaked with urine and was not cleaned up for the day related to staffing concerns.The Aspen Complaints/Incidents Tracking System (ACTS) complaint #NY00363355, Internet Quality Improvement & Evaluation System (iQIES) complaint #806626, documented the complainant reported 12/09/2024 Resident #10 did not have their brief changed regularly and would sit in the same incontinent brief from 8 AM to midnight related to staffing concerns.Resident #1 had diagnoses which included dysphagia (define), vascular dementia, and hypertension (high blood pressure) The Minimum Data Set (resident assessment tool) dated 06/18/2025 documented the resident had severe cognitive impairment and required substantial/maximal (helper does more than half the effort) assistance with eating.During an observation on 09/10/2025 at 8:45 AM Resident #1 was observed eating breakfast in their room with no staff present.Resident #2 had diagnoses which included protein calorie malnutrition, dementia, and chronic kidney disease. The Minimum Data Set, dated [DATE] documented the resident had severe cognitive impairment. The undated Comprehensive Care Plan documented Resident #2 required partial/moderate assistance with eating.During an observation on 09/10/2025 at 8:46 AM Resident #2 was observed eating breakfast in their room with no staff present.During an observation on 09/08/2025 at 12:05 PM Resident #8 was observed just given their lunch tray by Certified Nurse Aide # 3. Certified Nurse Aide #3 set the tray on the overbed table and exited the room. The resident was not dress and wearing a soiled incontinence brief. Resident #8 was struggling to sit up in bed to reach their meal tray.During an observation on 09/08/2025 at 12:20 PM Resident #6 was observed eating lunch in bed.During observations on the second floor on 09/10/2025 from 8:29 AM through 9:10 AM several residents that required supervision/touching assistance with eating were observed eating in their rooms with no staff present. Additionally, no staff were observed entering those rooms during the time frame.During an interview on 09/10/2025 at 8:22 AM, Certified Nurse Aide #1 stated they were the only aide on the unit, responsible for 38 residents. They stated they do the best they can but cannot do it all.During an interview on 09/10/2025 at 9:16 AM, Licensed Practical Nurse #1 stated there was not enough staff on the unit to supervise the residents eating in their rooms that required supervision or hands on assistance.During an interview on 09/10/2025 at 9:38 AM, the Occupational Therapy Assistant stated any resident that required supervision level of assistance or more should be out of their rooms and in the dining room for meals. We don't have the staff to get residents out of bed in the mornings, and it's happening more and more lately. One (1) or two (2) aides are not able to properly care for that many residents.Durning an interview on 09/08/2025 at 10:17 AM, Certified Nurse Aide #3 stated they have worked at facility since January. The assignment sheet for today documents four (4) aides but have only have two (2). They have 19 residents on their assignment today and that's usually the normal number of aides for this unit, they try to get the work done but it's very difficult. Showers usually don't get done.During an interview on 09/09/2025 at 9:42 AM, a family member stated they come to the facility every day from about 8:30 AM to 2:30 PM to provide care for their parent. They stated care is difficult because there is no staff. I provide all care and assist with all meals, I return each evening for supper because staffing is abysmal.During an interview on 09/09/2025 at 10:10 AM, Certified Nurse Aide #2 stated staffing was pretty bad, usually working with only two (2) aides on the unit. Additionally, they try their best, going room by room but were unable to complete showers and they were only able to provide care to each resident once a shift.During an interview on 09/12/2025 at 8:55 AM, Resident #3 stated they waited for over an hour to have their call light answered to use the restroom and have had accidents (incontinent episodes) waiting for assistance.During an interview on 09/12/2025 at 9:00 AM, Resident #4 stated they no longer bother putting on their call light because there was no staff to answer the light, so they just do things (going to restroom) on their own.During an interview on 09/12/2025 at 9:08 AM, Resident #5 stated they had some urinary problems from holding their urine for extended lengths of time and that it took over an hour to have their call light answered for assistance to use restroom when they were mechanical lift and needed the assistance of two (2) staff members. The resident also stated weekends are the worst, it's nightmarish here on weekends because there is even less staff than during the week.Durning an interview on 09/12/2025 at 9:09 AM, Resident #6 stated they usually must wait over an hour to use the bed pan and sometimes will have an accident (incontinent episode). At night they have to lie in a wet bed because there was only one (1) aide on and they can't get to everyone. Also they like to go to activities but a lot of times they cannot because there was not enough staff to get them out of bed.Durning an interview on 09/12/2025 at 9:14 AM, Resident # 7 stated they were independent and can go to the bathroom by themselves, but their roommate has to wait a long time to get help.During an interview on 09/12/2025 at 9:58 AM, the Director of Nursing stated the following were the minimum number of nursing staff:- 7 AM - 3 PM shift: four (4) nurses, seven (7) Certified Nurse Aides- 3 PM - 11 PM shift: four (4) nurses, seven (7) Certified Nurse Aides- 11 PM - 7 AM shift: three (3) nurses, 4.5 Certified Nurse AidesThe Director of Nursing stated it had been a very long time since the facility had ideal nursing staff and the facility depends on ancillary staff to assist on the units. The Director of Nursing stated residents that required a supervision level of assistance or above with eating would be monitored intermittently by the staff answering call lights and monitoring halls. A nurse or Certified Nurse Aide could not realistically have a resident in sight at all times. The Director of Nursing stated they did not know if showers were being given regularly.During an interview on 09/12/2025 at 10:05 AM, the Administrator stated the facility had not met minimum nurse staffing levels in a while. The facility offers staff incentives to get the staff to work and agency staff. The facility should have 17 certified nurse aides and nine (9) nurses for the day shift, and they were not even close to those numbers.10 NYCRR 415.13 (b)(1) (i-ii) (2)(ii)

Based on interview, and record review conducted during a Complaint investigation (NY00308641) during the Standard survey completed on 3/1/24, the facility did not ensure sufficient nursing staff to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident for three (First floor, Second floor, Third floor) of three resident care units. Specifically, the facility did not ensure they met their minimum staffing numbers. In addition, minimum staffing numbers were not included in the facility assessment. Resident #s 36, 52, 85 and 114 were involved. The finding is: The policy and procedures titled Nursing Policy & Procedure Benefit Improvement and Protection Act (BIPA) revised 8/22/18 and Emergency Staffing Strategies revised 1/6/24 had no documentation regarding minimum nursing staffing numbers. 1a. Review of the Facility Assessment completed in January 2024 revealed that the assessment did not include minimum staffing numbers. During an interview on 2/29/24 at 8:57 AM, Scheduler #1 stated they were instructed by administration to have minimum staffing numbers scheduled as 10 Certified Nurse Aides for the 7:00 AM to 3:00 PM and the 3:00 PM to 11:00 PM shifts and 5 for the 11:00 PM to 7:00 AM shift. Scheduler #1 also stated that they did not work on weekends and that they completed the schedule and the nurse supervisors for each shift were responsible to make calls and fill needed shifts. Review of the facility's BIPA (Benefit Improvement and Protection Act) staffing provision sheets dated 2/17/24 7:00 AM to 3:00 PM shift to 2/26/224 7:00 AM to 3:00 PM shift documented the facility did not meet their minimum staffing number of Certified Nurse Aides on the following dates: -2/17/24 3:00 PM to 11:00 PM shift - 6 (down 4) -2/18/24 7:00 AM to 3:00 PM shift - 8.25 (down 1.75) -2/19/24 3:00 PM to 11:00 PM shift - 9 (down 1) -2/21/24 3:00 PM to 11:00 PM shift - 7.5 (down 2.5) -2/22/24 3:00 PM to 11:00 PM shift - 7.5 (down 2.5) -2/23/24 3:00 PM to 11:00 PM shift - 6.25 (down 3.75) -2/24/24 7:00 AM to 3:00 PM shift - 8 (down 2) -2/24/24 3:00 PM to 11:00 PM shift - 6.5 (down 3.5) -2/25/24 7:00 AM to 3:00 PM shift - 9 (down 1) -2/25/24 3:00 PM to 11:00 PM shift - 8 (down 2) -2/26/24 7:00 AM to 3:00 PM shift - 8 (down 2) The facility census for these dates was between 136 and 139 residents. 1b. Review of Resident Council Meeting Minutes revealed the following: 2/15/24 meeting notes documented that residents raised concerns about nursing staff and the facility was aware of the staffing challenges and were working to get more Unit Assistants hired to enter the Certified Nurse Aide program. Individual personal concerns would be addressed separately. During a Resident Council meeting held on 2/27/24 at 11:05 AM with 10 residents participating, residents stated that getting assistance by using the nurse call light can take 20 minutes to as long as 5 hours, that staffing was an issue, and that residents' beds were not made until the 11:00 PM to 7:00 AM shift arrived, at times. 1c. Interviews with Residents and Family Members: During an interview on 2/27/24 at 10:38 AM, Resident #85 stated they sometimes had to wait for an hour to an hour and a half for assistance and sometimes did not make it to the bathroom on time. During an interview on 2/26/24 at 11:45 AM, Resident #114 stated that the facility was so short staffed on evenings that sometimes they don't even offer them a shower and they had to clean themselves on the side of the bed. They also stated that weekends were horrible with not enough aides working or only working partial shifts. During an interview on 2/27/24 at 9:28 AM, Resident #36 stated there was not enough staff. Sometimes staff answered their call light instantly, other times not. During a family interview on 2/29/24 at 12:58 PM, Resident #52's spouse stated that the facility did not have enough staff. They stated that sometimes they wait a half hour when they ring the call bell. 1d. Interviews with Facility Staff During an interview on 2/28/24 at 3:29 PM, Certified Nurse Aide #3 stated that sometimes they worked the unit with only two aides and that on Saturday (2/24/24) they worked as the only Certified Nurse Aide from 3:00 PM to 7:00 PM. Certified Nurse Aide #3 stated they were not able to get resident's showers done and the last resident got to bed at 10:50 PM that evening. During a telephone interview on 2/29/24 at 1:18 PM, Certified Nurse Aide #2 stated they usually worked the 11:00 PM to 7:00 AM shift on the First-Floor unit and there were usually 2 Certified Nursing Aides scheduled, but at times there was only one. They stated weekend nights were the shifts with the lowest staffing. There could be only one Certified Nurse Aide and one nurse per floor. On those nights, the supervising nurse will be working the floor and take a medication cart at the same time. During an interview on 2/29/24 at 2:45 PM, Certified Nurse Aide #1 stated they worked the 11:00 PM to 7:00 AM shift on the Third-Floor unit and that most nights they were the only Certified Nursing Aide working on this unit. They also stated they stayed late to get their work finished. During an interview on 2/29/24 at 2:59 PM, Certified Nurse Aide #4 stated they always worked with two (total) aides on their unit on their weekend shifts and had 22 residents on their assignment. They usually couldn't get showers done and it was exhausting. During an interview on 2/29/24 at 1:20 PM, Licensed Practical Nurse #1 stated they worked on 2/18/24 during the day shift as a supervisor and worked on a cart passing medications from 7:00 AM to 11:00 AM on the first floor. Staffing included three Certified Nurse Aides plus one orientee and two nurses on the first floor, two Certified Nurse Aides and one nurse for the second floor, and two Certified Nurse Aides and one nurse for the third floor. Licensed Practical Nurse #1 stated the facility census was 136 and the facility usually tried to have three Certified Nurse Aides per unit at a minimum on day and evening shifts. Licensed Practical Nurse #1 stated they asked the Administrator to send out a mass text to get more staff in, but the Administrator didn't get any answers from that request. The Licensed Practical Nurse #1 stated nobody from administration was in the facility during that day shift. During an interview on 2/29/24 at 10:40 AM, Registered Nurse #1 stated they did shift assignments for the 3:00 PM to 11:00 PM shift, as