Every finding on record at Highland Rehabilitation And Nursing Center

Based on record review and interviews, the facility failed to ensure the right to receive written notice, including the reason for the change, before the resident's room in the facility is changed for one of one resident (Resident #98) reviewed for room change. Specifically, there was no documented evidence that Resident #98 and/or their Representative were provided written notification prior to Resident #98's room change from a private room on the third floor to a semi-private room on the second floor. The findings include:The policy titled Room Change revised 01/2022, documented that all changes will be carried out with appropriate communication, coordination, and safety measures to ensure residents' well-being. Prior to changing room or roommate assignment, all parties involved in the change/assignment, residents and their representatives, will be notified.Resident #98 had diagnoses including diabetes mellitus, Parkinson's disease, and gastric cancer.The facility census log revealed that on 03/23/2025, Resident #98 had been readmitted and was in room [ROOM NUMBER]-S, a private room on the third floor. On 04/16/2025, Resident #98 was moved to a semi-private room, 208-D, on the second floor.The Progress Note dated 04/16/2026 written by the Director of Social Work documented that Resident #98 had a room change from 305-S to 208-D. The Administrator spoke with the resident prior to the move, and the resident agreed to the room change. Follow up as needed to ensure a smooth transition.There was no documented evidence in Resident # 98's electronic record to indicate that Resident #98's Representative was made aware of the room change to a semi-private room on the second floor.The quarterly Minimum Data Set (a resident assessment tool) dated 04/24/2025 documented that Resident # 98 had moderate cognitive impairment.During a telephone interview on 07/10/2026 at 09:08 AM, Resident #98's Representative stated that the Director of Social Work did not provide a reason for the move and that no paperwork was signed for the resident to be moved. They stated the Administrator informed Resident #98 that relocation would be possible, but the resident did not want to be moved. The Representative stated they visited and were told that Resident #98 had moved to the second floor. They stated Resident #98 was alert and oriented and was moved away from friends on the third floor and placed on a floor with residents that had behavior issues. During an interview on 07/13/2026 at 3:03 PM, the Director of Social Work stated Resident #98 was notified of a room change by a former Administrator. The Director of Social Work stated they were present when the former Administrator informed Resident #98 about the room change. They stated that this was not the normal process, and that the usual practice involved informing residents first about a room change, then reaching out to a family member, followed by documentation in the residents' chart. They stated they did not inform Resident #98's Representative about the room change. They stated Resident #98 informed their family about the move.10 New York Code Rules Regulations 415.3

Based on record review and interview the facility failed to ensure each resident was free from verbal and/or physical abuse and/or that supervision was provided to prevent abuse for one of three residents (Resident #24) reviewed for abuse. Specifically, on 02/19/2026 Resident # 93 walked over and grabbed Resident # 24 by the arms and legs when Certified Nurse Aide # 32 left the two residents in the common area unsupervised to obtain coffee from the kitchen for Resident #24 and on 04/07/2026, Resident #24 was involved in a verbal altercation with Resident #92 which resulted in Resident #92 throwing a cup of liquid at Resident #24. The findings include: The Policy for abuse prevention last reviewed 08/2020, documented that the facility is committed to providing residents with an environment that is free from verbal, mental and physical abuse, mistreatment, and neglect. Identify residents whose personal histories and diagnoses render them at risk for abusing other residents. Develop strategies to prevent recurrences and monitor for changes that would trigger abusive behavior. Resident #24 had diagnoses that included bipolar disorder, dementia and generalized anxiety. The Care Plan for potential for physical abuse dated 05/06/2025 for Resident #24 documented the resident will not be harmed by others. 08/17/2025 analyze time of day, place, triggers and what deescalates behavior. Ensure safety of the resident.The annual Minimum Data Set (a resident assessment tool) dated 02/01/2026 documented Resident #24 had moderately impaired cognition. The Investigation Summary Report dated 02/19/2026 documented that at approximately 7:00 AM, Resident #93 was ambulating around the unit when they overheard Resident #24 saying Look at her, Look at her to the other residents. Resident # 93 stated that they were telling Resident #24 to stop with their mouth, but they would not stop. Resident # 93 felt they were being targeted by Resident #24, therefore; Resident # 93 walked over and hit Resident # 24. During the altercation, Resident # 93 grabbed Resident # 24 by the arms and legs until staff could separate the residents. Both residents were separated, and a head-to-toe examination was done. Resident # 24 sustained a superficial scratch to their right forearm, and no injuries were noted to Resident # 93. Resident # 93 was transferred to another unit to prevent further interactions with Resident #24. The facility findings and root cause analysis documented that Resident # 24, and their diagnosis of dementia was unable to control their behavior and impulses. Their verbalization about other residents was something that they could not control due to their cognitive impairment. The physical altercation between the residents was substantiated. The Nursing Progress Note dated written by Licensed Practical Nurse #33 dated 02/19/2026 documented during medication administration the writer overheard residents yelling. As they got closer this writer heard the residents yelling louder. When they approached, they noticed the Resident #93 holding Resident #24's legs. Writer was able to get Resident #93 to let go of Resident #24's legs. The Care Plan Note dated 02/19/2026 at 10:12 PM written by Registered Nurse Unit Manager # 1 documented at approximately 7:03 AM, the writer was called to the common area to assess Resident # 93 after an altercation with Resident #24. Resident # 93 was asked what happened and stated since 5 AM, I have been walking around and the other resident continuously kept saying look at her, look at her to the other residents. I tried to tell her to stop with her mouth, she did not, so I hit her. The Care Plan for potential for abuse was updated on 02/19/2026 to include staff will closely monitor the resident when in the common area with other residents and encourage appropriate verbal interactions with others. During an interview on 07/14/2026 at 1:45 PM Certified Nursing Aide #32 stated that on the morning of 02/19/2026, Resident # 24 and Resident# 93 were in the common area of the unit. They stated that Resident # 24 was saying things to Resident #93, and they tried several times to redirect Resident # 24 to prevent an altercation between the residents. Certified Nurse Aide #32 stated that they stepped into the kitchen to prepare a cup of coffee for Resident #24 to help distract them. They stated while preparing the coffee, Certified Nurse Aide #32 heard yelling coming from the common area. They stated that when they came out of the kitchen, Licensed Practical Nurse #33 was separating the residents. During an interview on 07/14/2026 at 1:55 PM Licensed Practical Nurse #33 stated that they have never observed Resident #24 and Resident #93 interact with one another. They stated that they resided on opposite sides of the unit, and they usually came out of their rooms at different times. They stated that on the morning of 02/19/2026, they were passing medications and heard screaming coming from the common area. They stated that when they came into the common area, they saw Resident #93 holding Resident #24 by the legs. Licensed Practical Nurse # 93 stated that they separated the residents. The Accident and Incident Report dated 04/10/2026 documented that at approximately 7:35 PM, Resident #92 was at the nurse's station on the third floor and began speaking to the nurse. Resident #24 approached and attempted to join the conversation. Resident #92 started a verbal disagreement with Resident #24 which escalated physically when Resident #92 threw a cup of fluids at Resident #24. Resident #24 pushed their rollator towards Resident #92, and the two residents were separated by staff. After being separated, Resident #92 turned over Residents #24 rollator and dumped all their belongings on the floor. Resident #92 was transferred to another unit. The facility findings and root cause analysis concluded Resident #92 became annoyed with Resident #24 and initiated a verbal altercation with Resident #24 that escalated into a physical altercation between the residents.The Nurse Progress Note dated 04/05/2026 at 3:29 PM written by Registered Nurse #28 documented that Resident #24 had a disagreement with another resident. The other resident was escorted to their room where they remained. Will continue to monitor and keep residents separated. The Care Plan for potential for abuse updated 04/07/2026 documented redirect away from others in times of exhibiting increased agitation. Staff reeducated on proper protocol when interacting with resident with escalating behaviors. There were no documented updates to Resident #92's care plans after the 04/05/2026 incident.The 04/13/2026 facility employee termination form and the 4/13/2026 Notice of Separation of Employment for Licensed Practical Nurse #29 documented that they were terminated for failure to ensure resident safety. During an interview on 07/13/2026 at 1:00 PM, Resident #24 stated they did not recall the incident with Resident #92. They stated they have not been involved in any altercations with residents. During an interview on 07/13/2026 at 3:22 PM, Registered Nurse Unit Manager #1 stated Resident #24 has early dementia, likes to wander, and can be a little obsessive. They stated Resident #24 gets in arguments with other people. They stated staff know to keep an eye on Resident #24 to prevent any incidents when Resident #24 is around other residents. During an interview on 07/14/2026 at 10:43 AM, Licensed Practical Nurse #18 stated they witnessed the incident. Resident #92 was trying to talk to a nurse and Resident #24 came over and started talking back and forth. Licensed Practical Nurse #18 stated they tried to stop the verbal escalation and called to the second floor to get the supervisor nurse to come assist. The verbal disagreement escalated became physical when Resident #92 threw a cup of coffee at Resident #24 and Resident #24's walker was knocked over. They stated the residents had a previous disagreement. Licensed Practical Nurse #18 stated the residents were separated, and Resident #92 was moved to the second-floor unit. During an interview on 7/14/2026 at 12:17 PM, the Director of Nursing stated when it comes to resident-to-resident altercations, they expected staff to step in and de-escalate any situation, to redirect as needed, monitor residents and maintain safety of the residents. They stated Licensed Practical Nurse #29 was present at the time of the incident and did not believe Resident #92 was going to escalate the situation to a physical altercation. They stated Licensed Practical Nurse #29 did not act quickly enough to de-escalate the situation when it was still a verbal altercation. Licensed Practical Nurse #29 did not perform to the standard the facility expects. They stated Licensed Practical Nurse #29 was on probation as a new employee and was let go for their performance as a nurse in general. During an interview on 7/14/2026 at 1:35 PM by phone, Licensed Practical Nurse #29 stated the residents had a verbal altercation that turned physical with coffee being thrown and the walker being pushed towards Resident #24. Licensed Practical Nurse #29 stated they were standing behind the medication car and heard a verbal altercation. They stated a staff member was there and took Resident #24 away and back to their room. They stated they did not remember what happened to Resident #92. 10 New York Code Rues Regulations 415.4(b)(1)(i)

Based on record review and interview the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one of two residents (Resident #98) reviewed for insulin and one of three residents (Resident #92) reviewed for pain. Specifically, 1) the physician was not consistently notified when Resident #98's fingerstick blood glucose readings were greater than 401 as per physician order, and 2) Resident #92's Medication Administration Records for November 2025 and December 2025 revealed incomplete documentation for physician ordered intravenous cefazolin. The findings include:The policy titled Insulin Administration, dated 10/04/2024, documented that residents receiving sliding scale insulin should be observed for signs and symptoms of hypoglycemia and hyperglycemia following administration. Any abnormal findings should be addressed immediately according to the facility's hypoglycemia/hyperglycemia management policy and reported to the practitioner as clinically indicated.The policy titled Administration of Medications, dated September 2020, documented staff administered medications to residents via the correct route as ordered, immediately documented medications administered in the proper time and date square by initialing the Medication Administration Record, and identified initials by signature in the designated space on the Medication Administration Record.1)Resident # 98 had diagnoses including diabetes mellitus, Parkinson's disease, and gastric cancer.The Care Plan dated 3/14/2025 for diabetes mellitus documented monitor/document/report any signs/symptoms of hyperglycemia, increase thirst and appetite changes. The Physician Order dated 03/23/2025 documented Insulin Lispro subcutaneous solution pen injector 100 unit per milliliter. Sliding scale: 201-250 =2 units, 251-300= 4 units, 301-350= 6 units, 351-400 = 8 units, 401-450= 10 units and call physician.The Medication Administration Record for March 2025 documented 03/18/2025 fingerstick at 4:30PM was 440,10 units of insulin given. There was no documented evidence that the physician was notified as per order. The quarterly Minimum Data Set (a resident assessment tool) dated 04/24/2025 documented Resident # 98 had moderate cognition and received insulin.The Medication Administration Record for April 2025 documented 04/21/2025 fingerstick at 4:30PM was 421,10 units of insulin given. There was no documented evidence that the physician was notified as per order. During an interview on 07/13/2026 at 9:24 AM, Licensed Practical Nurse #16 stated in March 2026 they administered 10 units of insulin for Resident #98's fingerstick blood glucose of 440 and had not called Resident #98's physician to notify them of the elevated fingerstick blood glucose. They stated they could not locate any documentation in Resident # 98's chart indicating that they had informed the physician or nurse practitioner.During a telephone interview on 07/13/2026 at 3:09 PM, the Medical Doctor stated they did not receive any calls from the nurses when Resident #98 had a fingerstick blood glucose greater than 401. They stated that the nurses did not follow the orders to notify the physician for a blood glucose reading over 401.2)Resident # 92 had diagnosis of Presence of Left Artificial Knee joint (surgical aftercare) Poly-osteoarthritis and Chronic Obstructive Lung disease.The admission Minimum Data Set assessment dated [DATE] documented the resident had intact cognition and received Intravenous antibiotic therapy.The Physician's Order dated 11-19-2025 documented cefazolin sodium intravenous solution using 2 grams intravenously every 8 hours for infection until 12-23-2025There was no documented evidence in the November 2025 Medication Administration Record to indicate that cefazolin sodium was administered: 1400 dose on November 22, 2025; 2200 dose on November 24, 2025; 0600 and 2200 doses on November 25, 2025; 1400 dose on November 29, 2025; 0600, 1400, and the 2200 doses on November 30, 2025.There was no documented evidence in the December 2025 Medication Administration Record to indicate cefazolin sodium was administered: 1400 and 2200 doses on December 1, 2025; 2200 dose on December 2, 2025;1400 dose on December 4, 2025; 1400 dose on December 5, 2025; 1400 and 2200 doses on December 11, 2025; 1400 and 2200 doses on December 15, 2025;1400 dose on December 18, 2025;1400 dose on December 19, 2025; and the 0600 dose on December 22, 2025.During an interview on 07-08-2026, Unit Manager Registered Nurse #1 stated that a Registered Nurse was always available to administer intravenous antibiotics. They stated that there was typically a Registered Nurse in the building; however, if one was not present, an on-call Registered Nurse was available. They stated that the Director of Nursing served as the on-call Registered Nurse during the week and lived approximately 10 minutes from the facility. They stated the blank boxes on the Medication Administration Record did not necessarily indicate that the medication was not administered; rather, they indicated that the medication was not signed by the nurse after administration.During a follow up interview with Registered Nurse Unit Manager#1 on 07-14-2026 at 10:06 a.m., they stated that they were scheduled to work on 12-02-2025. They stated the 2200 dose was not signed on the Medication Administration Record, and there was no corresponding nursing note documenting administration. Registered Nurse Manager #1 stated that they probably became busy and did not sign for the medication after administering it. They stated that this was poor practice and stated that medications should be signed for immediately after administration.During an interview on July 10, 2026, at 11:00 a.m., the Director of Nursing stated the residents always received prescribed intravenous antibiotics. They stated that if there were no Registered Nurse in the building, the Registered Nurse on the on-call schedule would respond to the facility to administer the intravenous antibiotic. The Director of Nursing further stated that blank Medication Administration Record boxes did not necessarily indicate that the medication was not administered, but rather that it had not been documented as administered. They stated that, at times, the Registered Nurse administered the intravenous antibiotic and failed to document administration in the Medication Administration Record, which they identified as poor nursing practice. They stated the Registered Nurse should document medication administration immediately following administration.10 New York Code Rules Regulations 415.12