they worked the 7:00 AM to 3:00 PM shift. The stated they received a schedule from the Scheduler #1 and that Scheduler #1, and the Administrator would make calls for call-offs during the day. Registered Nurse #1 stated the absolute staffing minimum for Certified Nurse Aides on the 7:00 AM to 3:00 PM and the 3:00 PM to 11:00 PM shifts would be 4 Certified Nursing Aides on Floor 1, and 2 each on Floor 2 and Floor 3. They also stated that on the 3:00 PM to 11:00 PM shift it would be most important to have the needed number of Certified Nursing Aides on after 7 PM, as they needed to get residents ready for bed. Nurses could assist with lifts; however, when there was only one nurse per floor, medications and treatments could be done, but it would be hard and depend on the nurse to be able to get the work done. Registered Nurse #1 stated there were 17 residents on the Third-Floor unit who needed the assistance of 2 staff for transfers and lifts: 14 residents on the Second-Floor unit, and 10 or 11 residents on the First Floor unit. When asked specifically about the 3:00 PM to 11:00 PM shift on 2/23/24, Registered Nurse #1 stated that they knew the shift was short-staffed for Certified Nurse Aides and that one Certified Nurse Aide scheduled for that shift had been approved to have that day off. During an interview on 2/29/24 at 3:10 PM Registered Nurse #2 stated that the number of Certified Nurse Aides for the 3:00 PM to 11:00 PM shift should be 5 for the First-Floor unit, and 3 each for the Second and Third floor units. Registered Nurse #2 stated the facility used to operate with 6 Certified Nurse Aides on the First-Floor unit, and 4 each on the Second and Third Floor units. Registered Nurse #2 stated they made the assignments for the 11 PM to 7 AM shifts and there should be at least 2 Certified Nurse Aides per unit during that shift. If the Certified Nurse Aides were available, the First-Floor unit could use three, due to workload, and the Second-Floor unit could use three, as there were residents who were awake and moving about the unit at night. Registered Nurse #2 stated it was most important to have the needed number of Certified Nursing Aides from 5:30 PM to 9 PM, as they were needed for mealtime and getting residents ready for bed. Registered Nurse #2 stated that when there were only three other nurses on the shift with them, the supervising nurse would take on a medication cart for at least half of the shift, and this would impede their ability to immediately respond to any incidents happening in the facility, take them from being able to make calls to fill shifts on the 11:00 PM to 7 AM shift, and answer calls that were coming in. Registered Nurse #2 stated that when Certified Nurse Aides struggled to get their work done, nurses would be required to assist with providing feeding assistance and transfers of residents, which would delay the nurse's ability to pass medications and provide ordered treatments. They stated that they were to contact the Administrator and DON #1 when shifts could not be filled, and that administration did not usually come in to assist. During an interview on 2/28/24 at 3:41 PM, Registered Nurse #3 stated the facility tried to have 2 nurses on each unit during the 7:00 AM to 3:00 PM and the 3:00 PM to 11:00 PM shifts and 1.5 nurses per unit on the 11:00 PM to 7:00 AM shifts, where they would split a nurse for two units. RN #3 stated that often the 3 PM to 11 PM supervisor will be working on a medications cart and supervise the building at the same time. During an interview on 2/29/24 at 4:03 PM, the Administrator stated they did not have minimum staffing numbers in the Facility Assessment, and they did not meet their minimum staffing for the above shifts (see section 1a). They stated that the minimum staffing for these shifts was not met because there either were call-offs or no-call no-shows and there were some staff who would be willing to pick up other shifts and a group of staff will not pick up extra shifts. The Administrator stated they were not aware that the Facility Assessment required actual minimum staffing numbers and thought a general statement that the facility would do their best to ensure staffing needs were met was enough. 10 NYCRR 415.3(b)(1)(ii)

Based on observation, interview, and record review during the Standard survey completed on [DATE], the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Issues included undated and outdated food in refrigerators, potentially hazardous foods in refrigeration above 41 degrees Fahrenheit, a refrigerator missing a thermometer, and multiple soiled surfaces. This affected two (First Floor, Second Floor) of three resident use floors and the kitchen. The findings are: The undated policy and procedure titled Refrigerated Food Storage Labeling and Dating documented coolers will be maintained below 41 degrees Fahrenheit. All opened and prepared food items will be covered, labeled and dated so as to indicate a consume by or expiration date. Once the product is opened or prepared, keep it a maximum of four days (with today as day one). Exceptions to this are refrigerated staples/ condiments, which may include catsup, mustard, relish, pickles, salad dressing, jelly, syrup, dried or candied fruit, salsa, horseradish, minced garlic in water, or lemon juice. These items will have a storage date of 60 days. [NAME] the product with the date by which it must be consumed. If the food processor has marked the product with a use-by date, honor that date first. If you still have the product on the consume-by date, discard the food. Any product that is not dated must be discarded. The undated policy and procedure titled Storage documented two easily visible thermometers, interior and exterior, will be in place to record refrigerator temperature. Monitor and document refrigerator temperature a minimum of three times daily. Refrigerator air temperature should be approximately two degrees lower than desired internal temperature, desirable product temperature is 41 degrees Fahrenheit or lower. The policy and procedure titled Use and Storage of Food and Beverage Brought in for Residents, Food Procurement, revised [DATE], documented facility staff will be appointed to check resident refrigerators for proper temperatures, food containment and quality, and disposal of items per facility policy and food procurement regulations. A potential cause of foodborne illness is improper storage of PHF/ TCS (potentially hazardous foods and time/ temperature controlled for safety) foods. Refrigerators must be in good repair and keep foods at or below 41 degrees Fahrenheit. Routine audits will be conducted of the internal refrigerator gauges, and if temperatures are out of range, notify maintenance and follow facility policy for food disposal. 1a. Observation in the kitchen on [DATE] at 9:40 AM revealed the following food items were in the walk-in refrigerator: -An opened five-pound container of yogurt, with manufacturer's stamp best if used by [DATE] and hand-written label opened ,d+[DATE] -A bin that contained two cups of cooked cubed carrots in water dated [DATE] -A bowl that contained one cup of egg salad with illegible red writing on the plastic wrap covering -A bin that contained three cups of tuna fish dated ,d+[DATE] Continued observation in the kitchen at this time revealed a bin that contained ten pickle spears that was undated was located in the single door reach-in refrigerator. Continued observation in the kitchen at this time revealed the following food items were in the double door reach-in refrigerator: -One half of a ham and cheese sandwich wrapped in plastic wrap that was undated -Three and one half uncooked grilled cheese sandwiches wrapped in plastic wrap that were undated -A poured cup of orange juice labeled 240 -Two poured cups of orange and grape juice that were undated -An individual cup of prepared salad that was undated During an interview at the time of the observations, the Food Service Director stated the yogurt container could be kept in the refrigerator until the manufacturer's best if used by date, unless the package stated to discard after a certain number of days after opening. They also stated staff should not write on plastic wrap in red, because it smudges and is hard to read, but the date written in red on the egg salad was probably [DATE]. The Food Service Director stated they kept products like egg salad and tuna fish for three days and discarded on the fourth day. The sandwiches were made last night or this morning, and should be dated. The 240 label on the orange juice indicated the amount of juice, not a date. Also at this time, the Dietician Assistant stated they were not sure why the carrots were labeled with an April date, but they should be discarded. 1b. Observation in the kitchen on [DATE] at 10:00 AM revealed the thermometer inside the double door reach-in refrigerator indicated the air temperature was 50 degrees Fahrenheit. This Surveyor's digital thermocouple thermometer was placed in the refrigerator and indicated the air temperature was 51.5 degrees Fahrenheit. On [DATE] at 10:10 AM, the temperature of milk inside the refrigeratorr was measured as 41 degrees Fahrenheit with the facility's analog stem thermometer and 45.1 degrees Fahrenheit with this Surveyor's digital thermocouple. At this time, the potentially hazardous foods in this refrigerator included milk, juice, Mighty Shakes (nutrient-fortified shakes with a manufacturer's stamp keep frozen), sandwiches, prepared omelets, and a prepared salad. During an interview at the time of the observation, the Food Service Director stated they have had trouble with this refrigerator maintaining temperatures, so they only kept food in the refrigerator for about a half hour at a time, during tray line service. They stated they wanted the air temperature inside the refrigerator to be below 41 degrees Fahrenheit. The Food Service Director also stated the items should be removed from this refrigerator now because tray line service was done and workers must be busy with other tasks and have not yet gotten a chance to remove the items. Additionally, on [DATE] at 8:15 AM, the Food Service Director stated the analog stem thermometer they used on [DATE] was not able to be calibrated and they chose to discontinue using it. 1c. Observation on the First Floor on [DATE] at 12:55 PM revealed the following items were in the Multipurpose Room refrigerator: -A 16-ounce glass jar that contained an unknown peach-colored substance, labeled with a resident name, room number, and opened [DATE], expire [DATE] -A peanut butter and jelly sandwich labeled with date in/ open ,d+[DATE], expiration ,d+[DATE] -A white box that contained a half-eaten pastry with no name or date -An opened grocery store brand container of sliced Swiss cheese with three slices left with no name or date opened -An opened 8-ounce bag of pepperoni with no manufacturer's date stamp and not labeled with the date opened, pepperoni had a slightly gray color -Two cups of poured milk that were undated -An opened 32-ounce container of coffee creamer labeled with a resident name and room number, with manufacturer's date stamp best by 25Dec2023 and not labeled with the date opened -An opened 12-ounce container of cream cheese with a manufacturer's date stamp [DATE] and keep refrigerated and use within ten days of opening, not labeled with the date opened -An opened 8-ounce container of cream cheese with a manufacturer's date stamp [DATE] and keep refrigerated and use within ten days of opening, not labeled with the date opened, and on the inside wall of the container was a one-half of an inch diameter black, moldy-looking substance Additional observation at this time revealed the Multipurpose Room refrigerator had a log called Daily Refrigerator & Freezer Temperature Log and the most recent entry was ,d+[DATE]. At the time of the observation, the Food Service Director stated the Nursing department took care of this refrigerator, and Dietary staff did not maintain any refrigerators outside of the kitchen. They also stated it was the facility's policy to toss any food item that was not labeled or dated, and the unknown food in the glass jar, the pastry, the pepperoni, and the coffee creamer needed to be thrown out. The Food Service Director also stated none of the identified foods in the Multipurpose Room refrigerator came from the facility's kitchen, except the sandwich and the poured milks, which should have been dated. Continued observation at this time revealed a sign on the front of the refrigerator that said, Everything must have a label to identify ownership. Label must include date of placement/ opening and expiration date (four days including open/ placement date). All items that are not labeled or are past expiration date will be disposed of. During a second observation of the refrigerator in the Multipurpose Room on [DATE] at 9:25 AM, the thermometer inside of the refrigerator indicated the air temperature was 45 degrees Fahrenheit. This Surveyor's digital thermocouple thermometer was placed in the refrigerator and indicated the air temperature was 50.0 degrees Fahrenheit. At this time, according to the digital thermocouple, the temperature of the cream cheese in the 12-ounce container was 45.3 degrees Fahrenheit and the temperature of the cream cheese in the 8-ounce container was 46.9 degrees Fahrenheit. During an interview at the time of the second observation, the Food Service Director stated they did not know what date the cream cheese containers were opened and they did not know how long they had been above 40 degrees Fahrenheit, so they should be tossed. The Food Service Director also stated they reminded residents at Resident Council meetings that their personal foods needed to be labeled and a reminder sign was placed on the refrigerator and there were label stickers available at the refrigerator too. They stated the air temperature inside this refrigerator should be 35 to 40 degrees Fahrenheit. 1d. Observation on the Second Floor on [DATE] at 12:55 PM revealed the refrigerator in the Connections Room did not have a thermometer. The following potentially hazardous food items were in the Connections Room refrigerator: -One four-ounce Mighty Shake (nutrient-fortified shake) with a manufacturer's stamp keep frozen -One five-ounce Greek yogurt -One four-ounce plastic leftover container of cottage cheese, with no name or date -One opened 46-ounce container of orange juice with a manufacturer's stamp refrigerate after opening, but not labeled with the date opened During a second observation on [DATE] at 9:50 AM, the Connections Room refrigerator did not have a thermometer, and it contained the following potentially hazardous foods: -Two four-ounce Mighty Shakes -Two four-ounce yogurts - One opened 46-ounce container of orange juice with a manufacturer's stamp refrigerate after opening, but not labeled with the date opened -One re-usable lunch bag Continued observation revealed the front of the Connections Room refrigerator had a sign that stated, Resident Only Refrigerator. At the time of the second observation, Activities Assistant #1 stated the cottage cheese from [DATE] and the re-usable lunch bag belonged to staff members, and staff food should be stored in the staff refrigerator in the basement. Activities Assistant #1 also stated they were not sure who was in charge of maintaining this refrigerator and the food inside of it. Also, at the time of the second observation, this Surveyor's digital thermocouple thermometer was placed in the refrigerator and indicated the air temperature was 52.0 degrees Fahrenheit. At this time, according to the digital thermocouple, the temperature of the yogurt was 43.1 degrees Fahrenheit and the temperature of the orange juice was 47.2 degrees Fahrenheit. During an interview on [DATE] at 10:00 AM, Licensed Practical Nurse #2 stated Activities staff was mainly in the Connections Room and they would presume that Activities staff would check the refrigerator. Licensed Practical Nurse #2 also stated staff food should not be in the Connections refrigerator, but belonged in the staff Cafe area in the basement. They also stated they did not see a thermometer in the Connections refrigerator, and there should be one, and Maintenance staff needed to look at this refrigerator to check its temperature. 1e. Observation on [DATE] at 12:50 PM revealed the refrigerator in the First Floor Dining Room contained a full 32-ounce glass jar of a soup or stew that was labeled with a resident name, room number, and ,d+[DATE]. During an interview on [DATE] at 9:18 AM, Resident #114 saw the glass jar and stated, Oh my God, is that still in there? Give that to me. At this time, the resident threw it in the garbage. Resident #114 stated that their spouse made the soup last year and it was never sealed like [NAME] a fruit, it was just put in the jar and was definitely garbage. During an interview on [DATE] at 10:10 AM, the Activities Supervisor stated Dietary staff supplied the food for the Connections Room and Multipurpose Room refrigerators and Dietary staff checked and maintained them, as far as they knew. They stated checking and maintaining the refrigerators was not a duty of Activities staff. During an interview on [DATE] at 1:30 PM, the Education Facilitator/ Infection Control Preventionist stated they personally checked the refrigerators in the Multipurpose Room, the Connections Room, and all unit Dining Rooms on a daily basis, or at least a couple of times per week. They stated they checked for dates and temperatures, and ideal air temperature in a refrigerator was between 38 and 42 degrees Fahrenheit. The Education Facilitator/ Infection Control Preventionist stated if they saw a refrigerator air temperature above 42 degrees Fahrenheit, they would let Maintenance staff know. They stated they threw out food by the third or fourth day after opening, and they would let the resident know that their food was out of date, and if a food item had no name or date, they would throw it away. The Education Facilitator/ Infection Control Preventionist also stated residents could get sick if they ate foods that were outdated or out of temperature. Additionally, on [DATE] at 11:02 AM, the Education Facilitator/ Infection Control Preventionist stated they did not log the refrigerator air temperatures during their checks, and the refrigerator in the Connections Room should have had a thermometer. They also stated they usually checked foods for dates, and did not know the glass jar of soup or stew was in the First Floor Dining Room refrigerator, it must have been overlooked. During an interview on [DATE] at 12:45 PM, the Administrator stated the facility did not have a policy and procedure about monitoring refrigerators. The Administrator further stated Dietary staff maintained all refrigerators in the kitchen and in the resident dining rooms. They stated the refrigerator was added to the Multipurpose Room less than a year ago and the Connections Room had been closed during the COVID-19 pandemic but reopened about three months ago. The Administrator also stated no one had an assigned duty to check the Multipurpose Room's refrigerator, and they assumed it was done by Dietary staff, and the Infection Control Nurse, who performed audits which included refrigerators. 1f. Observation in the kitchen on [DATE] at 10:20 AM revealed the following environmental conditions: -Rear wall under the extinguishment hood was soiled with black debris at the base -Real wall under the extinguishment hood had brown streaks and splatters throughout -Floor under the metal shelf in the extinguishment hood had rust marks in a three foot long by three foot wide area and also a six inch diameter area of broken and missing floor tiles -Front and right side of convection oven had greasy streaks and dried food stains -Front and left side of stove/ oven had greasy streaks and dried food stains -Floors under most equipment, including reach-in refrigerators, stainless steel shelves on wheels, slicer table, toaster table, ice machine, juice rack, and coffee station, were discolored with brown debris -Solid layer of food debris on top of the automatic dishwashing machine, plus a drink lid, a pencil, a used paper towel, a used glove, and a piece of paper were on top of the automatic dishwashing machine -Two in-use wall fans in the dishwashing room had visible dust accumulation on their front and back cages During an interview at the time of the observations, the Food Service Director stated an employee was assigned to do extra cleaning tasks once every other week on the third shift to handle the cleaning tasks that were hard to do during the day when the equipment was in use. The Food Service Director also stated the kitchen floor was stripped and waxed about two months ago, but all furniture and equipment was not moved during the process. They also stated the Dietary staff swept the kitchen floor throughout the day and wet mopped the kitchen floor each night, but could not get under all of the equipment. The Food Service Director also stated some spots on the floor did not get thoroughly stripped and was waxed over, and could not be cleaned with regular wet mopping. They also stated they were not sure who cleaned the top of the dishwashing machine or how often, but it should be cleaned now, and the two fans also needed to be cleaned now. During an interview on [DATE] at 10:45 AM, the Housekeeping Supervisor stated they and the Director of Environmental Services stripped and waxed the kitchen floor overnight, but could not recall when. They stated they removed most kitchen equipment before stripping and waxing, with the exception of the refrigerators and ovens. The Housekeeping Supervisor stated they applied four coats of wax and it looked fine when they were done, but it did not hold up because the kitchen floor gets beat up with traffic. During an interview on [DATE] at 11:35 AM, the Director of Environmental Services stated they stripped and waxed the kitchen floor with the Housekeeping Supervisor in late [DATE] and it looked great when they were done. They also stated the rust under the extinguishment hood did not come up with the strip and wax. During an interview on [DATE] at 12:45 PM, the Administrator stated the facility did not have a policy and procedure about kitchen sanitization. 10 NYCRR 415.14(h) SubPart ,d+[DATE] - Food Service Establishments ,d+[DATE].40, ,d+[DATE].44, ,d+[DATE].110(d),,d+[DATE].170, ,d+[DATE].171

Based on interview and record review conducted during a Complaint investigation (#NY00332288) during the Standard survey completed on 3/1/24, the facility did not ensure that all alleged violations of abuse, were reported immediately, but not later than two hours after the allegation was made, to the Administrator and other officials including the State Survey Agency for one (Resident #92) of five residents reviewed. Specifically, alleged resident to resident sexual abuse was not reported to the Administrator of the facility and the New York State Department of Health within the required time frame. The finding is: The policy and procedure titled Resident Abuse Prevention Reporting System, revised 1/6/23, documented that it is the responsibility of employees to promptly report to facility management any incident or suspected incident of resident abuse. Any suspected abuse must be reported immediately. Immediately, in this context, means after ensuring the resident has been removed from any possibility of harm and is safe. All employees receive annual training pertaining to prevention, identification and reporting of resident abuse, and the consequences for failure to report allegations. Resident #92 had diagnoses that included mild cognitive impairment (may include problems with memory, language, or judgement), morbid obesity, and difficulty walking. The Minimum Data Set (a resident assessment tool) dated 1/24/24 documented Resident #92 was cognitively intact, was understood and usually understands. The assessment documented the resident exhibited no behaviors. The Care Plan, dated 12/11/23, documented Resident #92 had the potential for a communication deficit related to an intellectual delay and had the potential for unintentional re-traumatization from being admitted to a skilled nursing facility from living independently in the community. Interventions included ensuring respectful and professional boundaries and to ensure physical and emotional safety. Resident #104 had diagnoses that included alcohol dependence withdrawal delirium (may result in confused thinking and reduced awareness of surroundings), altered mental status and encephalopathy (a brain disease that alters brain function). The Minimum Data Set, dated dated dated [DATE] documented Resident #104 was cognitively intact, understood and usually understands. The assessment documented the resident exhibited no behaviors. The Care Plan revised in February 2024, documented Resident #104 had inappropriate behaviors towards a female resident with interventions including redirecting female residents away from resident as able and to remind resident that inappropriate behavior toward females was not acceptable. Ordered anti-depressant medication (Prozac) and to follow up with psychiatric services as ordered. Review of the facility investigation dated 1/26/2024 revealed it was reported by Activities Assistant #2 that Resident #92 made a statement to them that Resident #104 had tried to rape them a couple nights ago. They stated that Resident #92 then changed the subject and remained cheerful and giggling. The investigation did not include the date or time the resident reported the allegation to Activities Assistant #2. The New York State Complaint Tracking System Complaint/Incident Investigation Report received on 1/26/24 at 2:20 PM, documented that the Administrator was made aware of the allegation of resident to resident sexual abuse on 1/26/24 at 11:00 AM. During an interview on 3/1/24 at 8:51 AM, Activities Assistant #2 stated they were in the lobby at the end of their shift on 1/25/24, waiting for a taxi cab. Resident #92 was in their wheelchair next to them, when Resident #104 wheeled themselves into the lobby. Resident #92 then stated Resident #104 made them nervous because they tried to rape them last night. Activities Assistant #2 asked Resident #92 if they told anyone else about the incident and Resident #92 said no. Resident #104 left the lobby soon after they entered and there had been no interaction between the residents. Activities Assistant #2 then left the facility in their cab. Activities Assistant #2 stated they reported the incident to their manager the following day. They did not recall the exact time. During an interview on 3/1/24 at 9:01 AM, the Activities Supervisor stated they were told about the allegation of sexual abuse the morning of 1/26/24. They did not recall the exact time. The Activities Supervisor stated they explained to Activities Assistant #2 the incident was a reportable incident and should have been reported within two hours. They educated them about reportable incidents and then immediately reported the allegation to the Administrator. During an interview on 3/1/24 at 9:08 AM, the Administrator stated that the Activities Supervisor reported the allegation of sexual abuse to them on the morning of 1/26/24. They did not recall the exact time. They stated that Activities Assistant #2 was re-educated on reportable incidents and the responsibility of the employee to report them immediately, even when off the clock. 10NYCRR 415.4(b)(2)