Based on record review and interviews conducted during a Survey (2566010), the facility did not ensure that the resident's family representative was notified of a change in condition for one (Resident #1) of three(3) residents reviewed for notification of changes in condition for end of life care. Specifically, from [DATE] through [DATE], Resident #1 was prescribed Tramadol 50 mg for pain management. On [DATE], Tramadol was discontinued, and Resident #1 was prescribed morphine 5 mg every 6 hours as needed for pain and end-of-life care. On [DATE], the resident's morphine dosage was increased to 10 mg every 3 hours as needed for pain. Review of the medical record revealed no documented evidence of communication with the resident's family representative from [DATE] through [DATE] regarding changes in the resident's treatment, medication regimen, and health status. Resident #1 representative stated in an interview that they were only notified of a decline in the residents' health/change in treatment regimen on [DATE] when they called the facility to follow up on the resident. Resident #1 expired on [DATE].The Findings are: The Facility policy titled Change in Resident Status Notification, effective [DATE], documented that the resident's attending physician, or designee and Responsible Party will be notified by the Nurse Manager/Nursing Supervisor/Designee when there is a significant change in the resident's physical, mental, or psychosocial/emotional status and in any situation which requires a change in the Resident's plan of care, medication, or treatment regimen. Resident #1 was admitted with diagnoses including dementia, cerebral infarction, and heart failure. The [DATE] Quarterly Minimum Data Set (MDS) documented that Resident #1 had severely impaired cognition. Physician orders dated [DATE] through [DATE] documented that Resident #1 was prescribed tramadol 50 milligrams by mouth every morning and every bedtime for pain for 30 days. Physician orders dated [DATE] through [DATE] documented that Resident #1 was prescribed oxycodone 5 milligrams by mouth every six hours as needed for pain. Physician orders dated [DATE] through [DATE] documented that Resident #1 was prescribed morphine sulfate 5 milligrams every six hours as needed for pain, shortness of breath, and restlessness related to end-of-life hospice care. Physician orders dated [DATE] documented that Resident #1 was prescribed morphine sulfate 10 milligrams buccally every three hours as needed for pain, shortness of breath, and restlessness related to end-of-life hospice care. Physician orders dated [DATE] documented that Resident #1 was placed on two liters of oxygen via nasal cannula for low oxygen levels. Physician orders dated [DATE] documented that Resident #1 was prescribed acetaminophen suppository 650 milligrams, insert one suppository rectally one time for fever for one day. The [DATE] at 02:26 PM nursing progress note for Resident #1 documented that the writer received a telephone call from a hospice nurse regarding the resident's condition and pain regimen. The note documented that the writer advised they would follow up with the nurse practitioner in the morning to discuss the resident's pain regimen due to increased pain noted by the hospice aide. Review of Resident #1's medical record revealed no documented evidence that the resident's family representative was notified of the resident's increased pain or the discussion regarding potential changes to the pain management regimen at that time. The [DATE] at 04:24 PM nursing progress note for Resident #1 documented that Resident #1's designated family representative contacted the facility for an update and was informed of an increase in the resident's morphine dosage to address increased pain. The nursing progress notes for Resident #1 dated [DATE] at 08:47 AM documented that the resident expired, with the time of death recorded at approximately 8:09 AM. During an interview conducted on [DATE] at 12:00 PM, the Complainant stated that they were not notified when Resident #1 was started on morphine and were unaware that the resident was receiving morphine prior to [DATE]. The Complainant stated that they contacted the facility on [DATE] to follow up regarding the declination of the pneumonia vaccine, and during that call, the individual who answered the phone, whom they believed to be nursing staff, told them that Resident #1 was declining, that the resident had been in that condition for approximately one week, and that changes had been made to the resident's medication. The complainant stated that [DATE] was the first time they were informed of the resident's morphine use and changes to medication. During an interview on [DATE] at 03:34 PM, Nurse Practitioner #1 stated that family representatives are expected to be notified of changes in a resident's condition and medication regimen. Nurse Practitioner #1 stated that an increase in morphine dosage from 5 milligrams to 10 milligrams, reflects increased pain requiring additional intervention and such changes represent a significant change requiring family notification. Nurse Practitioner #1 stated that a change from lower-dose of pain management to higher-dose morphine is a significant change and that families should be notified when this occurs. During an interview on [DATE] at 01:13 PM, Licensed Practical Nurse Unit Manager #1 stated that staff are expected to document when there are significant changes in a resident's condition, including medication changes, and to notify the resident's family representative and document the notification. In the presence of the surveyor and the Director of Nursing, Licensed Practical Nurse Unit Manager #1 reviewed the progress notes for Resident #1 and was unable to identify documentation indicating that the resident's family representative had been notified of the medication changes. During an interview on [DATE] at 01:30 PM, the Director of Nursing stated that any changes in a resident's condition, including medications and health status, must be documented and that families must be notified, and that they expect all communication and changes to be documented in the progress notes. In the presence of the surveyor and Licensed Practical Nurse Unit Manager #1, the Director of Nursing reviewed the resident's progress notes and was unable to provide documented evidence that the resident's family representative had been notified of the changes. 10NYCRR 415.3

Based on record review and interviews conducted during the Abbreviated Surveys (2566010 and 2658860), the facility did not ensure the accurate and timely completion of the admission Minimum Data Set assessment for one resident (Resident #4) of six residents reviewed. Specifically, Resident #4 was admitted to the facility on [DATE]. The federally required Comprehensive Minimum Data Set assessment, which must be completed within 14 days of admission, was not initiated as of record review conducted on 01/02/2026. The Assessment Reference Date of 12/23/2025 reflected that the Comprehensive Minimum Data Set assessment was overdue by 10 days at that time. Upon revisit on 01/27/2026, record review revealed that the Comprehensive Minimum Data Set assessment associated with the same Assessment Reference Date remained incomplete and was 35 days overdue.The findings are:The facility policy titled MDS Scheduling dated 08/01/2025 documented that the facility will establish and maintain a systematic scheduling process for Minimum Data Set assessments to meet regulatory timeframes, optimize reimbursement, and support care planning. The Assessment Reference Data is established by the MDS Coordinator within the allowable window. The ARD must be selected to ensure all required clinical data is available for accurate coding. Late Assessment Reference Data selection is not permitted and may result in financial penalties. The Minimum Data Set Coordinator will maintain an Minimum Data Set Scheduling Calendar Minimum Data Set Tracking Log. All assessments will be cross referenced with admission Discharge records Physician Orders Nursing documentation.Resident #4 was admitted to the facility with diagnoses including, but not limited to hemiplegia and hemiparesis following cerebral infarction, major depressive disorder, and type two diabetes mellitus.Review of Resident #4's Minimum Data Set tracking documentation in Electronic Medical Record (PointClickCare) revealed that a Comprehensive Minimum Data Set assessment was required to be completed within 14 days of the resident's admission. Resident was admitted on [DATE]. The Comprehensive Minimum Data Set assessment was not completed by the required timeframe of 12/23/2025. On 01/27/2026, the Comprehensive Minimum Data Set assessment was reflected in the Facility Electronic Medical Record Tracking System as incomplete and 35 days overdue.During an interview on 01/02/2026 at 03:56 PM, the Minimum Data Set coordinator stated that the Assessment Reference Date for Resident #4 was tracking under the prior admission which resulted in a discharge in August 2025. The comprehensive care plan from that admission had not been completed and closed by all disciplines. This prevented closure of the admission assessment cycle and disrupted the Minimum Data Set assessment process for the resident's current admission.During an interview on 01/02/2026 at 05:30 PM, the Administrator stated that they were unaware of any issues related to the Minimum Data Set assessments, Assessment Reference Dates, or tracking within the Electronic Medical Record system (PointClickCare) for Resident #4. The Administrator stated that the Minimum Data Set coordinator reports directly to them and they had not been notified of any delays or issues related to Resident 4's Minimum Data Set assessment process.During a follow-up interview on 01/02/2026 at 06:39 PM, the Minimum Data Set coordinator stated that they contacted the administrators of the electronic medical record system for PointClickCare regarding Resident #4's Minimum Data Set assessment process and the resident's new admission on [DATE]. The Minimum Data Set Coordinator stated that they were informed that the prior admission assessment cycle could not be closed because the comprehensive care plan from the resident's prior admission, which ended with discharge home on [DATE], had not been completed and closed by all disciplines. The Minimum Data Set coordinator stated that as a result, the Assessment Reference Date from the prior admission remained active, which interfered with completion of the Minimum Data Set assessment timely for Resident #4's current admission on [DATE].Record reviews of the electronic Minimum Data Set tracking system during a revisit on 01/27/2026 revealed that the Comprehensive Minimum Data Set assessment for Resident #4 remained incomplete. The Assessment Reference Date was 35 days overdue for Resident #4's admission.During another follow up interview conducted on 01/27/2026 at 4:07 PM, the Minimum Data Set Coordinator stated that Resident #4's admission to the facility on [DATE] was a new admission and the Comprehensive Minimum Data Set assessment was required to be completed by 12/23/2025, in accordance with the federally required 14-day timeframe. The Minimum Data Set Coordinator stated that the Comprehensive Assessment was not completed as required because the admission was treated as a re-admission and the resident's admission status was not verified. The Minimum Data Set Coordinator stated that the Assessment Reference Date from the resident's prior admission remained active as the previous admission assessment cycle was not closed. This interfered with the comprehensive assessment for the current admission. The Minimum Data Set Coordinator stated that the comprehensive assessment was initiated as a late entry on 01/27/2026.Review of Resident #4's comprehensive assessment on 01/27/2026 revealed the comprehensive assessment remained incomplete because required sections had not yet been completed by other disciplines and it was 35days overdue.10 NYCRR 415.11(a)

Based on observation, record review, and interviews conducted during an Abbreviated Survey (2566010 and 2658860), the facility did not ensure a system was in place to easily identify residents to prevent accidents for two (Residents #2 and #5) of seven residents reviewed. Specifically, 1) on 10/27/2025, during the provision of routine podiatry services, the podiatrist identified Resident #2 by the incorrect name based on the identification band provided to the resident by the facility. Resident #2 was wearing another resident's identification wristband. 2) On 01/02/2026, Resident #5, who was newly admitted and was severely cognitively impaired, was observed without an identification wristband in place. Certified Nurse Aide #1 was asked by the surveyor to identify Resident #5(who was assigned to them) and was unable to identify Resident #5. The findings are: The facility policy titled Resident Identification System, effective 06/07/2023, documented that a resident identification system is used to help facility personnel provide medical and nursing care. During observation on 01/02/2026 at 12:05 PM with the Registered Nurse Unit Manager #1 on the dementia unit, Resident #2 and Resident #5 and other residents were observed without identification wristbands. Resident #5 was admitted with diagnoses including, but not limited to, dementia, myocardial infarction, and peripheral vascular disease. The 12/17/2025 Comprehensive Minimum Data Set documented that Resident #5 had severely impaired cognition. On 01/02/2026 at 12:15 PM, Resident #5 was observed without an identification wristband, name tag, or any other form of resident identifier. During an interview on 01/02/2026 at 12:15 PM, Certified Nurse Aide #1 was asked to identify Resident #5. Certified Nurse Aide #1 was unable to identify Resident #5 and stated that residents are supposed to wear identification wristbands for identification. Certified Nurse Aide #1 stated they were unable to identify Resident #5 because the resident was a new admission and had no identification band. Certified Nurse Aide #5 was the assigned staff to care for Resident #5 on 01/02/2026. Resident #2 was admitted with diagnoses including, but not limited to, anxiety disorder, intracardiac thrombosis, and major depressive disorder. The 12/08/2025 five-day Minimum Data Set documented that Resident #2 had intact cognition. During an interview on 01/02/2026 at 12:27 PM, Resident #2 stated concerns regarding resident identification and described an incident when they were issued and wore another resident's identification wristband. Resident #2 stated that the identification wristband belonged to another resident with a similar last name. The wristbands were mixed up and when the podiatrist came in to provide service, they called them by the name on the identification band, and it was the wrong name. During an interview on 01/02/2026 at 12:20 PM, Registered Nurse Unit Manager #1 stated that a family member reported concerns that Resident #2 was wearing another resident's identification wristband. Registered Nurse Unit Manager #1 stated that an incident or accident report was not completed because the incorrect identification wristband was worn for a brief period however Registered Nurse Unit Manager #1 was unable to provide the time frame the incorrect identification wristband was on Resident #2. Registered Nurse Unit Manager #1 also stated that Resident #5 was a new admission and that identification wristbands are included in the admission packet and are expected to be applied to all residents upon admission. Registered Nurse Unit Manager #1 stated they did not complete the admission for Resident #5 and therefore could not explain why an identification wristband was not applied. During an interview on 01/02/2026 at 12:24 PM, Certified Nurse Aide #3 stated that they identify residents by asking residents their names. When asked how residents are identified if they are unable to state their name, Certified Nurse Aide #3 stated that they rely on identification wristbands. Certified Nurse Aide #3 further stated that when floating to other units, identification wristbands are relied upon primarily to identify residents. During an interview on 01/02/2026 at 03:17 PM, the Director of Nursing stated that residents are expected to have identification wristbands applied and that nursing staff are responsible for checking identification wristbands to ensure right resident before providing care. The Director of Nursing stated that certified nurse aides rely on identification wristbands to identify residents because they do not have access to resident photographs in the electronic health records. The Director of Nursing stated that on one occasion Resident #2 was found wearing an incorrect identification wristband. The Director of Nursing was unable to identify the staff member who applied the incorrect identification wristband or confirm the length of time the incorrect identification wristband was in place. The Director of Nursing further stated that identification wristbands may fall off or break and may not be identified and therefore replacing them is not always done promptly. During an interview on 01/02/2026 at 05:13 PM, the Administrator stated that residents are expected to have identification wristbands applied for identification purposes. The Administrator stated that resident photographs are available in the Medication Administration Record and the Treatment Administration Record. The Administrator did not identify an alternate method in place to ensure resident identification when identification wristbands are missing or not present. The Administrator stated that identification wristbands are relied upon by certified nurse aides, visitors, and other staff in the facility who do not have access to the electronic health records to identify residents. The Administrator did not describe a process to ensure continued resident identification when identification wristbands fall off or break. The Administrator stated that the issue related to identification wristbands would be addressed with the team on 01/05/2026. 10 NYCRR 415.12(h)(1)

Based on observation, interview, and record review conducted during the recertification and abbreviated (NY00354392) the facility did not ensure the resident's right to a safe, clean, comfortable environment and reasonable care for the protection of resident property from loss or theft. This was evident for 1 (Unit 2) of 2 resident units and 1 (Resident #5) of 3 residents investigated for abuse. Specifically, 1) Unit 2 was observed with peeling wallpaper, floors covered in dirt, debris, a floor mat emanating a strong odor of urine, a soiled wheelchair, and radiators throughout the unit with air vent grates and metal conductor fins heavily covered and soiled in dirt, debris, dust, and dried crusty food and liquids, and 2) Resident #5's personal food was taken and eaten by staff while being stored in the dining room refrigerator designated only for resident food.The findings are:The facility policy titled Facility Cleaning – Housekeeping dated 10/2024 documented dust mop and then wet mop floors daily using the approved diluted cleaning agent in mop water. The policy did not document a cleaning process for heat/air conditioning radiators throughout resident rooms and common areas. The facility policy titled Environmental – Room of the Day dated 2/2025 documented all resident rooms and common areas would be terminally cleaned at least monthly and resident care environments were inspected for cleanliness and safety on an ongoing basis. Housekeeping was responsible for cleaning and disinfecting all horizontal surfaces including and not limited to windowsills, sinks, and overbed tables. The facility policy titled Terminal Room Cleaning dated 3/25/2025 documented resident rooms were terminally cleaned after a resident has been discharged and during infection outbreaks. The facility policy titled Food Preparation – Food Brought by Family/Visitor dated 6/2025 documented food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that it is clearly distinguishable from facility-prepared food. The housekeeping staff will discard perishable foods after 72 hours. 1) From 6/25/2025 at 10:33 AM to 7/03/2025 at 12:00 PM, Unit 2 was observed with the following: - a brown dried spill stain approximately 12 inches X 12 inches on the hallway floors near the double doors at the beginning of the hallway to room [ROOM NUMBER]; - warped, sagging, and peeling wallpaper held up by tape and thumbtacks near the double doors at the beginning of hallway to room [ROOM NUMBER]; - all floor to ceiling glass balcony doors and windows in the floor dining room were covered with fingerprints, grease stains, were cloudy, dusty, and dirty; - all heating/air conditioning radiators in the dining room and hallways had air vent grates and metal conductor fins covered with dirt, grime, dust, dried food, and dried crusty liquids or varying colors; - Resident #27 had a wheelchair soiled with dried crusty food particles and dried spilled food and drink stains; - room [ROOM NUMBER]D contained a large floor mat at the bedside with several tears in the vinyl exposing the internal foam. The floor mat had a strong foul urine odor emanating from it that was noticeable upon entering room [ROOM NUMBER]. On 7/01/2025 at 1:03 PM, Certified Nurse Aide #38 was interviewed in room [ROOM NUMBER] and stated they did not initially notice the urine odor coming from the room because they were desensitized because they were regularly around foul odors working in the facility. Certified Nurse Aide #38 stated the foul odor was coming from 236D’s floor mat. Certified Nurse Aide #38 stated they were unaware of a cleaning schedule for floor mats, or which department was responsible for cleaning them. The housekeeping department brought the mats to the unit upon request for fall risk residents. The Certified Nurse Aide #38 stated they were unaware whether housekeeping was made aware of the floor mat odor and torn vinyl. On 7/01/2025 at 2:10 PM, Registered Nurse #17, Unit 2 Manager, was interviewed and stated they spot-checked resident wheelchairs for cleanliness and directed staff to clean the wheelchairs when soiled. Registered Nurse #17 stated they did not keep a record of when wheelchairs were cleaned. After observing Resident #27’s wheelchair, Registered Nurse #17 stated the wheelchair was noticeably soiled with food stains from previous meals and required cleaning. During an interview on 07/02/25 at 3:45 PM Interview Certified Nurse Aide #15 stated no one cleaned the wheelchairs. If they noticed something on it, they would spot clean them, otherwise no other department would clean it. On 7/03/2025 at 12:00 PM, the Facilities Director was interviewed and stated floor mats were stored with the Maintenance Department in the basement. The nursing staff were responsible for placing a request for floor mats and the Maintenance staff were responsible for delivering the mats to the unit. Mats were cleaned before being placed in resident rooms. 2) Resident #5 had diagnoses of Diabetes Mellitus and anxiety. The Quarterly Minimum Data Set 3.0 assessment dated [DATE] documented Resident #5 was cognitively intact and did not display mood or behavior symptoms. On 06/26/25 at 11:22 AM, Resident #5 was interviewed and stated they stored their personal food in a refrigerator in the floor dining room. In 9/2024, they retrieved their food from the fridge and found that part was missing. The facility investigated and informed Resident #5 a staff member was caught on camera taking the resident’s meal from the refrigerator, eating some, and then putting the bag of leftover food back into the refrigerator. The facility reimbursed Resident #5 for the expense of the meal. Resident #5 stated they experienced no further personal food storage concerns since 9/2024. The facility Summary of Investigation dated 9/13/2024 documented Resident #5 reported an allegation of misappropriation of property. Licensed Practical Nurse #7’s statement documented Resident #5 reported to them that they placed a bag of food in the dining room refrigerator on 9/11/2024 and not all their food was there when the resident went to retrieve it on 9/12/2024. The Registered Nurse statement documented they observed a staff member on surveillance camera on 9/12/204 at 1 AM removing Resident #5’s bag of food from the dining room refrigerator, eating a portion of the food inside the bag, and then returning the bag to the refrigerator. A facility Memorandum dated 9/12/2024 documented all staff were reminded that refrigerators in floor dining rooms were for dietary and resident use only. Staff were to use the refrigerator in the staff lunchroom. Staff removal or consumption of resident food items was considered misappropriation of the resident’s personal property. Violators will be terminated from employment. A sign-in sheet documented Licensed Practical Nurse #7’s signature along with 19 other nursing staff. The Nursing Home Facility Incident Report Submission completed by the facility Administrator and dated 9/14/2024 at 10:34 PM documented the facility attempted to obtain Certified Nurse Aide #33’s statement on 9/13/2025 and the aide decided to resign effective immediately from facility employment. The facility documented Resident #5 did experience misappropriation of property. On 6/27/2025 at 12:06 PM, the unit dining room refrigerator was observed with a combination lock on the outside of the door that was disengaged and unlocked. The refrigerator was opened with Licensed Practical Nurse #36 present and an unlabeled, undated navy-blue canvas lunch bag and black plastic bag were observed on the door. The refrigerator door also contained an undated bottle of sweet Vidalia onion salad dressing labeled with Licensed Practical Nurse #7’s name. Licensed Practical Nurse #36 was interviewed at the time and stated neither bag was labeled with a date or name, and they did not know who they belonged to or how long they were in the refrigerator. Licensed Practical Nurse #36 stated staff were provided with inservice a few months ago and were reminded that no staff food was to be kept in the dining room refrigerators and any refrigerator food items must be labeled and dated. Licensed Practical Nurse #36 removed the black plastic bag from the refrigerator, opened it, and removed a large round unlabeled, undated plastic container filled with cooked pasta. Licensed Practical Nurse #36 stated the pasta possible belonged to Resident #5 but since there was no date or name, the container would be discarded. During the same observation, Licensed Practical Nurse #7 observed the refrigerator and confirmed the salad dressing was theirs. Licensed Practical Nurse #7 was interviewed and stated no staff food items should be in the dining room refrigerator and the facility had a staff lunchroom with refrigerator on the ground floor. Licensed Practical Nurse #7 stated all items should be labeled and dated and resident’s personal food was only kept for 3 days before being discarded. The dietary staff were responsible for checking and maintaining the dining room refrigerator. Licensed Practical Nurse #7 stated they did not place their salad dressing in the refrigerator and denied placing it there. Licensed Practical Nurse #7 the removed the navy-blue canvas lunch bag from the refrigerator and removed its contents – a moldy and rotted baby carrot and fuzzy, mold-covered plastic fork inside a plastic lunch container and a small round clear plastic container with a creamy white substance. Licensed Practical Nurse #7 opened the round clear plastic container, and a strong putrid, sour, foul odor emanated from the contents. The food contents were unidentifiable and was covered in white and black mold. License Practical Nurse #7 stated they were unable to identify what the substance was or who it belonged to but the navy-blue bag and its contents and the salad dressing would both be discarded. On 7/01/2025 at 1:31 PM, Certified Nurse Aide #34 was interviewed and stated they recalled receiving inservice a few months ago regarding the dining room refrigerators. Staff stored their personal food items in the staff refrigerator and the dining room refrigerators were only for resident food items. 10 NYCRR 415.5(h)(2)