Based on observation, interview and record review conducted during a Standard survey completed on 3/1/24, the facility did not ensure a resident who required respiratory care, including tracheostomy (an opening into the trachea (windpipe) to help air reach the lungs) care, provided such care consistent with professional standards of practice for one (Resident #51) of three residents reviewed for respiratory care. Specifically, during an observation of tracheostomy care, the nurse did not perform adequate hand hygiene/glove changes and did not clean the stoma (a surgically made hole) area. The finding is: Review of policy and procedure titled Cleansing Inner Cannula (a tube within the outer tube that can be removed and cleaned easily without having to change the whole (outer) tracheostomy tube) of Tracheostomy Tube/Trach Care tube revised on 4/27/17, documented that the care should provide wiping and washing of the neck around and under the cannula with a gauze. Review of policy and procedure titled Procedure for Handwashing review date 12/22/14, documented that hands should be washed after handling a resident's articles, dressing, supplies, or equipment used in their care. Review of the facility suction and trach care check list dated 5/15/2000, documented that staff were to cleanse around the outer cannula with gauze and wash their hands after the procedure. Resident #51 was admitted with a tracheostomy, anoxic brain damage (a disorder of the brain caused by decreased oxygen), and epilepsy (disorder of the brain causing recurring seizures). Review of the Minimum Data Set (a resident assessment tool) dated 1/10/24, documented that the resident was in a persistent vegetative state/no discernible consciousness and was dependent on staff for all care. Review of the Comprehensive Care Plan dated 2/8/23, documented Resident #51 was to receive trach care every shift and as needed. Review of the Physician Orders dated 5/18/23 documented that trach care should be completed every shift, three times a day and as needed. During an observation on 2/28/24 at 7:55 AM, Licensed Practical Nurse #3 was performing trach care for Resident #51. Licensed Practical Nurse #3 performed hand hygiene, gathered supplies needed, and set up the supplies on a sterile field on a tray table. Licensed Practical Nurse #3 did not wash their hands before donning sterile gloves and then removed the inner cannula, placed the inner cannula in a solution of hydrogen peroxide and sterile saline, and used the brush provided in the trach kit to clean the mucous from the inner cannula. Without changing their gloves and washing their hands, the Licensed Practical Nurse #3 rinsed the cannula with sterile saline, placed the inner cannula on the sterile barrier, dried it with gauze and placed it back into the outer cannula. Licensed Practical Nurse #3 removed the soiled gauze from around the stoma site, which had a small amount of yellow mucus on it. Licensed Practical Nurse #3 did not clean the stoma area, and using the same gloves, placed a sterile piece of gauze around to the stoma area and proceeded to clean the nebulizer equipment with the same gloves. During an interview on 2/28/24 at 8:05 AM, Licensed Practical Nurse #3 stated that they did not change their gloves after cleansing the inner cannula, removing the soiled gauze, and prior to replacing the cleansed inner canula and the clean gauze. They stated they forgot to change their gloves and that it was important to change their gloves to avoid cross contamination. During an Interview on 2/28/24 at 9:00 AM, Registered Nurse #1, the Unit 2 Manager, stated that they expected Licensed Practical Nurse #3 to follow the policy and procedure for tracheostomy care. They stated that the training on competencies for trach care should be completed every year and that the Licensed Practical Nurse #3 should have used clean gloves to remove and clean the inner cannula as well as removing the gauze. They stated when performing trach care, clean gloves should be worn while removing the inner cannula and soiled gauze, then gloves should be removed, hands should be washed, and sterile gloves should be donned prior to replacing the inner cannula and the new gauze. During an interview on 2/29/24 at 9:05 AM, the Licensed Practical Nurse #4, Educator Facilitator, and Infection Control Preventionist, stated they do not train the staff on trach care, the respiratory therapist does the training, and that staff were trained yearly. During a telephone interview with the Respiratory Therapist on 2/29/24 at 11:21 AM, they stated that they would expect Licensed Practical Nurse #3 to remove the reusable inner cannula, clean the inner cannula, and remove the dirty gauze with clean gloves, remove dirty gloves, wash hands, and then put on sterile gloves. They stated that they do not teach the nurses to use sterile gloves throughout the entire procedure but to use clean technique and then sterile. They stated that clean gloves should be worn when removing the soiled gauze, cleaning the stoma, and while cleaning the inner cannula. They stated that sterile gloves should be worn when replacing the inner cannula and when applying the clean gauze around the stoma cite. During an interview on 3/1/24 at 12:26 PM, with the Director of Nursing and the Administrator present, the Director of Nursing stated that they were aware that Resident #51 had a history of respiratory infections. The Director of Nursing stated that training for trach care was completed by the respiratory therapist. The Administrator stated they would expect the Licensed Practical Nurse to review the policy and procedures prior to performing trach care. The Administrator and the Director of Nursing both stated that they did not know if the Licensed Practical Nurse #3 should have cleaned the stoma area and that they would have to review the policy and procedure for trach care. 10NYCRR 415.12(k)(4)

Based on observation, interview, and record review during the Standard survey completed on 3/1/24, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes. Specifically, the facility was not in compliance with Section 915 of the 2020 Fire Code of New York State, which requires carbon monoxide detection in buildings with fuel-burning appliances and on-going preventative maintenance of carbon monoxide detectors. This affected three (First Floor, Second Floor, Third Floor) of three resident use floors and the Basement. The finding is: Observations during the building tour on 2/26/24 from 9:40 AM until 3:00 PM revealed fuel-burning appliances were located in the Main Kitchen on the First Floor and the Laundry Room and Boiler Room in the Basement. Further observation revealed single-station carbon monoxide detectors were located in the Basement corridor and the First Floor corridor. Review of the carbon monoxide detector manufacturer's User Guide revealed to keep the alarm in good working order, test the alarm once a week by pressing the Test/ Reset button and vacuum the alarm cover once a month to remove accumulated dust. During an interview on 2/27/24 at 9:15 AM, the Maintenance Supervisor stated the facility had two carbon monoxide detectors with ten-year batteries which were tested monthly. The Maintenance Supervisor stated the monthly test included pressing the 'test' button, and it was not documented. During an interview on 2/29/24 at 12:45 PM, the Administrator stated the facility did not have a policy and procedure about maintaining carbon monoxide detectors. 42 CFR 483.70(b) 10NYCRR: 415.29(a)(2), 711.2(a)(1) 2020 Fire Code of New York State, Section 915: 915.3.1, 915.6

Based on observation, interview, and record review completed during the Standard survey conducted from 5/2/22 to 5/6/22 the facility did not ensure that residents who require [CONDITION(S)] receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #270) of one resident reviewed for [CONDITION(S)]. Specifically, the pressure dressing was not removed from the AV fistula (arteriovenous - a tube or device surgically implanted to create an artificial connection between an artery and a vein) access site for greater than two hours as recommended by the [CONDITION(S)] center. The finding is: The facility policy and procedure (P&P) titled Hemodialysis dated 1/14/15 documented the hospital supplies a Nursing Home/[CONDITION(S)] Communication sheet that is filled out and sent with the resident for every appointment. The hospital in turn completes their section and returns it after each visit. Upon return the nurse reviews the communication sheet and looks for any changes or new orders requested by the hospital. Upon return the nurse will check the site for any problems including bleeding or infection. Will determine that bruit and thrill are present in the shunt. The policy did not address care of the access site post [CONDITION(S)] related to the pressure dressings on shunt. 1. Resident #270 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-a resident assessment tool) dated 2/7/22 documented Resident #270 had moderately impaired cognition. Review of the MDS dated [DATE] documented the resident was on [CONDITION(S)]. The Care Plan (CP) dated 4/25/22 documented under under Resident #270 had [CONDITION(S)] and had [CONDITION(S)] at 5:30 AM Tuesday, Thursday, and Saturday. The Baseline CP (BCP) dated 4/25/22 documented the resident had a [CONDITION(S)] fistula in their left arm, and to monitor site post [CONDITION(S)] treatment (tx). The BCP interventions did not provide guidance for removal of the pressure dressing from the LUA AVF. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the electronic medical record (EMR) physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication and Treatment Records dated 4/2022 through 5/2022 lacked documented evidence of monitoring or pressure dressing removal from the LUA AVF. Review of Nursing Home/[CONDITION(S)] Communication dated 4/30/22 documented the [CONDITION(S)] unit used the fistula for [CONDITION(S)] access. Treatment comments contained an asterisk (*) and documented to please remove dressings from LUA access 2 hours after returning to facility. Intermittent observations of Resident #270 5/3/22 through 5/6/22 between 8:37 AM to 3:49 PM identified the following: -5/4/22 at 8:37 AM Resident sitting in wheelchair (w/c) in room pressure dressings intact to LUA AVF. Resident stated they goes to [CONDITION(S)] on Tuesday, Thursday, and Saturday and asked, are you going to take them off now? -5/4/22 at 1:10 PM Resident in room watching TV. Pressure dressings intact to LUA AVF. -5/4/22 at 3:15 PM Watching TV. Pressure dressings intact to LUA AVF. The resident stated, no one has taken them off yet. -5/5/22 at 3:49 PM Resident in room listening to TV. States had [CONDITION(S)] this morning. Pressure dressings intact to LUA AVF. The resident asked, are you here to take them off? -5/6/22 at 7:47 AM Pressure dressings intact to LUA AVF. The resident stated they don't go to [CONDITION(S)] today (5/6). I still have my dressings on my arm, they will take them off tomorrow when I go to [CONDITION(S)]. Review of Interdisciplinary (ID) Notes dated 4/25/22 through 5/5/22 documented the following: -4/30/22 5:26 PM Resident returned from [CONDITION(S)] this morning. No new orders received from [CONDITION(S)]. Pressure dressing to LUA AVF is dry and intact. -5/2/22 at 7:56 PM Fistula site remains without signs or symptoms of infection. Dry dressing remains in place. -5/3/22 at 11:33 AM Picked up for [CONDITION(S)] at 5:00 AM. -5/3/22 at 12:12 PM Returned from [CONDITION(S)] at 11:20 AM. -5/3/22 at 12:56 PM Pressure dressing dry and intact to LUA with no drainage noted. -5/5/22 at 10:50 AM Returned from [CONDITION(S)] at 10:35 AM without incident. Fistula left arm, pressure dressing intact. No complaints. -5/5/22 2:06 PM Pressure dressing in place LUA due to [CONDITION(S)]. There was no documentation regarding bleeding or dressing removal. During a telephone interview on 5/5/22 at 12:53 PM, Registered Nurse (RN) Charge Nurse at the [CONDITION(S)] Center stated the pressure dressings to Resident #270 LUA AVF were still on when the resident arrived for [CONDITION(S)] treatment today (5/5). The RN stated it happens often that when Resident #270 comes in the next day for treatment and the pressure dressings are still on the LUA AVF. The pressure dressing should be taken off about two to four hours after [CONDITION(S)] because they can cause damage to the fistula. The AVF site should be monitored for bleeding, signs of infection and there should be no blood pressures or blood draws in the left arm. During interview on 5/6/22 at 9:26 AM, Licensed Practical Nurse (LPN) #1 stated the AVF is monitored for infection, redness, thrill (a buzzing vibration felt by palpation) and bruit (whooshing sound of blood flow). LPN #1 stated the RN will assess the site when the resident returns from [CONDITION(S)] and the pressure dressing comes off two hours after they return from treatment. LPN #1 stated the RN was responsible for assessing the AVF and removing the dressing. During interview on 5/6/22 at 9:36 AM, RN #1 Nurse Manager stated when a resident returns from [CONDITION(S)] the AVF was to be monitored for bleeding, thrill and bruit. The bandage is left in place until we make sure it is not bleeding then it can be removed. RN #1 stated they would think any nurse could remove the pressure dressing but would have to double check policy. During interview on 5/6/22 at 11:30 AM, RN Supervisor #2 stated they reviewed the Nursing Home/[CONDITION(S)] Communication dated 4/30/22 when resident #270 returned from [CONDITION(S)]. Normally, most places leave the pressure dressings on for a couple of hours then remove gently. Any nurse can do it. I would think everyone knows they are to be left on for a bit until you make sure the shunt is not bleeding. It should be a standing order and be on the Medication/Treatment Record, so the nurse knows it has to be removed. It should be reflected on the CP as well. During interview on 5/6/22 at 10:48 AM, the Director of Nursing (DON), in the presence of the facility Administrator, stated the expectation was that if a resident on [CONDITION(S)] had a shunt with a pressure dressing in place it should be removed as recommended by [CONDITION(S)]. Additionally, any nurse could remove the presure dressing. 415.12

Based on observation, interview, and record review conducted during an Abbreviated survey (#NY 957), completed on 10/20/21, the facility failed to ensure appropriate use, entrapment risk assessment, and maintenance of bed rails for three (Resident #1, 6 and 7) of seven residents reviewed for bed rail use. Specifically, Resident #1 was assessed, and care planned not to use bed rails while in bed. Certified Nurse Aide (CNA) staff did not follow the care plan and put the bed rails (side rails) in the up position. The facility did not develop and implement a routine monitoring system to protect residents from entrapment risk when using various types of side rails. Additionally, the facility did not have a complete inventory of types of beds and rails currently in use. Subsequently, on 10/17/2021, Resident #1 was found sitting on the floor with their head wedged between the bed rail and the mattress, resulting in lacerations and abrasions of the face and finger. This resulted in Immediate Jeopardy/Substandard Quality of Care for Resident #1. The finding is: The facility policy and procedure (P&P) titled Side Rail Use dated 1/14/2015 documented the Registered Nurse (RN) shall conduct Side Rail Assessments, the RN shall write a risk/benefit statement using the information gathered by the assessment to determine side rails are not being used due to risk factors. The RN shall complete a care plan and CNA worksheet for residents assessed and found to be safe for using side rails. The policy did not include assessing entrapment risk or maintenance of side rails. The User Manual Resident LTC Bed from Hill-Rom provided by the Director of Environmental Services on 10/20/21 at 9:49 AM documented a safety tip and warning to evaluate patients for entrapment risk according to facility protocol and to monitor patients appropriately. Failure to do this this could cause serious injury or death. 1. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-resident assessment tool) dated 9/27/21 documented Resident #1 had moderate cognitive impairment, required extensive assistance of one person for transfers and bed mobility. The MDS documented the resident did not use bed rails. The Side rail assessment dated [DATE] at 2:39 PM documented Resident #1 had mild cognitive impairment, needed one assist for bed mobility and two assist for transfers. The resident was educated on the risk of injury including death, and zero (0)side rails were to be used. The Care Plan dated 9/20/21 documented Resident #1 was at risk for falls; had cognitive loss/dementia; required limited assisted of one person with use of arm rests, bed rail, or grab bar for transfers in and out of bed and did not use side rails (while in bed). The CNA Worksheet care plan for Friday 10/15/2021 (last revised 10/15/2021) documented side rails: none daily. Interdisciplinary Notes (IDT) dated 10/17/21 at 3:53 AM documented Resident #1 was found sitting on the floor with their head stuck between the bed and the side rail. The resident obtained a small laceration above their left eyebrow, two skin tears to their right side of cheek (2 centimeters (cm) x 2 cm) and a skin tear (2cm x 1cm) to their right-hand distal area of their thumb. Resident #1 complained of left hip pain. The provider was notified, and new orders were received for neurological checks every four hours for 24 hours and to obtain an x-ray of the left hip. IDT Notes dated 10/17/21 at 3:38 PM documented Resident #1 accepted Tylenol for discomfort and had bruising to their cheek and under their chin. The Resident Incident Report dated 10/17/21 at 3:30 AM documented Resident #1 had a fall in their room, injuries included lacerations and skin tears. The resident was found sitting on the floor with their head stuck between the bed and the side rail. The resident was trying to get out of bed to go to the bathroom. Review of an untitled report dated 10/17/21 completed by the Administrator documented the incident as staff's failure to follow the care plan that resulted in injuries. The after action plan included that an audit was put into place to compare closet care plan (guide used by staff to provide care) with actual care plan use, and a plan to educate staff on closet care plans (reading and reviewing). The action plan did not include an audit of bed rail safety or entrapments risk assessments. During an observation on 10/19/21 at 10:20 AM, Resident #1 was awake, lying in bed, appeared very thin and small framed. The resident was alert with confusion, had steri-strips intact to their left eyebrow and a scabbed area on their right hand. The resident was unable to state their name and could not remember how the injury to their head happened. During an interview on 10/19/21 at 11:38 AM, CNA #1 stated they were familiar with Resident #1 and every time they were assigned to Resident #1, the side rails were always in the up position. CNA #1 stated the resident was in bed when they arrived for their 11:00 PM -7:00 AM shift (10/16 into 10/17). At first rounds around midnight, the head of the resident's bed was elevated and there were 2 upper side rails in the up position. Around 2:30 AM CNA #1 stated they checked on Resident #1, who was still in bed with the side rails up and the resident denied needing any assistance. A few minutes before 3:00 AM CNA #1 stated they were taking care of another resident when the nurse came and said Resident #1 was on the floor with their head caught between the bed rail and the bed. CNA #1 went immediately to Resident #1's room and saw the resident trying to get their head out from between the mattress and the side rail. CNA #1 stated when Resident #1 was first admitted the CNA looked at the care plan but stated they did not look at the CCP (closet care plan) the night Resident #1 fell . CNA #1 stated that no one had ever told them the side rails should not be up and whoever put Resident #1 into bed, put the side rails up. CNA #1 stated they should have checked the CCP more often because it could have changed. During an interview on 10/19/21 at 12:15 PM, CNA #2 stated they were familiar with Resident #1 and that they were assigned to the resident on 10/16/21 for their shift, which started at 5:30 PM. CNA #2 stated Resident #1 didn't generally get out of bed during the shift. CNA #2 stated the upper side rails were in the up position when the resident was in bed that evening and that Resident #1's upper side rails were always up when the resident was in bed. CNA #2 stated they last checked on the resident about 10:00 PM and did not know Resident #1 was not supposed to use side rails. CNA #2 stated that nobody ever told them the resident wasn't supposed to have side rails. CNA #2 stated it was their fault because they didn't check the CCP and never thought to do so. CNA #2 added some residents were not care planned for side rails, but the rails were still on the bed, in the down position. During an interview on 10/19/21 at 5:48 PM, Licensed Practical Nurse (LPN) #1 stated they were familiar with Resident #1 and the resident's side rails were always up. At around midnight Resident #1 was lying in bed and thought the side rails were up. LPN #1 stated they saw the resident lying in bed at 2:00 AM, they got back from their break and sat at the desk for a while, then heard Resident #1 call out and went to their room. They found Resident #1 on the floor facing the door (right side of bed). The resident's back was against the bed, their buttock was on the floor and their chin was underneath the side rail. The side rail was holding Resident #1's head in between the bed and the rail and their neck was hyperextended. LPN #1 stated they checked Resident #1's care plan and they were not care planned for side rails. LPN #1 stated CNAs were supposed to check the closet care plans every day and nurses should check that the CNAs were following the closet care plan and safety sheets During an interview on 10/19/21 at 1:27 PM, the Physical Therapist (PT) stated they completed an admission screen for Resident #1. The resident transferred with limited assist of one person, was not ambulatory and did have side rails on their bed during the PT assessment. The PT stated the controls for the bed were located on the side rails, so the rail needed to be up to use the controls. The PT wasn't sure if Resident #1 was able to use the controls for the bed or if the staff had to do it for the resident. The PT stated Resident #1 did use the bed rail for transfers, but if they were just lying-in bed, the side rails should be down. The PT stated they had a couple different types of beds in the facility; some have smaller rails and others have ½ rails. The PT stared the therapy department doesn't do any measurements for side rails or mattresses (entrapment risk assessments) and if they found any loose rails, they would bring it to maintenance's attention. During an interview on 10/19/21 at 1:45 PM, the RN Unit Manager (UM) #1 (who completed Resident #1's side rail assessment) stated if a resident was not alert and oriented enough to know the safety risk of using a side rail, they did not use them. RN UM #1 stated some beds still have them on the frame even if they are not being used, it depended on the type of bed in the room upon admission. RN UM #1 stated there were times the rails were used for mobility/rolling in bed but then they should be put back down afterward by the staff member taking care of the resident. RN UM #1 stated Resident #1 would not be able to operate the bed controls independently and that staff could operate the bed with the side rails in the down position, but it was easier to have the bed rail up to push the control buttons. RN UM #1 stated staff would know if a resident was to use side rails because it was on the CCP and staff also get safety sheets (quick reference guide). The safety sheets were located at the desk, they were printed out daily for all shifts, and they have used them for years. The RN UM #1 stated Resident #1 was rarely out of bed and it was the responsibility of the CNA and the medication nurse to make sure the care plan was being followed. During an interview on 10/19/21 at 1:55 PM, RN UM #2 stated a lot of their beds had side rails because the bed controls were located within the rail, and some residents used side rails to turn and position. Residents that were not care planned to use side rails, the CNAs should put them back down. The nurse or UMs should make sure the care plan was being