Based on observation, interview, and record review conducted during the recertification survey from 6/25/2025 to 7/3/2025, the facility did not ensure residents unable to carry out activities of daily living received necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This was evident for 3 ( Resident #54, #19, and #27) of 4 residents reviewed for activities of daily living. Specifically, 1) Resident #54 was observed with long, jagged, brown and yellow nails, 2) Resident #19 was observed in bed on multiple occasions and there was no evidence the resident was provided with the assistance to transfer out of bed to their wheelchair, and 3) Resident #27 was observed with long, jagged fingernails covered with brown crusty stains. The findings are: The facility policy titled Activities of Daily Living, Range of Motion, and Mobility dated 3/1/2025 documented care and services would be provided to maintain a resident’s current activity of daily living status based on the resident’s needs and choices. Care and services included hygiene, mobility, and transfers. 1) Resident #19 had diagnoses of Alzheimer's disease and history of right leg deep vein thrombosis. The Significant Change Minimum Data Set 3.0 assessment dated [DATE] documented Resident #19 was severely cognitively impaired, required supervision with eating, was totally dependent on staff assistance for transfers in and out of bed, and enjoyed doing things with groups of people. On 6/26/2025 at 10:08 AM, Resident #19’s Representative was interviewed and stated staff used to transfer Resident #19 out of bed to eat in the dining room and participate in group activities in the floor day room . The Representative stated staff have not taken Resident #19 out of bed in recent times, and they have not seen the resident out of bed the last several times they visited the facility. On 6/25/2025 at 11:23 AM, 6/26/2025 at 10:47 AM, 11:22 AM, and 12:17 PM, and 7/01/2025 at 12:07 PM, Resident #19 was observed lying in bed in their room. A wheelchair labeled with Resident #19’s name was observed in the resident’s shared bathroom behind a closed door. There were no observations of Resident #19 receiving the necessary assistance for staff to be transferred out of bed to their wheelchair. The Comprehensive Care Plan related to activities of daily living initiated 6/22/2020 and last reviewed 6/22/2025, documented Resident #19 had a history of right leg deep vein thrombosis (blood clot) and was totally dependent on 2 staff members and a mechanical lift for transfers out of bed. The Comprehensive Care Plan related to nutrition, initiated 6/22/2020 and last reviewed 3/10/2025, documented Resident #19 was at risk for malnutrition and dehydration. Interventions included Resident #19 would eat 2 of 3 meals in the common area. The care plan documented Resident #19 did not respond well eating in room - isolation. The Comprehensive Care Plan related to risk for falls initiated 6/22/2020 documented Resident #19 be encouraged to participate in activities that promote exercise and physical activity. The care plan was revised on 4/9/2022 and documented Resident #19 would be changed by the day shift in the afternoon and left in the common area for close supervision. The Baseline Care Plan dated 3/13/2025 documented Resident #19 ate their meals in the dining room. The Wound Doctor Note dated 6/18/2025 documented recommendations for Resident #19 to be out of bed for limited intervals of time, alternating activity to minimize pressure. The Bedside Kardex as of 6/30/2025 documented Resident #19 was dependent on 2 staff and mechanical lift for transfers, should be offered an out of bed nap after breakfast if sleepy, would eat 2 of 3 daily meals in the common area for a more enjoyable meal experience, should participate in activities that promote physical activity and exercise for strengthening and mobility. On 7/01/2025 at 11:25 AM, Licensed Practical Nurse #7 was interviewed and stated Wound Nurse Practitioner recommendations were reviewed by a licensed nurse and communicated to the Medical Doctor responsible for prescribing a resident’s treatment orders. Licensed Practical Nurse #7 stated nursing staff tried to get Resident #19 out of bed when possible but there was no set out-of-bed schedule or instructions for staff to follow. On 7/01/2025 at 1:17 PM, Certified Nurse Aide #6, assigned to Resident #19, was interviewed and stated the unit’s get-up schedule was changed several months ago to make the Certified Nurse Aide assignments more manageable. Resident #19 used to get out of bed and before the get-up schedule was changed. Certified Nurse Aide #6 stated unit nursing staff determined Resident #19 did not try to climb out of bed and did not require assistance with eating, so they were not a candidate to be on the list to come out of bed. 2) Resident #54 had diagnoses of dementia, failure to thrive, gastrostomy status. The Annual Minimum Data Set 3.0 assessment dated [DATE] documented Resident #54 was severely cognitively impaired and required assistance from staff to perform personal hygiene and grooming. The Comprehensive Care Plan related to activities of daily living initiated 1/27/2021 and last reviewed 7/30/2024 documented Resident #54 was dependent on staff to perform personal hygiene The Comprehensive Care Plan related to potential skin impairment was initiated 3/3/2021 documented Resident #54’s fingernails should be clipped, filed, and maintained. The care plan was revised and documented Resident #54 had a skin tear to their left arm on 4/7/2025 and open purpura to their left upper arm on 6/19/2025. On 7/01/2025 at 2:40 PM, Resident #54 was observed in a recliner in their room and 10 of 10 fingers were observed with long fingernails [NAME] past the tips of their fingers. Resident #54’s fingernails were stained yellow and brown, were cracked, broken, uneven, and jagged at the edges. Nail clippers were observed in the drawer to Resident #54’s bedside dresser. At 2:44 PM, Licensed Practical Nurse #37 entered the room and administered medication to Resident #54. Licensed Practical Nurse #37 did not address Resident #54’s fingernails. On 7/01/2025 at 3:08 PM, Certified Nurse Aide #38 was interviewed and stated they were assigned to Resident #54 and were responsible for assisting Resident #54 who was totally dependent on staff for personal hygiene, grooming, and nail care. Resident #54 had fragile skin and was risk for scratching themselves with their own nails. Certified Nurse Aide #38 stated they developed a routine of providing their assigned residents nail care every Friday. Certified Nurse Aide #38 stated they were unsure what he facility’s policy on providing resident nail care was and it was their decision to only cut resident’s nails on Friday. Certified Nurse Aide #38 observed Resident #54’s fingernails and stated they were too long because they had grown past the tips of Resident #54’s fingers. Certified Nurse #38 stated they did observe Resident #54’s nails to be long during their rounds earlier today but it was not the designated nail day – Friday. Certified Nurse Aide #38 stated they did not cut Resident #54’s nails last Friday because they floated their assignment and was not assigned to Resident #54 last Friday. 3) Resident #27 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Major Depressive Disorder. The 4/29/25 quarterly Minimum Data Set assessment documented Resident #27 had severely impaired cognition and was dependent on staff for assistance with activities of daily living.The 4/4/25 Activities of Daily Living, self-care deficit Care Plan documented Resident #27 required extensive assist of one staff with personal hygiene and oral care.The Kardex documented showers are given on Mondays and Thursdays and the resident requires extensive assistance of one staff with showering twice a week. During an observation on 06/25/25 at 12:46 PM the resident was observed with brown substance on nails and were dirty while eating lunch. During an observation on 06/25/25 at 03:26 PM the resident was noted to have dirty fingernails caked with old food and brown substance.During an observation on 06/26/25 at12:24 PM the resident was feeding themself a peanut butter and jelly sandwich and dirty nails with dried brown substance were visible.During an interview on 07/02/25 at 3:45 PM Nurse Aid #15 was asked about Resident #27's dirty nails and they stated they have seen the dirty nails but has not tried to clean them and stated the resident often gets their hands into a lot of food and bowel movements but it is a good idea though.During an interview on 07/02/25 at 5:14 PM with Certified Nurse Aid #21 they stated the nails are done with activities sometimes and they come and clean them. Otherwise on shower day the water will run over the hands and whoever is doing the shower will clean them with a washcloth. They stated they do not know why they are dirty but should be cleaned.During an interview on 07/02/25 at 5:18 PM Registered Nurse #22 stated the Certified Nurse Aids will let the nurses know when there are dirty nails. During evening cares they will also make sure the residents hands were washed properly. Sometimes it can be a struggle to get them done but needs to be done, must be done. All say nails need to always be clean especially if the resident is eating with their hands. Nurses are supposed to make sure nails are clean. The process is nails are checked on shower days and a skin check is done by nurses. The nail assessments are part of the skin assessment. Registered Nurse#22 stated nurses are responsible to make sure the skin, hair and nails look clean after shower. During an interview on 07/03/25 at 10:12 AM Licensed Practical Nurse Unit Manager #17 stated they do not know why skin checks and nails were not done on the shower day but if it had the nails would have been addresses sooner as it is part of care. 10 NYCRR 415.12(a)(3)

Based on observation, interview, and record review conducted during recertification survey from 6/25/2025 to 7/3/2025, the facility did not ensure each resident was provided with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs. This was evident for 1 (Unit 2) of 2 resident units during dining review. Specifically, Unit 2 residents eating in the floor dining room were not consistently served their entire meal in accordance with Physician Order and meal tickets. The findings are: During observation on 6/25/2025 from 11:56 AM to 12:51 PM, 22 residents, including Residents #79, #46, #8, #27, and #39, were seated in the Unit 2 dining room during lunch meal service. Meal tickets for each of the residents documented cinnamon apples as part of the lunch meal. The meal tickets for Resident #27 and #39 also documented magic cup as part of their meal. Dietary and Nursing staff were observed serving residents in the dining room from the hot steam table. The meal service ended at 12:51 PM and residents were wheeled out of the floor dining room by staff. A bin of 15 cinnamon apple cups was observed sitting on a counter by the hot steam table. There were no observations of magic cups being served to Resident #27 and #39. There were no observations of cinnamon apples being served to any of the 22 residents in the unit dining room. During observation on 6/26/2025 from 12:00 PM to 12:42 PM, 17 residents were observed seated in the Unit 2 floor dining room for lunch meal service. The meal tickets for each resident documented cake. Residents #39 and #27 had magic cup listed on the meal ticket. There were no observations of cake being served to 16 of 17 residents seated in the dining room. There were no observations of Residents #39 and #27 being served magic cups. Nursing staff were observed taking resident plates away and wheeling them from the dining room at 12:42 PM.During an observation on 6/27/2025 at 12:17 PM, Residents #39, #27, and #83 were observed with meal tickets documenting they should receive a magic cup. No magic cups were observed in the dining room or served to the residents. Certified Nurse Aide #6 was interviewed at 1:13 PM, immediately following the meal observation, and stated magic cups were not available for residents who ate in the Unit 2 dining room. Residents who eat in their rooms received magic cups. Certified Nurse Aide #6 stated they did not know the reason residents eating in the dining room did not receive items listed on their meal ticket and did not report the discrepancies to their supervisor. During an interview on 06/27/2025 at 1:15 PM Certified Nurse Aide #36 was interviewed and stated the Unit 2 dining room did not have magic cups, so residents were provided with vanilla ice cream instead.During an interview on 06/27/2025 at 1:59 PM, Dietary Aide #10 stated the kitchen staff were supposed to restock the Unit 2 dining room refrigerator daily with magic cups, so they were available for residents during meal service. Dietary Aide #10 stated they did not know why the refrigerator was left unstocked and that Nursing staff could call the kitchen to bring more magic cups for residents if necessary. During observation of tray line service in the kitchen on 7/03/2025 at 11:28 AM, a bin of milk, Lactaid, and other cold beverages was prepared in an ice bath. Dietary Aide #39 was interviewed during observation and stated they did not have a list of residents and their diet orders for each unit. Dietary Aide #39 stated they decided the quantity of milk, ice creams, and shakes to be delivered to each unit based off their experience working for the facility. At 11:47 AM, a cart containing trays prepared with resident meal tickets and cold beverages was observed in the warm kitchen awaiting delivery to the units. The trays for Residents #48 and #67 had a meal ticket that documented Milk 1%, and their tray contained full-fat milk. Resident #38's tray was observed with a vanilla mighty shake and a meal ticket that documented chocolate mighty shake. Dietary Aide #40 was present at the time of observation and asked about the discrepancy between meal ticket and drinks on the tray and stated the facility did not have any more 1% milk left, and the full-fat milks were placed on the trays as a substitute. On 7/02/2025 at 1:57 PM, the Diet tech was interviewed and stated mighty shakes and magic cups were nutritional supplements used to boost residents' caloric intakes due to weight loss or risk for weight loss and were delivered during meals on the resident's meal tray. Nursing staff brought drinks to resident tables and food from the hot steam table was plated and served to the residents in the dining room first. Residents in the dining room were only offered dessert, but every resident should get the food listed on their meal ticket. Certified Nurse Aides were responsible for ensuring residents were provided with dessert and their supplements. The Diet tech stated the Unit 2 dining room was scheduled for lunch from 12:00 PM to 12:45 PM. Residents were transported out of the room by nursing staff by 12:50 PM regardless of whether residents were done with their meals. The Diet tech stated they expressed their concerns to the Administrator regarding the current meal delivery system. The Diet tech stated they were not involved in the creation of the menu or calculating caloric intake of each meal service.On 7/03/2025 at 12:20 PM, the Food Service Director was interviewed and stated the dietary staff prepared meal trays with the cold beverages and/or ice creams for Unit 2 residents eating meals in their room. These trays were brought to Unit 2 at 12:00 PM but not delivered to residents in their rooms until after the dining room was finished eating at 12:45 PM. Dietary and Nursing staff were responsible for checking for meal tray accuracy. The Food Service Director and the former Director of Nursing believed the food delivery system was faulty and communicated this to the Administrator. Certified Nurse Aides were responsible for placing some items on the tray and Dietary Aides were responsible for plating others which led to tray inaccuracy. Dietary and Nursing staff were provided a verbal in-service regarding the changes in meal delivery process and their responsibilities in plating. The facility's Registered Dietician worked 100% remotely and was responsible for reviewing the nutritional value of each meal. The Food Service Director and the Diet tech have not received any information from the Registered Dietician regarding the nutritional value of each resident meal.On 7/03/2025 at 4:13 PM, the Administrator was interviewed and stated each individual department had separate meetings weekly to discuss statistics and trends. Dietary staff and the dietician compiled their own statistics and presented them to the Administrator and relevant department heads but did not discuss the method of analyzing the data collection methods or benchmark statistics to ensure improvement in identified areas of concern.10 NYCRR 415.14

Based on observation, interview, and record review conducted during the recertification survey from 6/25/2025 to 7/3/2025, the facility did not ensure resident food was stored, prepared, distributed and served in accordance with professional standards for food service safety. This was evident for 1 (Unit 2) of 2 resident units during dining review. Specifically, 1) Unit 2 floor dining room refrigerator held undated, unlabeled food, and 2) potentially hazardous foods were not held within a safe temperature range during food service. The findings are: The facility policy titled Food Preparation - Food Brought by Family/Visitor dated 6/2025 documented food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that it is clearly distinguishable from facility-prepared food. The housekeeping staff will discard perishable foods after 72 hours.1) On 6/27/2025 at 12:06 PM, the unit dining room refrigerator was observed with a combination lock on the outside of the door that was disengaged and unlocked. The refrigerator was opened with Licensed Practical Nurse #36 present and an unlabeled, undated navy-blue canvas lunch bag and black plastic bag were observed on the door. The refrigerator door also contained an undated bottle of sweet Vidalia onion salad dressing labeled with Licensed Practical Nurse #7's name. Licensed Practical Nurse #36 was interviewed at the time and stated neither bag was labeled with a date or name, and they did not know who they belonged to or how long they were in the refrigerator. Licensed Practical Nurse #36 stated staff were provided with inservice a few months ago and were reminded that no staff food was to be kept in the dining room refrigerators and any refrigerator food items must be labeled and dated. Licensed Practical Nurse #36 removed the black plastic bag from the refrigerator, opened it, and removed a large round unlabeled, undated plastic container filled with cooked pasta. Licensed Practical Nurse #36 stated the pasta possible belonged to Resident #5 but since there was no date or name, the container would be discarded. During the same observation, Licensed Practical Nurse #7 observed the refrigerator and confirmed the salad dressing was theirs. Licensed Practical Nurse #7 was interviewed and stated no staff food items should be in the dining room refrigerator and the facility had a staff lunchroom with refrigerator on the ground floor. Licensed Practical Nurse #7 stated all items should be labeled and dated and resident's personal food was only kept for 3 days before being discarded. The dietary staff were responsible for checking and maintaining the dining room refrigerator. Licensed Practical Nurse #7 stated they did not place their salad dressing in the refrigerator and denied placing it there. Licensed Practical Nurse #7 the removed the navy-blue canvas lunch bag from the refrigerator and removed its contents - a moldy and rotted baby carrot and fuzzy, mold-covered plastic fork inside a plastic lunch container and a small round clear plastic container with a creamy white substance. Licensed Practical Nurse #7 opened the round clear plastic container, and a strong putrid, sour, foul odor emanated from the contents. The food contents were unidentifiable and was covered in white and black mold. License Practical Nurse #7 stated they were unable to identify what the substance was or who it belonged to but the navy-blue bag and its contents and the salad dressing would both be discarded.On 7/01/2025 at 1:31 PM, Certified Nurse Aide #34 was interviewed and stated they recalled receiving inservice a few months ago regarding the dining room refrigerators. Staff stored their personal food items in the staff refrigerator and the dining room refrigerators were only for resident food items.2) During observation of tray line service in the kitchen on 7/03/2025 at 11:47 AM, a cart containing trays prepared with resident meal tickets and cold beverages was observed in the warm kitchen awaiting delivery to the units. At 12:05 PM, Dietary Aide #40 and [NAME] #41 arrived in the Unit 2 dining room with carts containing trays prepared with cold items for service to residents who ate in their rooms and hot food trays placed on the steam table for service to residents who ate in the dining room. [NAME] #41 obtained the temperatures of food items in the food tins. There were no observations of temperatures being taken for cold items placed on resident trays and for grilled cheese sandwiches separate from the steam table. Upon request, temperatures of the grilled cheese were obtained by the [NAME] #41 and were 112 F. A random milk carton on Resident #14's meal tray was tested by Dietary Aide #40's thermometer and was 62 F. Dietary Aide #40 was interviewed at the time and stated the dietary staff did not have a system in place to regularly test the cold meal items or any items on trays for service to resident rooms.On 7/03/2025 at 12:20 PM, the Food Service Director was interviewed and stated the dietary staff on the unit were responsible for testing the temperature of food on the unit prior to meal service. Cold items should be kept at below 40 F and hot items should be held at 135 F. 10 NYCRR 415.14(h)