followed and implemented. The CNAs involved weren't reading the CCP as the resident had been care planned for no side rail when in bed since admission. Resident #1 should not have had their side rails up. RN UM #2 stated they had never done side rail checks or measurements (entrapment risk) and wasn't sure if maintenance had or not. During an interview on 10/19/21 at 2:15 PM, the Director of Nursing (DON) stated they didn't think anyone routinely checked side rails. During an interview on 10/19/21 at 3:06 PM, the Director of Environmental Services stated beds go through a regular inspection and they had a measurement device, which mimics a head. The Director of Environmental Services stated they didn't know the last time this type (entrapment risk) of audit was done as they had recently started working at the facility. The Director of Environmental stated they went through all their binders/papers but couldn't find anything for bed entrapment or side rail audits. During an observation on 10/19/21 at 3:13 PM the Director of Environmental Services completed an entrapment audit on Resident #1's prior bed (located in room [ROOM NUMBER]). The right-side rail was checked first and when the Director of Environmental Services touched the rail stated, this rail is in rough shape and I can tell this needs attention. The Director of Environmental Services stated they checked the four required zones, and the right rail failed 3 of the 4 zones. The Director of Environmental Services stated they were not happy with the right- side rail because it was looser than the left. The Director of Environmental Services stated they didn't know how many of those beds (bed with controls within the rail system) were in the facility, and that metal on metal would have natural wear and tear, and the bed was probably close to [AGE] years old. The Bed System Measurement Device Test Results Worksheet (for Resident #1's prior bed) dated 10/19/21 completed and provided by the Director of Environmental Services after the observation on 10/19/21 at 3:13 PM documented the bed assessment did not pass and the right- side rail failed zones 1 (open space between the parameters of the rail), 2 (under the rail between the mattress), and 4 (gap between mattress and the lowest portion of the rail). The left side rail failed zones 1, 2, 3 (the space between the inside surface of the bed rail and the mattress), and 4. Failure of zones 1, 2, 3 pose a risk of head entrapment, failure of zone 4 poses a risk of neck entrapment per FDA (Food and Drug Administration) guidance. During an interview 10/19/21 at 3:40 PM, the DON stated the facility did not have a documented list of type of beds (beds with the controls in the rail) and rails but would work on providing one. Review of the First Floor Shift Report A Side; First Floor Shift Report B Side; 2nd Floor Shift Report, and 3rd Floor Q Shift Side Rail Audit documents provided by the DON on 10/19/21 at 4:15 PM, documented there were 27 residents who were not care planned to use side rails but had the type of bed where the bed control was located on the side rail. Review of the First Floor Shift Report B Side list documented Resident #6 had the type of side rails that the bed controls were within the rail. During an observation on 10/19/21 at 4:20 PM Resident #6's bed did not have side rails. Review of the First Floor Shift Report A Side list documented Resident #7 had the type of side rails that the bed controls were within the rail. During an observation on 10/19/21 at 4:23 PM Resident #7's bed did not have side rails. During an interview on 10/19/21 at 4:17 PM, the Administrator stated they didn't know how many different types of side rails were used in the facility. At 4:28 PM, the Administrator stated a basic overall assessment of each bed, such as motor mechanics and operation was done bi-annually, but they did not document these assessments and the Administrator did not know if the basic assessment included side rail safety and entrapment risk. The Administrator stated that there was no facility policy on the maintenance and safety/entrapment assessments of side rails. During an interview on 10/19/21 at 4:18 PM, the DON stated they thought 4 different types of rails were used within the facility. One type was ¼ assist rails, and the other three were ½ side rails. The DON stated this type of rail (referring to Resident #1's prior bed) cannot come off the bed because of the controls for the bed, and they still had a lot of them left in the facility. The DON stated on the list they provided, the starred residents had the same type of bed as Resident #1, where the controls were located on the side rails. During an interview on 10/19/21 at 5:48 PM, Licensed Practical Nurse (LPN) #1 stated they were familiar with Resident #1 and the resident's side rails were always up. At around midnight Resident #1 was lying in bed and thought the side rails were up. LPN #1 stated they saw the resident lying in bed at 2:00 AM, they got back from their break and sat at the desk for a while, then heard Resident #1 call out and went to their room. They found Resident #1 on the floor facing the door (right side of bed). The resident's back was against the bed, their buttock was on the floor and their chin was underneath the side rail. The side rail was holding Resident #1's head in between the bed and the rail and their neck was hyperextended. LPN #1 stated they checked Resident #1's care plan and they were not care planned for side rails. LPN #1 stated CNAs were supposed to check the closet care plans every day and nurses should check that the CNAs were following the closet care plan and safety sheets. During an interview on 10/19/21 at 6:27 PM, the DON stated Resident #1's side rails should not have been up. The CNAs should have followed the resident's care plan and the safety sheets, and that anyone going into the room should have checked that the care plan was followed. During an interview on 10/20/21 at 11:10 AM, the Administrator stated the CNAs didn't follow the care plan, and it was considered a failure to follow the care plan resulting in injuries. The Administrator stated there were no audits of beds with side rails that could not be removed and no audits to check residents who were care planned not to use side rails to ensure they didn't have them in the up position. During further interview at 1:35 PM, the Administrator stated they had no specific policy for closet care plans or safety sheets. During an interview on 10/20/21 at 2:15 PM, the Medical Director stated they saw Resident #1 upon their admission and was not involved with determining who needed side rails. The Medical Director stated if the care plan said no side rails, they never should have been up, and all staff were to follow the care plan. Additionally, the Medical Director stated they would expect entrapment assessments to be part of the routine maintenance of side rails since they had the equipment in the building but didn't know the facility policy regarding entrapment checks. 10NYCRR 415.12 (h)(1)

Based on interview and record review conducted during an abbreviated survey (#NY 957) completed 10/20/21, the facility did not ensure a quality assurance and performance improvement (QAPI) program that put forth good faith attempts to identify and correct quality deficiencies as well as opportunity for improvement. Specifically, the facility did not identify the lack of development and implementation of a routine monitoring system to protect residents from entrapment risk when using various types of side rails. Additionally, the facility did not have a complete inventory of types of beds and rails currently in use. This involves Resident #1, 6 and 7. Refer to F 700-Bedrails The finding is: Review of the facility policy and procedure (P&P) titled Quality Assurance Performance Improvement (QAPI) Program and Committee dated 11/2/2018 revealed the facility would conduct an ongoing evaluation of all services provided to residents in order to ensure Quality Care and Qualify of Life. The QAPI team will be chaired by the Administrator and will consist of representatives from all departments including Director of Environmental Services. Current findings will be presented, reviewed, and discussed by the team. The team will monitor results and report at regularly scheduled meetings. Any report of findings, recommendations, and follow up will be reported to the QAPI committee at regularly scheduled quarterly QAPI Committee (CQI) meetings or on an as needed basis. 1. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-resident assessment tool) dated 9/27/21 documented Resident #1 had moderate cognitive impairment, required extensive assistance of one person for transfers and bed mobility. The MDS documented the resident did not use bed rails. The Side rail assessment dated [DATE] at 2:39 PM documented Resident #1 had mild cognitive impairment, needed one assist for bed mobility and two assist for transfers. The resident was educated on the risk of injury including death and zero (0) side rails were to be used. The CNA Worksheet careplan for Friday 10/15/2021 (last revised 10/15/2021) documented side rails: none daily. The Resident Incident Report dated 10/17/21 at 3:30 AM documented Resident had a fall in their room, injuries included lacerations and skin tears. The resident was found sitting on the floor with their head stuck between the bed and side rail. Resident was trying to get out of bed to go to the bathroom. Recommendation included removal of side rails. Review of an untitled report dated 10/17/21 completed by the Administrator documented the incident as staff's failure to follow the care plan that resulted in injuries. The after action plan included that an audit was put into place to compare closet care plan (guide used by staff to provide care) with actual care plan use, and a plan to educate staff on closet care plans (reading and reviewing). The action plan did not include an audit of bed rail safety or entrapments risk assessments. During an interview 10/19/21 at 3:40 PM, the DON stated the facility did not have a documented list of type of beds (beds with the controls in the rail) and rails but would work on providing one. Review of the First Floor Shift Report A Side; First Floor Shift Report B Side; 2nd Floor Shift Report, and 3rd Floor Q Shift Side Rail Audit documents provided by the DON on 10/19/21 at 4:15 PM, documented there were 27 residents who were not care planned to use side rails but had the type of bed where the bed control was located on the side rail. Review of the First Floor Shift Report B Side list documented Resident #6 had the type of side rails that the bed controls were within the rail. During an observation on 10/19/21 at 4:20 PM Resident #6's bed did not have side rails. Review of the First Floor Shift Report A Side list documented Resident #7 had the type of side rails that the bed controls were within the rail. During an observation on 10/19/21 at 4:23 PM Resident #7's bed did not have side rails. During an interview on 10/20/21 at 11:00 AM, the DON stated they attended monthly QA meetings and the facility had not identified anything through that process regarding side rails. The DON stated they used historical events for topics to be discussed and at their next meeting, side rails will be involved along with following the care plan. During an interview on 10/20/21 at 11:10 AM, the Administrator stated they have quarterly CQI meetings along with monthly PIP (Performance Improvement Project) committee meetings. The PIPs focused on troubled areas. The Administrator stated the issues of not following the care plan or side rails haven't been discussed in their QA meetings. The Administrator stated no maintenance staff attended the quarterly CQI and PIP meetings and they didn't know the reason. The Administrator stated it would make sense to have all directors at the meeting. The Administrator stated they have attended monthly safety committee meetings since August of 2019, where they talk in-depth about safety concerns with equipment in the building, and side rails had never been discussed. During an interview on 10/20/21 at 2:08 PM, the Vice President (VP) of Quality and Clinical Operations stated they attended quarterly QA meetings at the facility since the 2nd quarter of this year and could not think of anything specific about side rails being discussed. During an interview on 10/20/21 at 2:15 PM, the Medical Director stated they attended quarterly QA meetings. The Medical Director stated they would expect entrapment assessments be part of the routine maintenance of side rails since they had the equipment in the building but didn't know the facility policy regarding entrapment checks. The Medical Director stated side rails were not routinely talked about in QA meetings and that staff were expected to follow the care plan. 10NYCRR 415.27(a-c)

Based on interview and record review during the Standard survey completed on 4/26/19, the facility did not implement written policies and procedures for screening employees that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not provide documentation that verified one (Employee #1) of six employees who were subject to the New York State Nurse Aide Registry had been screened through the New York State Nurse Aide Registry prior to their employment. The finding is: Record review on 4/23/19 of the personnel file for Employee #1 (Dietary Aide) revealed Employee #1 was hired on 10/2/18 and the New York State Nurse Aide Registry Verification Report was dated 4/23/19. Further review revealed Employee #1 worked in the facility a total of 515 hours between 10/2/18 and 2/13/19 before the New York State Nurse Aide Registry was checked on 4/23/19. Additional review of the personnel file revealed Employee #1 received a negative determination letter from the New York State Criminal History Record Check (CHRC) system dated 2/12/19, and also a letter dated 3/29/19 stating the negative determination had been reversed. During an interview on 4/23/19 at 1:55 PM, the Director of Human Resources stated she usually checks the New York State Nurse Aide Registry for new employees at the time she calls them to schedule a job interview. She additionally stated she could not locate the Nurse Aide Registry verification sheet for Employee #1, so she printed one today from the Registry website. Continued interview revealed Employee #1 last worked at this facility on 2/13/19, but remains a current employee. Review of the Dietary Aide job description, signed by Employee #1 on 10/2/18 revealed the following essential position functions: delivers food carts and prepared meals to resident dining rooms, ensures carts are returned to the kitchen, may be responsible for assisting in serving the meals to residents, collects and removes trash, and delivers nourishments to nursing units and/or resident rooms as required. Review of the facility's document called Hiring Policy and Procedure, dated 8/1/18, revealed all employees, agency staff, contracted staff, medical director, consultants, contractors, volunteers, nurse aide trainees, students, and any caregiver who provides care and services to residents on behalf of the facility, will be screened through the New York State Nurse Aide Registry. 415.4(b)(1)(ii)(a)(b)

Based on interview and record review conducted during the Standard Survey completed on 4/26/19, the facility did not ensure that alleged violations involving abuse are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the officials (State Survey Agency) in accordance with State Law as required for two (Residents #108, 113) of two residents reviewed for alleged abuse. Specifically, the facility did not report an incident of resident to resident verbal abuse to the state survey agency as required. The finding is: Review of a facility policy and procedure entitled Resident Abuse Prohibition Protocol dated 7/8/18 revealed the purpose of this policy is to establish a mechanism for educating all responsible parties, and to create a procedure for reporting and investigating all allegations of resident neglect, mistreatment and abuse. Resident to Resident Abuse must be reported to the Department of Health if another resident is mentally or physically harmed by the aggressor. Verbal Abuse must be reported immediately if it puts the Resident in fear of harm. Abuse - According to CMS guidelines means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Verbal abuse: yelling, threatening, belittling, making rude or sarcastic remarks (whether the resident actually hears or even is incapable of hearing). 1. Resident #108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 3/27/19 revealed the resident is severely cognitively impaired, is understood and usually understands. Resident #113 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident is cognitively intact, understood and understands. Review of a Resident Incident Report (for Resident #108) dated 2/16/19 at 1:50 PM revealed the resident was accused of threatening her roommate Resident #113. Resident #108 did not deny the accusation. No physical contact was made. The physician and family were notified. Recommendations were made to change the resident's room. Statement taken from Resident #108 revealed I can recall no specific event from last night. But there is always something between us. Resident #113 is a nice lady and is always doing something nice for others, but we are different people. When specifically asked if she threatened her, Resident #108 stated, Probably, I say probably because we both have said things to one another. We were good friends, but not anymore. A Resident Incident Report (for Resident #113) dated 2/16/19 at 1:40 PM revealed Resident #113 claimed that Resident #108 threatened her on the evening of 2/15/19 with a reacher and no physical contact was made. The physician and family were notified. No injury and vital signs were taken. A statement obtained from Resident #113 revealed she walked into the room and was undressing near the glass cabinet and told Resident #108 she was going to shut off the lights to go to bed. Resident #108 from her wheelchair began shaking the reacher and yelling at Resident #113. Resident #113 got in bed without incident. Resident #113 stated, I'm afraid to stay here with her. Resident #108's comprehensive Care Plan (CCP) for behavior dated 3/4/14 documented she exhibits occasional episodes of agitation, can be verbally and physically aggressive towards staff. [DIAGNOSES REDACTED].#108 has behavior issues related to [DIAGNOSES REDACTED]. Can be verbally and physically aggressive towards staff and others. 2/16/19 - verbal disagreement with Resident #113. Resident #113's CCP dated 3/28/19 documented the resident has behavior issues related to a [DIAGNOSES REDACTED]. 2/16/19 - verbal disagreement with Resident #108. Will be easily redirected from Resident #108 and room change made for Resident #108. Review of Interdisciplinary Notes for Resident #13 revealed the following: - 2/16/19 at 6:07 AM - Alert and oriented, explained to writer that roommate had taken her grabber and was shaking it in her face. Resident #113 is very weepy, complaining about roommate and back pain. Refuses to take shower this morning reporting that roommate kept her awake. - 2/16/10 at 2:26 PM - Resident (#113) refused all AM (morning) medications and treatments related to not moving roommate out of room. Resident was crying all morning saying roommate was being mean to her and wanted her roommate moved out of the room. Roommate refused staff to bring her out of room. Supervisor aware and issues are being looked into. - 2/16/19 at 2:50 PM - Statement obtained (from Resident #113) regarding threatening behavior from roommate. Roommate moved at this time for safety of both. Administrator aware of incident and recommended moving roommate out at this time. Son notified of incident. - 2/18/19 at 10:32 PM - Resident #113 discussed the altercation with her roommate over the weekend. She stated that her roommate came after her with her grabber. Resident #113 was upset saying, I've never been anything but nice to her and this is how she treats me. She stated that it scared her. Roommate was relocated and will not return to the room. Review of an untitled report of the investigation, completed by the Assistant Administrator, dated 2/18/19 revealed the following: - On 2/16/19, it was reported that a verbal altercation occurred between Resident #108 and Resident #113. - Per Resident #113's statement, on 2/15/19 at approximately 8:45 PM, Resident #108 shook her grabber at Resident #113 and yelled at her. Per interview with Nurse Supervisor, Resident #113 stated Resident #108 was threatening her and she was afraid to stay in the room with her. - Per Resident #108 interview with Nurse Supervisor, she states that she couldn't recall events of the evening prior but also didn't deny threatening Resident #113. - Per Resident #113, no physical contact was made. Upon report of the event, Resident #108 was moved to another room temporarily to avoid further conflict during the investigation. Additional review of the untitled investigation revealed the Assistant Administrator documented with further investigation of this incident it was agreed that the action of Resident #108 was not aggressive and there was no intent of harm. This event was reviewed with Director of Nursing and Administrator; hence this incident was not reported to NYSDOH (New York State Department of Health). Review of a Social Work Interdisciplinary Note dated 2/18/19 revealed Resident #108 was moved to another room on Saturday 2/16/19 after getting into an altercation with her roommate. Per the roommate's report, Resident #108 became angered and came at her with a grabber. Staff notes that verbal conflict between the roommates has been evident but neither wanted to move and they would eventually forgive each other. It was explained to son that current room was temporary and offered another long term semi-private room which would allow the resident to remain on the first floor. Son was told that the roommate in the semi-private room isn't as verbal and shouldn't distract or aggravate his mother. Review of a Physician Interdisciplinary Note for Resident #108 dated 3/6/19 revealed there was a room change due to an altercation with her roommate. There was no physical contact, but the other resident said she went after me with a reacher. There were no other witnesses to the event. During an interview on 4/25/19 at 1:51 PM, Resident #113 stated she entered the room and told her roommate (Resident #108) she was going to turn the lights off. Resident #108 began shaking her grabber at Resident #113 saying I am going to hit you, you son of [MEDICATION NAME]. Resident #113 stated she was so scared and screamed. Resident #113 stated she was really scared and when she sees this resident in the hallway she is still afraid of her. During an interview on 4/25/19 at 2:51 PM, the Assistant Administrator stated, I believe we did not report this incident to the NYSDOH because there was no physical contact and Resident #113 did not report the incident until the next morning. Resident #108 was moved to another room during the investigation. When asked why Resident #108 was not moved back to the room if the facility felt that there was no issue, no answer was given. When interviewed on 4/25/19 at 2:51 PM, the Administrator stated, They were roommates and squabbled often. Resident #108 was across the room when she shook the grabber at her, but I do not think she could have physically hit her with it. Staff called me on the day it was reported, and I did have them move Resident #108 to another room until we could do an investigation. 415.4(b)(4)

Based on observation, interview, and record review conducted during the Standard survey completed on 4/26/19, the facility did not ensure that a resident who is unable to carry out Activities of Daily Living (ADLs) receives the necessary services to maintain grooming, personal hygiene. Specifically, one resident (Resident #95) of three residents reviewed who are dependent on staff for ADL's had an issue with incomplete urinary incontinence care. The finding is: The policy and procedure (P&P) entitled Care of the Incontinent Resident, dated 10/14 documented it was the facilities policy to keep the resident with problems of involuntary elimination, clean and dry in order to promote cleanliness, comfort, dignity and to prevent skin issues. The P&P entitled Peri Care dated 1/16 documented for the female resident use soap and water. Separate the female external genitals and wash from front to back (away from the urinary meatus (the point where urine exits the urethra) with the washcloth. Using a different part of the wash cloth for each swipe, begin with a swipe down the middle and then one on each side of the external genitals. Then wash the groin using a different area of the washcloth. With a clean washcloth, rinse the area in the same manner and dry thoroughly. 1. Resident #95 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 4/3/19 documented the resident had severe cognitive impairments, was usually understood and usually understands. The MDS also documented the resident required extensive assist of two people for personal hygiene and was always incontinent of bowel and bladder. The Comprehensive Care Plan (CCP) dated 4/22/19 documented the resident required total assist of two for toilet transfers and change in bed. The CCP further documented the potential for frequent UTI's, and occasional urinary incontinence. During an observation of morning care on 4/24/19 at 8:40 AM Certified Nurse Aide (CNA) #1 removed a soiled incontinent brief containing a moderate amount of yellow urine. CNA #1 washed the pubic bone (area of the body between the lower abdomen and genitalia) with a washcloth and then proceeded to wash the right and left groin. CNA #1 did not wash the external folds of female genitalia. During an interview on 4/24/19 at 9:43 AM CNA #1 stated the procedure for peri care included swiping down the right and left side of the (external folds of female genitalia) and then down the center after folding sections of the washcloth, so each swipe is done with a clean portion of the washcloth and would rinse the same way. CNA #1 stated he stays away from the lady parts and typically would ask a female co-worker to take over but did not. During an interview on 4/25/19 at 10:07 AM, Registered Nurse (RN) #1 Unit Manager stated she would expect the (external folds of female genitalia) to be separated and washed down the middle, then the sides of the (external folds of female genitalia) with a soapy washcloth and would expect the same procedure for rinsing. During an interview on 4/25/19 at 10:44 AM, RN #3 stated the expectation was to wash using a soapy wash cloth, make three swipes from front to back. First down each side and then the middle of the (external folds of female genitalia) using a different section for each swipe to prevent urinary tract infections. During an interview on 4/26/19 at 9:02 AM, the Director of Nursing (DON) stated peri care was expected to be done properly and efficiently to prevent urinary tract infections and eliminate odors. 415.12(a)(3)