Based on interview and record review conducted during the recertification survey from 6/25/2025 to 7/03/2025, the facility did not ensure the facility-wide assessment was updated to determine what resources were necessary to ensure residents were able to maintain or attain their highest practicable physical, functional, mental, and psychosocial well-being and meet current professional standards of practice. Specifically, the Facility Assessment did not include the staff training/education and competencies required for all personnel listed, did not include specific staffing needs for each facility unit and did not develop and maintain a plan to maximize recruitment and retention of direct care staff. The findings are: The Facility Assessment last updated 08/08/2024 and reviewed on 05/25/2025 documented the facility had 98 resident beds with average daily census of 92 residents. The Facility Assessment did not document the required level of staff training/education and competencies for all personnel listed. The Facility Assessment did not document specific staffing needs for each facility unit, the Second Floor and the Third Floor. The Facility Assessment did not document how the facility planned to recruit and retain enough medical practitioners who are adequately trained and knowledgeable in the care of the residents. The policy Facility Assessment dated 11/08/2023 documented the facility will conduct, document, and annually review a comprehensive facility-wide assessment, which includes both resident population and the resources the facility needs to care for all residents, to determine the resources necessary to care for the residents competently during both day-to-day operations and emergencies. The Facility Assessment includes staff competencies and skill sets needed and a breakdown of the training, licensure, education, skill level and measures of competency for all personnel. On 07/02/25 at 1:16 PM, the Administrator stated during an interview that they were responsible for the facility assessment. The Administrator stated the following facility assessment sections were not completed: Section 3, Individual Staff Assignment, Section 4, Staff Training/Education and Competencies, Section 5, Policies and Procedures for Provision of Care and Section 6 & 7, Working with Medical Practitioners. The Administrator stated they did not review the entire facility assessment and concentrated on the clinical areas during meetings. 10 NYCRR 415.26

Based on observation, record review and interview conducted during the recertification survey from 6/25/25 to 7/3/25, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infection for all residents. Specifically, the facility did not provide documentation of screening, administration or declination and education provided for 1 of 5 Residents (Resident#25) and 10 of 10 staff (Certified Nurse Aides #26, #27, Food Service Workers #25, #30, Activities Aide #24, Occupational Therapist #23, Dietary Technician #14 Licensed Practical Nurses #7, #4, Registered Nurses #28), reviewed for COVID-19 vaccinations. The findings are:During the recertification survey, the facility was asked to provide documentation that COVID-19 vaccination was offered, education was provided, and staff had the opportunity to consent or decline the vaccine for Certified Nurse Aides #26, and #27, Food Service Workers #25, and #30, Activities Aide #24, Occupational Therapist #23, Dietary Technician #14 Licensed Practical Nurses #7, and #4, Registered Nurses #28. The facility was unable to provide the requested documentation. During an interview on 7/2/25 at 1:58 PM, the Assistant Director of Nursing and Infection Preventionist stated they were new to the role and the facility and could not find any proof of COVID vaccinations for staff and Resident #25. They stated that the COVID vaccine had not been offered to the staff and did not know why. When they started at the facility in January 2025 staff were not being offered at the time as it was not a condition of hire. During an interview on 7/2/25 at 3:41 PM, Certified Nurse Aide #16 stated they had not seen a COVID clinic at the facility in a while and would be interested in a COVID shot.During an interview on 7/2/25 at 03:41 PM, Certified Nurse Aide #21 stated they had not been offered a COVID vaccine at the facility.During an interview on 07/03/25 at 9:58 AM, the Director of Nursing stated residents are offered vaccines on admission. The other residents should have been offered vaccines as needed. 10NYCRR 415.19 (a)(1-3)

Based on record review and interviews during recertification and abbreviated (NY00374708) surveys conducted from 6/25/2025-7/03/2025, the facility did not ensure residents had the right to receive visitors of their choosing at the time of their choosing for 1 of 2 residents (Resident #25) reviewed for choices. Specifically, the facility restricted Resident #25's friend's visitation based on the resident's family member and the Administrator's wishes.Findings include: The facility policy, Resident Visitation, dated 5/2017, last reviewed 2/2025 documented all residents have the right to receive visitors of his or her own choosing at the time of his or her own choosing, subject to the residents right to deny visitation, and in a manner that does not impose on the rights of another resident. Supervised visits will depend on each residents' individual needs, safety, & issues (concern) at the time decisions are made. Resident #25 had diagnoses including adult failure to thrive, hypertension and interstitial lung disease. The Social Work Director note dated 2/18/25 documented that the Administrator and social worker contacted Residents #25's friend because the residents' family member requested visitation limitations due to variety of reasons regarding the residents' finances. The friend was informed of the visitation limitations and did not express any issues and/or concerns at this time.The Social Work Director note dated 3/24/25 documented staff received a call from the resident's family member regarding the resident's friend using the resident's debit card. The family member stated the friend was a [NAME] and Resident #25 was not in the right mind to let someone use their money. The 3/31/2025 quarterly Minimum Data Set (assessment tool) documented the resident had severely impaired cognition. The Psychiatric notes dated 4/09/2025 and 4/23/2025 documented the resident was alert, able to focus and answer questions appropriate, had a confused thought process, fair judgement, fair insight, and fair impulse control.On 5/13/2025, a New York Supreme Court judge ordered that a temporary guardian be appointed over Resident #25, pursuant to Mental Hygiene Law 81.21 through a petition filed by the Social Worker Director and the facility. The temporary guardian was ordered to take all steps to insure the safeguarding of the accounts, personal property, and assets of Resident #25. In addition, the temporary guardian was ordered to determine who shall provide personal care and assistance to Resident #25 including aides, nurses and other health care providers.On 6/30/25 at 9:45 AM, Resident #25 stated during an interview they wanted to see their friend and they never said they did not want to see their friend.On 06/30/25 at 4:08 PM, the Social Work Director stated during an interview that the family member was not the health care proxy, did not have a guardianship or hold a power of attorney.On 7/01/25 at 11:09 AM, Licensed Practical Nurse #20 stated during an interview that Resident #25 was a pleasant person and had issues with their friend visiting. Licensed Practical Nurse #20 stated that sometime 2-3 months ago, Resident #25 told them they wanted their friend to visit. There was drama between the friend, Resident #25's family member and the facility. They stated Resident #25 told them that their family member says the friend cannot visit here. On 7/02/25 at 12:02 PM, the Administrator stated during an interview that in March 2025, Resident #25 wanted to meet with their friend and give them cash. The friend was waiting outside the facility and the Administrator restricted Resident #25 and did not allow the visit to occur. Resident #25 was unable to meet with their friend and the friend left the facility. The Administrator stated they believed Resident #25 was being taken advantage of and with their severely impaired cognition and financial concerns, put restrictions on the visits. The Administrator stated they offered supervised visits to the friend, but they did not accept. The Administrator stated they told Resident #25 about supervised visits but Resident #25 stated it was their money and they wanted to see their friend. The Administrator stated they felt it was necessary and appropriate to restrict the friend for safety of Resident #25.On 7/03/25 at 11:03 AM, Certified Nurse Aide #16 stated during an interview that Resident #25 had spoken about wanting to visit or see their friend, but the facility would not allow it. They stated Resident #25 was sad and angry about not being able to see their friend and always stated they did not know why the facility would not allow it.10 NYCRR 483.10(f)(4)

Based on observation, interview, and record review conducted during the recertification and abbreviated (NY00354392) surveys from 6/25/2025 to 7/3/2025, the facility did not ensure a resident's right to be free from misappropriation of property. This was evident for 1 (Resident #5) of 3 residents investigated for abuse. Specifically, Resident #5's personal food was not stored safely and was eaten by staff, and facility staff diverted Resident #5's income directly to the facility without the resident's consent or knowledge. The findings are:The facility policy titled Abuse Prevention dated 5/23/2023 documented examples of misappropriation of resident property included identity theft, theft of money from bank accounts, and unauthorized or coerced purchases from resident's funds. The facility policy titled Food Preparation - Food Brought by Family/Visitor dated 6/2025 documented food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that it is clearly distinguishable from facility-prepared food. The housekeeping staff will discard perishable foods after 72 hours. A sample of the facility's current admission Agreement documented the facility provided reasonable security and locked storage upon request for resident personal property. The facility can only insure (to a maximum of $100) against the loss of valuable items if deposited with management (this limitation does not include the facilities management of resident funds).Resident #5 had diagnoses of Diabetes Mellitus and anxiety. The Quarterly Minimum Data Set 3.0 assessment dated [DATE] documented Resident #5 was cognitively intact and did not display mood or behavior symptoms.On 06/26/25 at 11:22 AM, Resident #5 was interviewed and stated they stored their personal food in a refrigerator in the floor dining room. In 9/2024, they retrieved their food from the fridge and found that part was missing. The facility investigated and informed Resident #5 a staff member was caught on camera taking the resident's meal from the refrigerator, eating some, and then putting the bag of leftover food back into the refrigerator. The facility reimbursed Resident #5 for the expense of the meal. Resident #5 stated they experienced no further personal food storage concerns since 9/2024. 6/25/2025 at 12:43 PM, Resident #5 was interviewed and stated the facility took their monthly income check without their consent or knowledge. Resident #5 stated they did not receive a 6/2025 deposit into their personal bank account as they normally did every preceding month since their admission to the facility. Resident #5 and their Representative spoke with the Finance Coordinator and was informed their monthly income check had been diverted to the facility's bank account because Resident #5 owed money to the facility. Resident #5 stated the Finance Coordinator reported that the Former Finance Coordinators took control of their income and made the changes. Resident #5 stated they were distrustful of the facility and was upset and frustrated by the situation because the Finance Coordinator told them there was nothing that could be done to address their concerns because the Former Finance Coordinator stopped working for the facility 2 months ago. Resident #5 stated the facility made no effort to inform them of monies owed, offer a payment plan, discuss other options, obtain their consent to make changes to their monthly income, and inform them after changes were made. The Comprehensive Care Plan related to psychosocial wellbeing was initiated 5/20/2025 and documented Resident #5 was at risk for a psychosocial wellbeing problem and interventions included increasing communication between resident and caregivers about care and living environment. The Comprehensive Care Plan related to mood initiated 6/11/2020 documented staff were to identify and reinforce Resident #5's strengths and positive coping skills.The facility Summary of Investigation dated 9/13/2024 documented Resident #5 reported an allegation of misappropriation of property. Licensed Practical Nurse #7's statement documented Resident #5 reported to them that they placed a bag of food in the dining room refrigerator on 9/11/2024 and not all their food was there when the resident went to retrieve it on 9/12/2024. The Registered Nurse statement documented they observed a staff member on surveillance camera on 9/12/204 at 1 AM removing Resident #5's bag of food from the dining room refrigerator, eating a portion of the food inside the bag, and then returning the bag to the refrigerator. A facility Memorandum dated 9/12/2024 documented all staff were reminded that refrigerators in floor dining rooms were for dietary and resident use only. Staff were to use the refrigerator in the staff lunchroom. Staff removal or consumption of resident food items was considered misappropriation of the resident's personal property. Violators will be terminated from employment. A sign-in sheet documented Licensed Practical Nurse #7's signature along with 19 other nursing staff. The Nursing Home Facility Incident Report Submission completed by the facility Administrator and dated 9/14/2024 at 10:34 PM documented the facility attempted to obtain Certified Nurse Aide #33's statement on 9/13/2024 and the aide decided to resign effective immediately from facility employment. The facility documented Resident #5 did experience misappropriation of property. There was no documented evidence a Comprehensive Care Plan related to Resident #5's risk for abuse/misappropriation of property was developed and implemented.On 6/27/2025 at 12:06 PM, the unit dining room refrigerator was observed with a combination lock on the outside of the door that was disengaged and unlocked. The refrigerator was opened with Licensed Practical Nurse #36 present and an unlabeled, undated navy-blue canvas lunch bag and black plastic bag were observed on the door, as well as an undated bottle of sweet Vidalia onion salad dressing labeled with Licensed Practical Nurse #7's name. Licensed Practical Nurse #36 was interviewed at the time and stated staff were provided with an in-service a few months ago and were reminded that no staff food was to be kept in the dining room refrigerators and any refrigerator food items must be labeled and dated. Licensed Practical Nurse #36 removed the black plastic bag from the refrigerator, opened it, and removed a large round unlabeled, undated plastic container filled with cooked pasta. Licensed Practical Nurse #36 stated the pasta possibly belonged to Resident #5 but since there was no date or name, the container would be discarded. On 7/01/2025 at 1:31 PM, Certified Nurse Aide #34 was interviewed and stated they recalled receiving in-service a few months ago regarding the dining room refrigerators. Staff stored their personal food items in the staff refrigerator and the dining room refrigerators were only for resident food items. A Request to be Selected as Payee Form dated 2/18/2025 documented Resident #5 lived in the facility, did not have access to their funds, and was unable to manage their own finances. The facility would be able to pay the resident's bills and get the resident access to their personal funds. The form was signed by the facility's Former Finance Coordinator. The facility Personal Needs Account Statement for Resident #5 documented a deposit for $532 on 6/3/2025, an auto-withdrawal debit of $482 on 6/3/2025, and a debit for $40 used at the facility gift shop on 6/17/2025, with a balance of $10 remaining in Resident #5's account. There was no documented evidence Resident #5 was aware of or gave consent to their monthly income being managed by the facility and diverted to a bank account managed by the facility.On 7/02/2025 at 4:56 PM, the Finance Coordinator was interviewed and stated Resident #5 approached them and inquired as to the status of their income check for 6/2025. The Finance Coordinator stated they were informed by their corporate oversight that the Former Finance Coordinator applied to become Resident #5's Representative Payee, giving them the power to change the bank account receiving the resident's income deposit. The Finance Coordinator stated that upon admission to the facility, residents agreed to allow the facility to apply for Medicaid and obtain the financial documents necessary to complete the application. The Facility contacted the resident's financial institutions and, when possible, obtained information on the resident's behalf. Resident #5 and their Representative approached the Finance Coordinator after the resident's 6/2025income check was not deposited in their resident's personal bank account. The Finance Coordinator stated the resident, and their Representative were very upset, and the discussion became confrontational. The Former Finance Coordinator was responsible for communicating with Resident #5 and informing them of monies owed to the facility, choice and consent to open a personal funds account managed by the facility, and decision to submit a Representative Payee application n Resident #5's behalf. The Finance Coordinator was unable to produce documented evidence of meetings or discussions between the Former Finance Coordinator and Resident #5. The Finance Coordinator stated it was not the facility's policy to become Representative Payee for cognitively intact residents without their consent or knowledge. The Finance Coordinator stated there was no recourse or action for Resident #5 to take and they did not offer the resident an opportunity to file a grievance. The Finance Coordinator stated the Administrator was aware of Resident #5's financial concerns and directed staff to only allow Resident #5's Representative to visit the facility under staff supervision. The Finance Coordinator was in-serviced on abuse prevention during their new employee orientation with the facility and stated taking control of a resident's income without their consent could be considered misappropriation of resident property. On 7/03/2025 at 8:43 AM, the Director of Nursing was interviewed and stated if any staff member witnesses or receives a report alleging abuse, they were responsible for reporting up the chain of command. All staff received abuse prevention in-service within the past year. Allegations of abuse needed to be reported to ensure an investigation is completed to determine whether abuse occurred. 10 NYCRR 415.4(b)

Based on observations, interviews, and record review conducted during the recertification and abbreviated (NY00356178) surveys conducted from 6/25/25 - 7/3/25, the facility did not ensure that Comprehensive Care Plans were reviewed and/or revised for 1 of 5 residents (Resident #345) reviewed for Accidents and 1 of 3 residents (Resident #363) reviewed for Abuse Specifically, 1. for Resident #345, there was no documented evidence the comprehensive care plan was reviewed and/or revised after a 6/22/25 fall and 2. there was no documented evidence comprehensive care plans were reviewed and/or revised to address Resident # 363's ongoing behaviors after 9/8/24, 9/12/24 and 9/22/24 episodes of physical and/or verbal aggression. The findings included:1. Resident #345's diagnoses included end stage renal disease, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and long-term use of opioid analgesic.A care plan titled Activities of Daily Living, dated 6/17/25, documented the resident has a performance deficit and decline in physical mobility related to hemiplegia and pain. Resident requires limited assist of one staff for locomotion and toileting and transfers.A care plan titled Resident is a Risk for Falls, dated 6/17/25, documented the resident is at risk for falls (score 13) related to deconditioning, gait / balance problems, left leg bypass graft. Interventions included to anticipate and meet the resident's needs, educate the resident /family/caregiver about safety reminders and what to do if a fall occurs, and ensure the call bell is within reach. The five-day entry Minimum Data Set (a resident assessment tool) dated 6/22/25 documented Resident #345 was cognitively intact, ambulated by wheelchair, required partial to moderate assistance with toileting and transfers, and had prescribed pain medication for 10/10 pain, An Accident and Incident Report dated 6/22/25 documented the resident was last seen three minutes prior to heading to the restroom. Emergency bell heard. Upon entering the resident room, bathroom door was observed locked from the inside. Door was unlocked and resident was found on the floor with back against the toilet bowl complaining of right elbow and shoulder pain. Resident stated they slipped and hit right elbow against the wheelchair trying to transfer to the toilet. On-Call Physician notified, and X-ray of the right shoulder and elbow ordered. Resident not taken to hospital. No injuries observed at time of incident. There was no documented evidence that the care plan was reviewed and/or revised after a 6/22/25 fall. During an interview on 07/02/25 at 11:55 AM, the Director of Nursing stated resident care plans should be updated immediately after an incident and investigation. The Director of Nursing stated the Fall Care Plan was not updated to include the fall and did not include new interventions. They stated the Unit Manager, or any Registered Nurse staff, should have updated the care plan status post fall. During an interview on 07/02/25 at 01:23 PM, Registered Nurse Unit Manager #5 stated they were aware of a recent fall Resident #345 had in the bathroom. They stated the fall was not reported directly to them as they were just starting position in facility. They stated they did not update the care plan. They stated the Director of Nursing or Assistant Director of Nursing would have been responsible for updating the resident care plan. 2. Resident #363 had diagnosis of Cerebral Infarction (stroke).The Comprehensive Care Plan initiated 11/27/23 documented Resident #363 is/has potential to be verbally aggressive related to dementia, ineffective coping skills, and poor impulse control and has impaired cognitive function/dementia or impaired thought processes. When the resident becomes agitated, intervene before agitation escalates and 7/10/24 observe around others and when the resident becomes agitated, intervene before agitation escalates.The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #363 had moderate cognitive impairment.A Nurse Progress note dated 9/08/24 documented Resident #363 was observed going into other residents' room by the activities staff. The Nurse encouraged Resident #363 to leave the other resident's room. Resident #363 stated they could do what they wanted. Resident #363 became agitated in the hallway and threw their cup at the nurses and punched a nurse in the side. The nurse encouraged Resident #363 to keep their hands to themselves.A Nurse Progress note dated 9/12/24 documented Resident #363 was yelling at nurses and tried to hit a nurse with a hanger.A Nurse Progress note dated 9/20/24 documented Resident #363 was moved to room [ROOM NUMBER].A Nurse Progress note dated 9/22/24 documented Resident #363 became agitated and threw their breakfast tray when yelling at staff. Resident #363 was yelling, cursing, and throwing things around the room.There was no documented evidence that care plans were reviewed and/or revised to address Resident # 363's ongoing behaviors after the 9/8/24, 9/12/24 and 9/22/24 episodes of physical and/or verbal aggression. 10 NYCRR 415.11(c)(2)(i-iii)

Based on observation, interview, and record review conducted during the recertification survey from 6/25/2025 to 7/3/2025, the facility did not ensure resident/s received necessary treatment and services to prevent new pressure ulcers from developing and/or promote healing of a facility acquired pressure ulcer for 1 of 2 residents (Resident #19) reviewed for pressure ulcer. Specifically, for Resident #19 with a documented 2/20/2025 superficial (surface) sacral wound, Braden Assessment/s were incomplete and did not include a score to determine resident risk for pressure ulcer, labs were not obtained as per the 2/20/2025 medical doctor note, and use of an air mattress as per the 3/3/2025 wound doctor note was not implemented until 3/20/2025. Subsequently the sacral wound progressed to stage 4 (full thickness tissue loss with exposed bone and tendon).The findings include:The 2/2025 policy titled Pressure Injury Prevention and Management/Wound Rounds, documented all residents were assessed for the risk of pressure injuries and appropriate preventive care plans will be implements when indicated. Resident #19 had diagnoses including Alzheimer's Disease, Hypernatremia and Stage 4 Sacral Pressure Ulcer.The 11/19/2024 and11/29/2024 Braden Assessment was incomplete and did not include a score to determine resident risk for pressure ulcer. The 2/20/2025 Medical Doctor Note documented Resident #19 was found with a superficial (surface) sacral wound 1.9cm X .2cm with no active discharge. The note documented Medi honey (wound gel) was ordered to treat Resident #19's sacral area. Add a multivitamin and obtain labs. There was no documented evidence that labs were obtained as per the 2/20/2025 Medical Doctor Note. The 2/20/2025 Physician Order documented turn and position every 2 hours and was discontinued on 2/24/2025.The 2/27/2025 Nurse Weekly Skin Check documented no skin issues. The 3/3/2025 Wound Doctor Note documented Resident #19 had a stage 3 sacral cluster of 3 new wounds measuring 10cm squared, with 90% granulation (new skin tissue), 10% slough (dead skin cells), and moderate amount of serous exudate (clear fluid). The note documented recommendations for Resident #19 to receive an air mattress, turning and positioning, a nutritional consult and should be out of bed as tolerated for limited intervals of time alternating activity to minimize pressure. There was no documented evidence the air mattress was put in place as per the 3/3/2025 Wound Doctor recommendation. The 3/6/2025 Physician Order documented turn and reposition every 2 hours. The 3/6/2025 Nurse Weekly Skin Check documented a treatment was in place for a known wound.The 3/7/2025 Medial Doctor Note documented turn and position every 2 hours and continue multivitamin. The 3/10/2025 Wound Doctor Note documented Resident #19's sacral ulcer was worsening, measured 12cm squared, and family consent was required to debride (removal of dead skin) the wound. The 3/10/2025 Nursing Note documented a message was left for Resident #19's Representative requesting consent for wound debridement. The 3/12/2025 Hospital Transfer Form documented Resident #19 was transferred to the hospital due to altered mental status. Resident #19 had a sacral pressure ulcer at the time of transfer. The 3/13/2025 Clinical admission Evaluation documented Resident #19 was readmitted with no skin issues.The 3/13/2025 Braden Assessment was incomplete and did not include a score to determine resident risk for pressure ulcer. The 3/13/2025 Baseline Care Plan documented Resident #19 was dependent on staff for activities of daily living and had a sacral pressure ulcer.The 3/15/2025 Nursing Weekly Skin Check documented Resident #19's skin was intact.The 3/17/2025 Wound Doctor Note documented no consent was obtained and no debridement was done to Resident #19's worsening sacral ulcer measuring 14cm squared. The 3/18/2025 Significant Change Minimum Data Set Assessment documented Resident #19 was totally dependent on staff assistance for transfers in and out of bed, did not receive a scheduled pain medication regimen, had a weight loss of 5% or more in 1 month or 10 % or more in 6 months, and received pressure ulcer care for a facility acquired unstageable pressure ulcer due to slough and/or eschar. The 3/20/2025 Physician Order documented Resident #19 was to receive an air mattress. There was no documented evidence an air mattress was ordered and or put in place for Resident #19 until 3/20/2025. The 3/24/2025 Wound Doctor Note documented no consent was obtained, and no debridement was done to Resident #19's worsening sacral ulcer measuring 48.75cm squared. The 4/7/2025 Wound Doctor Note documented debridement was performed on Resident #19 sacral ulcer. The note documented Resident #19's wound was unattached at the edges with the presence of tunneling and undermining. The 5/28/2025 Physician Order documented cleanse sacral wound sacral wound daily and as needed with normal saline followed by applications of calcium alginate and silver to the wound and zinc oxide paste to the peri-wound, cover with border form.The Comprehensive Care Plan related to activities of daily last reviewed 6/22/2025, documented Resident #19 required 2 staff members to assist with a mechanical lift transfer in and out of bed, 1 person to assist with bed mobility. The 6/23/2025 Physician Order documented roho (pressure relief) cushion to the wheelchair.The Comprehensive Care Plan related to pressure ulcer risk reviewed 6/24/2025, documented Resident #19's sacral area reopened on 2/20/2025. Interventions included use of roho cushion in Resident #19's wheelchair and nutrition monitoring. During observation on 6/25/2025 at 11:23 AM Resident #19 was observed positioned flat on their back in bed. During interview on 6/26/2025 at 10:08 AM, Resident #19's Representative was interviewed via telephone and stated staff used to transfer Resident #19 out of bed, but they have not seen the resident out of bed the last several times they visited the facility. Resident #19's nutrition has also been an issue. The facility was inconsistent when contacting the Representative with updates regarding Resident #19's condition and the Representative stated they were aware that Resident #19 had a stage 4 pressure ulcer on their sacrum. During observation on 6/26/2025 at 10:47 AM, 11:22 AM, and 12:17 PM Resident #19 was observed positioned flat on their back in bed. The June 2025 Certified Nurse Aide Kardex Instructions documented Resident #19 was checked for incontinence and turn/position every 2 hours and was transferred out of bed using a mechanical lift and 2-person assist. On 7/01/2025 at 11:01 AM, Licensed Practical Nurse #7 was interviewed and stated they were preparing to perform Resident #19's sacral ulcer treatment. Resident #19 was ordered to have their sacral area cleansed with normal saline, packed with calcium alginate and silver, zinc applied to the border of the wound, and covered with bordered foam. During observation on 7/01/2025 at 12:07 PM, Resident #19 was observed positioned flat on their back in bed. During wound observation on 7/01/2025 at 11:05 AM Certified Nurse Aide #6 held Resident #19 on their left side while the resident was turned and lying on their right side in their bed. Licensed Practical Nurse removed the bordered gauze covering dated 6/30/2025 from Resident #19's sacral area. Resident #19 began to moan loudly and squirmed in their bed while Licensed Practical Nurse #7 dripped normal saline into the opening of their sacral wound. Resident #19 moaned louder and writhed away from Licensed Practical Nurse #7's touch as the nurse was attempting to pack Resident #19's sacral wound with calcium alginate. Certified Nurse Aide #6 stated at the time that Resident #19 was grabbing onto and squeezing their backside as Licensed Practical Nurse #7 was observed applying the zinc to the edges of the resident's sacral ulcer. During interview on 7/01/2025 at 11:25 AM, Licensed Practical Nurse #7 stated Resident #19 was at risk for pressure ulcers prior to the development of their current sacral ulcer. Licensed Practical Nurse #7 stated they were not working when the wound was discovered and did not know how it started. Resident #19's wound continued to worsen the first few weeks after it was discovered and worsened in the hospital in 3/2025. Nurses performed skin checks on all residents weekly and the Certified Nurse Aides performed skin checks twice weekly during resident shower days. The Wound Nurse Practitioner also performed a skin assessment monthly for all residents in the facility. The staff attempted to turn and position Resident #19 more often and tried to get the resident out of bed. Resident #19 did not have an air mattress in place until 3/20/2025 and did not have an out-of-bed schedule recommended for them. They stated Wound Nurse Practitioner recommendations were reviewed by the nursing staff/unit manager and communicated to the Medical Doctor who then wrote the orders. Consent for debridement should be obtained by the unit manager and did not take more than 1 week to obtain. Licensed Practical Nurse #7 stated they performed Resident #19's treatment on 6/30/2025 and covered the resident's dressing with bordered gauze. Resident #19 was ordered to receive a bordered foam covering. Licensed Practical Nurse #7 stated there was a difference in the 2 coverings and bordered gauze was used on 6/30/2025 because bordered foam was not available. Licensed Practical Nurse #7 stated Resident #19 was moving around and responded to stimulus during the treatment. There was no order for pain medication or pain management. Licensed Practical Nurse #7 stated they did not know whether Resident #19 had been assessed by the Medical Doctor or the Nurse Practitioner for pain related to sacral ulcer. During interview on 7/01/2025 at 1:17 PM, Certified Nurse Aide #6 stated they were aware and did observe Resident #19 with redness to their sacral region before the skin opening occurred but Resident #19 was not at risk for skin breakdown at the time. Resident #19 did not have an air mattress in place until after their sacral ulcer developed. At the time Resident #19's sacral ulcer was discovered, the facility had staffing issues on the overnight shift. Certified Nurse Aide #6 stated they would come in to work in the morning and all residents on their assignment required total bed changes because they were not changed or cleaned during the night shift. Certified Nurse Aide #6 stated there were times that only 1 aide was assigned the floor overnight and cared for up to 50 residents by themselves. There have been improvements with staffing and the get-up scheduled was changed to make the assignments more manageable. Resident #19 did not try to climb out of bed and did not require assistance with eating, so the nursing staff determined Resident #19 was not a candidate to come out of bed anymore. 10 NYCRR 415.12(c)(1)