Based on observation, interview, and record review completed during the Standard survey completed on 10/26/17, the facility did not ensure that the resident has the right to reside and receive services in the facility with reasonable accommodations of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. Two (Residents #62 and 92) of twenty-one residents reviewed for accomdations of needs did not have a mattress of the appropriate width to adequately accommodate the residents while in bed. In addition, the combined weight of the residents exceeded the manufacturers weight limit for the mattress. Review of policy and procedure entitled Privacy, dated 9/23/09 revealed the resident has the right to share a room with his/her spouse, relative or partner when the spouse, relative or partner lives in the same facility and both consent to the arrangement. Review of manufacturer specifications for the premium therapeutic foam mattress utilized on the bed in Resident #62's room revealed a weight capacity of 400 pounds. The findings are: 1. Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 9/13/17 revealed the resident is moderately cognitively impaired, understands and is understood. Review of a Profile Face Sheet for Resident #62 revealed the resident resides in a private room and is married to Resident #92. Review of Fall Risk Assessment Form dated 9/13/17 revealed the resident is at high risk for falls. Review of a Resident Incident Report dated 10/5/17 the report documented that included the following: - Resident rolled out of bed, lying on right side on floor. Prior to fall resident was lying in bed with her husband. Recommend a wider bed. - Resident Statement: I rolled over and fell out of the bed. The bed is too narrow - Recommendations: Spoke with resident about being cautious in bed with her husband. Has the widest bed available in the facility at this time. Review of Interdisciplinary Notes, dated 9/28/17 included a weight of 212.6 pounds. Resident #92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact, understands and is understood. Review of Fall Risk Assessment Form dated 8/2/17 revealed the resident is at moderate risk for falls. Review of Interdisciplinary Notes, dated 10/23/17 included a current weight of 200.2 pounds. Review of a Profile Face Sheet for Resident #92 revealed the resident resides in a semi-private room and is married to Resident #62. Observation of Residents # 62 and 92 on 10/22/17 at 11:20 AM revealed both residents lying in bed together. Resident #92 was partially out of the bed as there was not enough width to the mattress to accommodate both residents. Interview with Residents #62 and 92 on 10/22/17 at 11:25 AM revealed both residents have complained of the bed being too narrow for both of us. Interview with Certified Nurse Aide (CNA #5) on 10/25/17 at 9:42 AM revealed, Resident #92 spends most nights in Resident #62's room. In addition, Resident #62 used to have a smaller bed, the facility did provide a larger bed but Resident #62 still complains the bed is too small for her and her husband. Interview with the Social Worker on 10/25/17 at 11:33 AM revealed Resident #92 a lot of times spends the night in Resident #62's room. In addition, the Social Worker stated that she has addressed the size of the bed Resident #62 and 92 are sharing with the Administrator and the Registered Nurse (RN) Director of Nurses (DON) as they could benefit from something (mattress) wider. Interview with CNA #3 on 10/25/17 at 11:51 AM revealed Resident #92 usually spends the night in Resident #62's room. Interview with the RN Nurse Manager #3 on 10/25/17 at 11:54 AM revealed, Resident #62 and 92 spend most nights together. I can see the bed being a little tight for the two of them. They have the widest bed we have available here. Interview further revealed the RN Nurse Manager was not aware of the mattress weight limits. Interview with the RN DON on 10/25/17 at 1:43 PM revealed Resident #62 has the largest bed available in the building. The DON further stated he was unsure if the mattress was designed for two people or if the combined weights of Residents #62 and 92 exceeded the mattress weight limit. Interview with the manufacturers of mattress, RN Clinical Support Manager on 10/26/17 at 12:38 PM revealed, the mattress Resident #62 and 92 are sharing is designed for single person use. In addition, the recommended manufacturer weight limit of the mattress is four hundred pounds. 415.5(e)(1)

Based on observation, record review and staff and resident interview, the facility did not ensure that a resident who is incontinent of bladder receives appropriate treatment and services to restore as much normal bladder function as possible. One (Resident #153) of three residents reviewed for Foley catheters (tube inserted into the bladder to drain urine) had issues involving the ongoing use of a Foley catheter without documentation of medical justification for continued use. The resident had an indwelling Foley catheter for ten months following admission. There were no attempts to remove the catheter. The resident had multiple urinary tract infections (UTIs) and sustained a lateral urethral slit (an extended slit in the skin originating from the external opening of the urinary tract). This resulted in actual harm that is not immediate jeopardy. The findings are: 1. Resident #153 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident is cognitively intact and has no behavior issues. Additional review of the MDS revealed the resident had an indwelling catheter. The medical record Profile Face Sheet documented that the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Review of a hospital Discharge Summary dated 3/10/11 revealed the resident's discharge [DIAGNOSES REDACTED]. Review of an Addendum to an Admission H&P (History and Physical), documented in the Interdisciplinary Notes by the Nurse Practitioner (NP) and co-signed by the Physician dated 3/16/11 revealed the resident had a Foley catheter. Review of Physician order [REDACTED]. Review of Physician Notes, documented in the Interdisciplinary Notes, dated 5/2/11 through 12/15/11 revealed the resident had a long term Foley catheter with intermittent bleeding around the catheter related to "tugging" or pulling. Review of a Urology Consult dated 5/19/11 revealed the resident was seen due to drainage from the male genitalia. The Consult documented that the resident had a catheter and it was unknown how long the catheter had been present. Additional review of the Consult revealed the resident had unspecified [MEDICAL CONDITION], a penile erosion due to the catheter and a large size opening in the urethral meatus (external opening leading from the bladder to discharge urine from the body). Review of Microbiology Laboratory Reports dated 6/26/11 through 1/12/12 revealed the resident had positive urine cultures as follows: - 6/5/11 - Yeast < (less than) 10,000 cfu/ml - 6/26/11 - [DIAGNOSES REDACTED] pneumoniae (type of bacteria) > (more than) 100,000 cfu/ml. Pseudomonas aeruginosa (type of bacteria) > 100,000 cfu/ml. - 1/12/12 - Klebsielle pneumoniae > 100,000 cfu/ml. Review of a physician's orders [REDACTED]. Review of a physician's orders [REDACTED]. Review of the "Comprehensive" Care Plan (CCP) dated 12/22/11 revealed that the resident had a history of [REDACTED]. The CCP documented that the resident has an indwelling Foley catheter for [MEDICAL CONDITION]/ [MEDICAL CONDITION]. Review of a physician's orders [REDACTED]. Review of a Nursing Interdisciplinary Note dated 1/12/12 revealed the resident returned from the hospital at 12:00 noon with new orders for an antibiotic. Review of a Physician order [REDACTED]. Review of physician's orders [REDACTED]. During an interview on 1/24/12 at 10:22 AM, the Licensed Practical Nurse (LPN) Nurse Facilitator stated that Resident #153 has a Foley catheter for retention. Observations on 1/24/12 at 9:59 AM and 1/25/12 at 12:09 PM revealed the resident was sitting in a Geri chair and had a Foley catheter connected to a urinary drainage bag, which was attached to the side of the chair. During an interview on 1/26/12 at 10:37 AM, the NP stated the resident cannot "go" without the Foley, however she would have to look back through the resident's previous medical record to know why. The NP stated there has been no attempt to remove the Foley catheter since the resident was admitted to the facility on [DATE]. During an interview on 1/26/12 at 10:43 AM, the resident stated he has had the Foley catheter since he returned from the hospital (3/10/11). The resident stated that the catheter "tore" the end of his male genitalia and he has asked if it could be taken out. The resident stated he asked the evening LPN if the catheter could come out and he was told "no". The resident explained that the catheter causes him discomfort when it gets pulled. He pointed to his left leg and stated "I have a band on my leg and when I pull the band on my leg up, it takes the pressure off the penis". The resident stated he has not been back to see the Urologist but did go to the emergency room and was seen by a Physician Assistant (PA) in 1/12 because he had bleeding from the catheter. During an interview on 1/26/12 at 11:00 AM, the NP stated she reviewed the resident's previous medical records and there is no documentation in the previous or current admission regarding why the resident has a Foley catheter. The NP stated she did not record the reason for the Foley catheter in her admission note dated 3/16/11. The NP stated she "lost track" of the Foley and she cannot defend why the resident has the Foley. The NP stated the resident was admitted with the Foley and she "did not follow through". The NP stated there was no documentation that she had discussed the risks and benefits of the Foley with the resident. The NP stated should have taken the Foley out to see if the resident could void and has not done that. During the interview, the NP stated that Resident #153 has had a lot of UTIs and bleeding from the Foley and the resident's "mental changes (in the past) probably go along with the UTI's". The NP stated she is aware that the resident has "irritation and bleeding" around the Foley but was not aware that the resident's urethral meatus is slit. When interviewed on 1/26/12 at 12:34 PM, the Registered Nurse (RN) Nurse Manager revealed she was not aware of the urethral meatus slit. During an observation on 1/26/12 at 12:37 PM, the NP removed the resident's brief and the Foley catheter tubing was observed to be pulled taut. The NP removed the Foley catheter from the leg strap around the resident left thigh and stated "they did not leave much room". The NP was observed to examine the resident and stated there was a 1/2 inch (") slit in the male genitalia. The skin at the base of the slit was observed to be reddish purple. The NP informed the resident that she would remove the Foley catheter and do an ultrasound (a diagnostic imaging method using high-frequency sound waves) to see if the bladder empties. The NP asked the resident if he would see the Urologist and the resident agreed. Review of a Special Visit Note, written by the NP, dated 1/26/11 revealed the resident complained of soreness at the tip of the male genitalia and a 2.0 centimeter (cm) lateral slit was observed from the right side of the urethra to the right side of the male genitalia. During an interview on 1/26/12 at 12:49 PM, the certified nurse aide (CNA) assigned to the resident, stated she provided Foley care to the resident today and noticed the slit on his male genitalia but she did not tell anyone about it because she thought the nurse already knew. When interviewed on 1/26/12 at 12:54 PM, the resident stated he has had the slit on his male genitalia for a couple of weeks. The resident stated he told a CNA, but could not remember who it was. During an interview on 1/27/12 at approximately 11:00 AM, the Administrator stated Resident #153 should have been assessed upon admission for the continued use of the catheter. 415.12(d)(1)