Based on observation, record review and interviews conducted during the recertification and abbreviated surveys (NY00372410), the facility did not ensure each resident received adequate supervision consistent with resident's needs to prevent accidents. This was evident for 1 of 5 residents (Resident #67) reviewed for accidents. Specifically, Resident #67 was assessed to be at high risk for falls, had multiple unwitnessed falls and complete investigations were not done to determine the root cause and/or add interventions to protect the resident. The findings included:The facility policy titled, Falls, and Fall Risk Managing Fall, last reviewed 3/25, documented: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions.Resident #67 was admitted [DATE] with diagnoses including dementia with other behavioral disturbances, encephalopathy (disease, damage, or malfunction of the brain that results in impaired brain function), repeated falls, and fracture of femur (thigh bone) following insertion of orthopedic implant. The admission Minimum Data Set (a resident assessment tool) dated 12/8/24 documented Resident #67 was moderately cognitively impaired, used a wheelchair, required substantial/maximal assistance with transfers and toileting, and had a fracture related to a fall in the six months prior to admission. A fall risk assessment dated [DATE] documented Resident #67 had one to two falls in last three months, was chairbound and had gait/balance problem while walking. The falls risk score was 15.0, indicating Resident #67 was a moderate fall risk. A Resident care plan dated 12/3/24 documented at risk for falls related to poor safely awareness. The goal was to be free of falls and interventions included to assist resident with ambulation and transfers, utilizing therapy recommendations, determine resident's ability to transfer, ensure bed is kept in lowest position, ensure call light is available to resident. Evaluate fall risk on admission and as needed. Evaluate resident's environment to identify factors known to increase risk of falls. If fall occurs, alert provider. If resident is a fall risk, initiate fall risk precautions. Utilize devices as appropriate to ensure safety (ie. bed mats, sensor alarms).The Accident and Incident reported dated 12/18/24 documented Resident #67 had an unwitnessed fall at 3:45 PM. Resident #67 was observed on the floor in their room with a laceration above their left eye. Resident #67 was transferred to hospital. The Post Fall evaluation dated 12/18/24 documented floor mats were not in place at time of fall. Contributing factors documented the resident had poor safety awareness, was oblivious to needs and safety, and on the floor at the foot of bed. A hospital Discharge summary dated [DATE] documented Resident #67 was admitted [DATE], discharged [DATE] and treated for a subdural hematoma (brain bleed) and closed fracture of right hip/displaced fracture of right femoral neck. Nursing progress notes dated 12/27/24 documented the resident returned from the hospital. The Fall Risk Evaluation documented a score of 24 indicating the resident was at high risk for falls. A Social Service note dated 12/27/24 at 1:29 PM, documented they met with the resident's representative and the representative requested the resident's bed be lowered and pats put on the floor. Made request to the Director of Nursing. A licensed practical nurse nursing note dated 2/6/25 at 12:47 PM, documented Resident #67 was observed on the floor in sitting position in the dining room at approximately 11:00 AM and the supervisor was notified. The Nurse Practitioner conducted an examination and ordered the resident's immediate transport to the emergency room for evaluation. Review of the resident's record revealed no documented evidence an accident/incident report or investigation was completed for the 2/6/24 fall at 11:00 AM.The licensed practical nurse's nursing note dated 02/06/2025 at 11:00 PM documented Resident #67 returned from hospital via ambulance at 6:15 PM. Resident #67 continued to be verbally disruptive and at 6:50 PM, was observed on the floor in resident room in sitting position at the bedside. The Supervisor was informed.The registered nurse's nursing note dated 02/07/2025 at 3:22 AM documented the resident arrived back on unit around 6:15 PM from the hospital and was placed in bed where resident was relaxing. At 6:50 PM, the resident was observed sitting on the floor at bedside. The resident could not explain what happened due to baseline confusion. On assessment, he had neither visible injury nor change in range of motion to any extremity. Resident verbalized they were not in any pain at the time. The bed was in the lowest position with call bell within reach. The floor was dry and clutter-free. The light in the room was adequate. Resident #67 was assisted into bed with assistance of two members of staff and Physician notified. The accident and incident report dated 2/7/25 documented Resident #67 had an unwitnessed fall at 6:50 PM, on 2/6/24. Resident was observed sitting on the floor of bedroom. Resident could not explain what happened due to baseline confusion. Resident was not sent to hospital. No injuries observed post incident. The report documented the care plan was followed, and the resident was non-compliant with the care plan. There were staff statements attached to the incident report but no statement from the staff assigned to the resident. There was no indication if the resident had floor mats. The resident care plan was not updated after the fall. The licensed practical nurse's nursing noted dated 2/15/25 at 9:39 AM, documented at approximately 8:30AM Resident #67 was observed on the floor in their room in right lateral position. Resident #67 reported they hit their head on the cabinet. The physician was notified and the resident was sent to emergency room for evaluation. Review of the resident's record revealed no evidence an accident/incident report or investigation was completed after the 2/15/25 fall to determine if interventions could be put in place to prevent further falls. The resident's care plan was not updated with new interventions after the 2/15/25 fall. The registered nurse's nursing note dated 2/16/2025 at 6:10 AM documented the resident returned from the ER in the evening on stretcher accompanied by two emergency medical technicians. The emergency room report documented no acute intracranial abnormality, no evidence of acute fracture or malalignment of the cervical spine and X-rays of the pelvis and right hand were also reported by the emergency room to have shown no fracture. The resident woke up from around 2:30 AM and would not go back to bed. Staff had to take turns to do 1:1 observation on the resident for safety. The accident and incident report dated 5/9/25 documented Resident #67 had an unwitnessed fall. At approximately 8:00 PM, Resident was heard yelling loudly in sitting area where they were found resident out of wheelchair, on floor, stating that right knee was hurting badly. No other injuries were observed. Nurse Practitioner notified and ordered resident be sent to emergency room for x rays of right knee. The nursing progress note dated 5/9/25 at 8:36 PM documented the resident was heard yelling loudly in sitting area where they were found resident out of wheelchair, on floor, stating that right knee was hurting badly. When the emergency medical services came, the resident was telling staff he needed to use the bathroom and was toileted prior to transfer. Resident to be toileted after dinner.The resident care plan was updated 5/9/24 to include the following interventions: anticipate and meet the resident's needs, ensure call bell is in reach, physical therapy evaluates and treat as ordered or as needed, keep personal items within reach and toilet after supper . The accident and incident report dated 5/11/25 documented Resident #67 had an unwitnessed fall. At approximately 5:30 PM, the resident fell out of wheelchair in common area. A Certified Nurse Aide heard the fall and responded immediately. Resident remained alert and lying on right side and stated they hit their head. Slight redness noted to left side and of head and resident complained of pain in head. Nurse Practitioner informed and requested resident be sent to emergency room for evaluation. The resident care plan was updated to include the following interventions: Bed in lowest position (5/12/25) and resident to be monitored at all times when out of bed (5/11/25). The accident and incident report dated 5/16/25 documented Resident #67 had an unwitnessed fall. Resident was found by certified nurse assistant around 5:30 AM on the floor between beds. Resident #67 was naked, copious amounts of feces was found on the bed, floor, sheets curtain and spread throughout the resident's body. Urine was found on the floor. Resident complained of pain but indeterminate area. Resident was found on buttocks, reclining, favoring the right side, propping up on roommate bed. Resident transferred to hospital about 6:00 AM. There was no investigation to determine when the resident was last toileted and as to how the fall occurred. There was no documentation that floor mats had been put in place. No new interventions were added to the resident care plan after the fall to prevent recurrence. A nurse note dated 5/28/2025 at 3:40 PM documented Resident #67 had an unwitnessed fall. Writer called by certified nurse assistant to resident room. Observed resident laying on floor on left side. Skin tear noted to left wrist. Resident was assessed by Nurse Practitioner. The facility was unable to provide an accident /incident report. The resident care plan was not updated after the fall. An accident and incident report dated 6/1/25 documented Resident #67 had a witnessed fall. At approximately 9:40 PM, resident was lying in L shape, head hanging of the left side of bed, feet off bed, hands were gripping side rail. Resident landed on arms first, body and head followed. Aide ran to side of bed resident fell on, and resident was observed with head on the floor. Two linear indentations noted on forehead. Resident was lying near call bell, call bell wired (indentations were about the size of wire). Previous wound on left wrist opened, bandage was off and actively bleeding. Wound cleaned with normal saline and rebandaged. The resident was cleaned an a brief and gown were put on. Resident was transferred to emergency room for evaluation. The Certified Nurse Aide's statement did not document when the resident was last toileted. The resident care plan interventions were updated 6/1/25 to include fall mats on floor when in bed. An accident and incident report dated 6/3/25 documented Resident #67 had an unwitnessed fall at 10:15 PM. Resident was found on knees. Water was found on floor by nightstand. Resident was picked up by staff members. Upon whole body assessment, no visible marks, discomfort, pain noted. Resident unable to give description. Upon assessment, no need to send resident to hospital. Resident made clean and safe in wheelchair with dry diaper. Resident refused clothes, placed in blanket and brought to nurse station to watch closely until calm enough for bed. The Certified Nurse Aide assigned to the resident documented on their statement dated 6/3/25, the last time they saw the resident was 5:10 PM in the sitting area. For the question regarding if the resident was checked, changed, or toileted in the past 2 hours, yes or no was not selected and written in was changed by daughter. Another Certified Nurse Aide's statement documented they helped the nurse and the assigned aide change the resident's brief after the fall. There was no documentation as to if the fall mats were in place. A nurse note dated 6/25/25 at 2:37 AM documented Resident #67 was found on the thick mat in between the resident and the roommate's beds. Resident had stripped of clothing and brief. The resident was cleaned and dressed by two certified nurse assistants and safely placed in bed in lowest position and went back to sleep. An accident and incident report was not provided by facility. During an observation on 6/25/25 at 10:54 AM, Resident #67 was observed lying in bed. Floor mat was on left side, in between beds. Bed was in lowest position. Call bell was within reach. During an observation on 6/25/25 at 12:27 PM, Resident #67 was assisted with eating during lunch. The resident was removing shirt during service aggressively, staff tried to reorient the resident, the resident refused to place shirt back on and returned to room. During an observation on 6/26/25 11:31 AM Resident #67 was observed resting quietly in a Broda chair in dining/day room. An accident and incident reported dated 6/26/25 documented Resident #67 had an unwitnessed fall at approximately 11:00 PM. Resident out of bed, at room door, sitting on buttocks holding on to the nurse aide. Resident unable to give description. Resident assisted off the floor, cares administered. Resident transferred into chair and taken to nurse station for close supervision. Due to notable hematoma, the resident was transferred to emergency room for further evaluation per Nurse Practitioner order. Injuries noted front of right knee abrasion and face hematoma. The resident care plan was updated with the following intervention on 6/27/25: check on resident within first ten minutes after shift change. During an interview with the resident representative on 06/27/25 at 11:37 AM , they stated Resident #67 received a left side floor pad in room on 6/25/25. Prior to that, the resident did not have floor pads in room despite their requests for them to be placed and bed is kept in lowest position. During an interview and observation on 6/27/25 at 4:03 PM, Certified Nurse Assistant #2 stated Resident #67 arrived back from emergency room at approximately 3:15 PM after a fall on 6/26/25. Floor mat was observed on the left side of resident bed. Resident was observed with redness on right temple area. Certified Nurse Assistant #2 stated they were assigned to provide 1:1 observation with Resident #67 until 11:00 PM. They stated that Resident #67 frequently yelled out and attempted to sit up in bed and get out of their wheelchair. They stated Resident #67 has had numerous falls and wass a fall risk. During an interview on 06/27/25 at 4:10 PM, Certified Nurse Assistant #3 stated Resident #67 is frequently agitated and strikes out and spits at staff. They stated that Resident #67 has one floor mat in place, left side, between the beds. Bed is kept in lowest position. They stated Resident #67 frequently had a 1:1 observation with a Resident Assistant. When not available, Certified Nurse Assistant staff checked frequently and sat with resident when possible. During an interview on 06/30/25 at 0:34 PM, Registered Nurse Unit Manager stated that Resident #67 has had a 1:1 observation aide assigned since returning from emergency room after a fall on 6/26/25. They stated 1:1 observation was provided as needed basis prior to this. They stated they were not aware why only one floor mat was placed in Resident room on left side, between beds and they would investigate why there are not bilateral bedside floor mats in place. During interviews on 07/02/25 at 11:23 AM and 07/03/25 at 02:22 PM, the Director of Nursing stated they were aware of Resident #67's frequent falls and had fall care plans in place which were updated after incidents. They stated Resident #67 fluctuates between being agitated and periods of being cooperative. When behavioral issues are observed, close monitoring is put in place. They stated physical therapy had assessed Resident #67 numerous times and was not a candidate for services due to dementia/behaviors. They stated the missing accident and incident reports and investigations should have been completed by the Unit Manager on unit who was no longer employed by facility. During an observation on 7/2/25 at 4:45 PM, Resident #67 observed in room with 1:1 observation staff present. Bilateral floor pads in place. During an interview and observation on 7/3/25 at 9:54 AM, Director of Rehabilitation stated the bilateral floor mats order was placed on 6/2/25. During an interview on 07/03/25 at 10:31 AM with the Director of Social Work, they stated that Resident #67's falls have been a concern for the Residents family representative and for the facility. They stated that family representative stated they were happy with facility but wanted more interventions to assist in decreasing fall activity including 1:1 observation on a regular basis. They stated family representative had not mentioned floor mats at care plans meetings. A review of the electronic medical record with Social Worker observed a note from 12/27/24 documenting family representative requesting floor mats and bed in lowest position. The Director of Social Work stated the documented note and conversation was with a prior facility Social Worker and they were not aware of the note or request. During an interview and observation on 7/03/25 at 12:00 PM, the Facilities Director stated nursing or therapy staff add an order for floor mats when required for a resident to the maintenance work order software program. Once order is received, mats are delivered to resident room, usually the day order received. Requests were reviewed, 6/2/25 requested fall mats please be placed on the left and right side of Resident #67's bed. The Facilities Director stated the work order was completed 6/5/25. On 6/30/25 a work order documented: please put floor mat for the right side of resident's bed. There is one on left side, none on the right side. Facilities Director stated they presented to Resident #67's room and found that a right mat was in the room but on the window side folded against the wall of room. There was no other order in the system for floor mats to be placed in Resident #67's room prior to 6/2/25.10 NYCRR 415.12 (h) (2)

FACILITY Based on observations, record review, and interviews during the recertification survey from 6/25/25 to 07/03/25, the facility did not ensure a medication error rate of no more than 5%, during a medication administration observation, when 4 of 40 opportunities (10.0%) resulted in error for 1 of 4 residents (Resident #22) observed. Specifically, 1) Resident #22 was administered two inhalant medications (Incruse Ellipta and Fluticasone-Salmeterol) in succession without having the resident rinse their mouth in between and after inhalations or waiting one to three minutes in between inhaler administration. 2). Resident #22 was administered two different eye drops medications (artificial tears and cyclosporine emulsion) to the bilateral eyes without waiting three to five minutes in between administation to allow for absorption. The findings are: The facility policy titled Administration of Medication - General, revised 3/25, documented: It is the facility policy that medications will be administered to residents in a timely and accurate manner by a licensed nurse or physician. Resident #22 was admitted to the facility with diagnoses including but not limited to chronic obstructive pulmonary disease, type II diabetes mellitus and anemia. The Minimum Data Set (an assessment tool) dated 4/7/25 documented the resident had moderate cognitive impairment. A physician order dated 6/22/25 documented Incruse Elllipta inhalation aerosol powder breath activated, 62.5 micrograms. One puff daily orally one time a day for chronic pulmonary obstructive disease. A physician order dated 6/22/25 documented Advair Diskus Aerosol Powder Breath Activated 100-50 micrograms/dose (Fluticasone-Salmeterol), one inhalation. Inhale orally one time a day for chronic pulmonary obstructive disease. Rinse after use. A physician order dated 6/22/25 documented Artificial Tears Ophthalmic Solution 0.5-0.6% (Polyvinyl Alcohol-Povidone (Ophth). Instill one drop in both eyes two times a day for dry eyes. A physician order dated 6/22/25 documented cyclosporine emulsion 0.05 %. Instill one drop in both eyes two times a day for dry eyes due to inflammation. During an observation of medication observation on 06/30/25 at 09:58 AM, Licensed Practical Nurse # 7 administered two different inhaler medications (fluticasone-salmeterol and Incruse Ellipta) without rinsing in between or after each administration. Licensed Practical Nurse was also observed administering two different eye drop medications (artificial tears and cyclosporine emulsion) to Resident #22 right after each other, without allowing three to five minutes for absorption in between medications. During an interview on 07/01/25 at 12:13 PM, Licensed Practical Nurse Unit Manager #17 stated nursing staff administering inhalation medications should have resident pause for one to three minutes in between inhaler pump medications and resident's mouth should be rinsed in between and after different inhalant medications are administered. They stated that eye drop medications should not be given immediately after each other. There should be a five-to-ten-minute wait in between eye drop administration. During an interview on 07/01/25 at 12:17 PM, Licensed Practical Nurse #7 stated they are aware that the eye drops administered to Resident #22 were administered right after each other. They stated they should have waited three to five minutes in between administering medications. They stated they are also aware that they did not provide a time interval in between inhalant pump medications administered to Resident #22. They stated they should have asked Resident #22 to rinse mouth in-between and after inhaler administration or provided education if resident #22 refused to rinse. 10NYCRR 415.12(m)(1)

Based on observations and interviews, during the Recertification Survey from 6/25-7/3/25, the facility did not ensure that all drugs and biologicals accessible for use were not expired and that all drugs and biologicals were stored in locked compartments accessed only by authorized personnel. Specifically, 1) nine boxes of Sequirus Flucelvax influenza vaccine were observed in freezer section of the Third floor unit medication refrigerator, 2) expired biologicals and medications for five residents no longer in the facility or no longer receiving medications were found stored in the Third floor medication room and not returned to the pharmacy or disposed of and 3) expired and undated medications were observed in the Second and Third floor units medication carts. Findings include:The Facility policy titled, Storage of Medication, revised 1/2/25, documented that the facility stores all drugs and biological in a safe, secure and orderly manner. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 1) During an observation and interview on 6/30/25 at 02:06 PM of the medication storage room on the third floor, accompanied by Licensed Practical Nurse #9 and Registered Nurse Unit Manager #5, the following was observed:During an observation of the medication refrigerator, nine (9) boxes of Sequirus Flucelvax influenza vaccine were stored in freezer portion of refrigerator. The freezer was observed with ice formation in and around the freezer section. Registered Nurse Unit Manager #5 stated they were not aware why the Sequirus Flucelvax vaccinations were stored in the freezer and removed medication to be discarded. 2) During an observation of sink/countertop area and a three-drawer plastic storage unit, unused medications for five residents were observed. Licensed Practical Nurse #9 stated the medications were no longer administered due to residents being previously discharged or residents no longer taking the prescribed medication. They stated medications should have been disposed of or returned to pharmacy. Twenty-nine (29) 23-gram x 1.09 safety syringes were observed in plastic storage Unit. The safety syringes expired 5/31/24. Registered Nurse Unit Manager #5 removed syringes and medications for disposal. 3) During an observation and interview on 07/01/25 08:36 AM of the Third-floor unit medication cart, the following were observed: Breo ellipta 200-25 microgram/ 30 inhaler. Directions documented to discard six weeks after opening. Medication not dated when opened. Twenty-nine doses remaining. Incruse Ellipta 62.5 microgram/30 inhaler. Directions documented to discard six weeks after foil tray opened or when counter reads zero, whichever comes first. Twenty-nine inhalations remaining. Medication not dated when opened. Fluticasone and salmeterol oral inhalation. 100-50 microgram /60. Directions documented to discard one month after opening. Medication not dated when opened. Lantus Solostar pen 3 milliliters. Directions stated to discard after 28 days at room temperature. Medication not dated when opened. Humalog Kwik pen 3 milliliter. Directions documented once opened, discard after 28 days. Dated opened 5/15/25.During an interview with Registered Nurse Unit Manager #5 on 07/01/25 at 08:36 AM, they stated all expired medications will be removed from medication room and carts.During an observation on 07/01/25 at 11:14 AM of the Second-floor unit cart, the following expired medications were found:Tresiba FlexTouch 100 units/milliliter. Directions documented once opened store at room temperature for up to fifty-six days. Medication not dated when opened. Two insulin aspart 100 units/milliliter flex pens. Directions documented once opened, store at room temperature for up to 28 days. Both medications were opened 5/15/25. Admelog Solostar 100 unit/milter 3 milliliter pen. Directions documented once opened, store at room temperature for up to twenty-eight days. Medication opened 5/10/25. During an interview and observation on 07/01/25 at 12:01 PM Licensed Practical Nurse Unit Manager #17, medications found in medication cart that were out of date or not dated when opened were reviewed. They stated the expectation is for nursing staff to date all medications, including insulins, eye drops, inhalers, when opened. They stated they should also document expiration date for timed medications such as medications that need to be disposed of twenty-eight days after opening. They stated unit medication carts are reviewed by Pharmacy and expired / no longer used medications are removed. They stated they were not aware how often this occurs. They stated they were also not sure of schedule for unit nurses to conduct review of medications carts for expired medications. During an interview on 07/01/25 at 1:39 PM, the Pharmacon Pharmacist stated medication rooms and carts are reviewed once a month and as needed for expired medications and to pick up / remove unused/expired medications. They stated facility staff are expected to also check medication carts/rooms to ensure there are no expired medications. They stated all medication should be dated when opened. During an interview on 07/01/25 at 2:18 PM, Pharmascript Pharmacist stated that medication should be dated when opened including insulins and inhalers and removed from medication carts when expired.During an interview on 07/02/25 at 12:10 PM, the Director of Nursing stated nurses should check expiration dates on medications prior to administration and expired meds should be removed from carts. They stated medication carts and rooms are checked by nursing night shift weekly on Sundays. Expired/no longer used medications are removed from medication rooms on Monday, Wednesday and Friday and as needed. They stated medications that are no longer used are returned to pharmacy about once every two weeks when Pharmascript representative comes to facility. NY10CRR 415.18(e)(1-4)

Based on record review and interview during the recertification survey conducted 06/25/25 to 07/03/25, the facility did not ensure each resident was offered influenza and pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations for 1 of 5 residents (Resident #25) reviewed. Specifically, there was no documented evidence Resident #25 had been offered, declined, or educated about the influenza and pneumococcal and immunization.Findings include:The facility policy for Influenza Vaccine dated 3/2024 and reviewed 3/2025 documented the purpose is to reduce morbidity and mortality from influenza by vaccinating all residents who meet criteria established by the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices The facility policy for Pneumococcal Vaccination dated 5/23/23 and last reviewed 3/2025 documented, it is the policy to provide pneumococcal vaccinations to all residents on admission to reduce morbidity and mortality in accordance with Centers for Disease Control and Prevention and the New York State Department of Health recommendations.Resident #25 had diagnoses including Adult Failure to Thrive, hypertension and interstitial lung disease. The Minimum Data Set, an assessment tool, dated 3/31/25 documented the resident had severe cognitive impairment, and needed partial assistance from staff for personal hygiene.There was no documented evidence the resident/resident representative received education, was offered the vaccination, or declined the influenza or pneumococcal vaccine.During an interview on 07/03/25 at11:40 AM the Assistant Director of Nursing and Infection Preventionist, stated the admitting nurse was responsible for gathering the resident's vaccine data and putting it in the resident's record. They were new to the facility and were not at the facility in the fall so they do not know what happened in this case, but all residents need to have their vaccine status addressed so they can determine what vaccines the resident needs. During an interview on 07/03/25 at 09:58 AM the Director of Nursing stated the facility process included all residents were offered vaccines on admission. Residents should be offered vaccines when they were eligible for those vaccines. 10NYCRR 415.19 (a) (1-3)