Every finding on record at Hudson Hill Center for Rehabilitation & Nursing

Based on observation, interviews and record review, the facility failed to ensure each resident received adequate supervision and/or assistive devices to prevent elopement for two of six residents (Resident #1, Resident # 2) reviewed for elopement. Specifically, 1) Resident #1 was assessed as an elopement risk on 05/20/2026, refused a wander guard and was placed on hourly head counts. On 06/19/2026, Resident # 1 eloped from the facility with the last hourly head count for Resident #1 documented at 10:00 AM. Subsequently, the Nurse Progress Note dated 06/20/2026 at 01:00 PM documented the facility received a phone call from a detective at the [NAME] Police Department, who confirmed that Resident # 1 had gone to Resident # 1's Representative's residence (Manhattan) and stayed there overnight; and 2) Resident #2's medical record revealed that the resident had a physician order for a right wrist wander guard and was assessed on 05/26/2026 as an elopement risk. On 06/23/2026 at 02:14 PM, Resident # 2 was observed sitting in the dayroom with no wander guard in place. The facility's failure to conduct an hourly head count to monitor Resident #1 who was an elopement risk resulted in Resident #1 eloping from the facility which posed a likelihood for serious injury, serious harm, serious impairment, or death that was Immediate Jeopardy and Substandard Quality of Care. The findings include:The facility's policy titled Elopement Prevention/Wandering Behavior Management last reviewed on 09/05/2025 documented utilize all possible measures to maintain the safety and well-being of all residents. Have system and tools in place that are reasonable to identify and prevent unsafe wandering and/or elopement and act quickly and prudently should either occur.1) Resident # 1 had diagnoses that included but were not limited to dementia (loss of thinking, remembering and reasoning skills), aphasia (communication disorder affecting speech and understanding), and depression (mood disorder that causes persistent sadness and loss of interest).The Elopement assessment dated [DATE] documented that Resident # 1 had a score of 0, (not an elopement risk).The Nursing Progress Note dated 05/20/2026 at 04:55 PM documented staff reported that the resident was observed unescorted and smoking in the patio area. Resident # 1 stated, I like to smoke sometimes, not every day. Resident # 1 was educated regarding the facility's smoking policy and informed them that a smoking contract will be required. Resident # 1 verbalized understanding. Resident # 1 was also reminded that they were not permitted on the patio without staff supervision. When asked if they had a lighter or extra cigarettes, Resident #1 refused and refused to consent to a room search. Resident # 1 also refused to have a wander guard. Resident # 1's picture was given to the front desk. Social Worker #1 was notified. The Medical Director was notified. Review of Elopement assessment on 05/20/2026 indicated that Resident # 1 had a score of 1; indicating the resident was an elopement risk.The Comprehensive Care Plan for elopement dated 05/20/2026 documented Resident# 1 was at risk for elopement and Resident #1 refused the wander guard. Encourage facility sponsored activities. Ensure all door alarms are working. Ensure Interdisciplinary team is aware of the wandering and elopement risks. Involve the family in the plan of care. Picture of the resident to be given to the front desk for additional layer of monitoring. Wandering and elopement risk assessment must be initiated upon admission and as needed.The quarterly Minimum Data Set (a resident assessment tool) dated 05/23/2026 documented Resident #1 had severe cognitive impairment, did not document that resident had wandering or exit seeking behaviors. Instead, it documented that there were no behaviors, no impairment to the upper and lower extremities, and there was no wander alarm in place.Review of the 5th floor headcount/visuals checks for 07:00 AM- 03:00 PM shift for 06/19/2026 documented that Resident #1 was last seen in the facility at 10:00 AM, by using a code 4 which indicated Resident #1 was in the dayroom. There was no documented headcount/visual check for Resident #1 after 10:00 AM on 06/19/2026. The nursing progress note dated 06/20/2026 documented on 06/19/2026 while the writer was in the dining room during dinner, Certified Nurse Aide # 1 reported that Resident # 1 was not in their room (dinner arrived on the unit late, approximately 06:20 PM). Facility elopement protocol was followed. Front desk announced Code Orange (staff alert). Room search was done. The nursing supervisor (Nursing Supervisor # 1) was notified.The Nursing Progress Note dated 06/20/2026 at 09:21 AM written by Registered Nursing Supervisor # 1 Late Entry for 06/19/2026 at 07:00 PM, documented Resident # 1 was observed not in their bed, Code Orange initiated, and a comprehensive facility search was conducted; 911 was contacted. Resident #1's Representative was notified and reported that Resident #1 had called them stating they were outside the facility. Law enforcement remains actively engaged in the search, and the facility will continue to follow up for updates.The Nursing Progress Note dated 06/20/2026 at 1:00 PM, documented the facility received a phone call from a detective at the [NAME] Police Department, who reported that they successfully spoke with Resident #1's Representative. The detective confirmed that Resident #1 had gone to Resident #1's Representative's residence and stayed there overnight. During a telephone interview on 06/23/2026 at 04:57 PM, Resident #1's Representative confirmed that Resident #1 was at home with them, and that Resident #1 took three buses to get to Manhattan where they are located. They stated when Resident #1 arrived, they were dressed appropriately. Resident #1's Representative stated the facility informed them that the resident left the facility. Resident # 1 stated to them that they did not want to be in the nursing home, and they were uncomfortable, and wanted to go back to the hospital as opposed to the nursing home. Resident #1's Representative stated that every second or third conversation with the resident, the resident verbalized to go home. A police officer did a wellness check and confirmed that Resident #1 was there. Resident #1 answered the door when the police knocked. Resident #1's Representative stated they spoke to Social Worker # 1 yesterday to report that Resident #1 was at their house, and they would come to the facility to pick up their belongings. Resident #1's Representative stated when Resident # 1 arrived, they had no bruises and no evidence of altercation. During an interview on 06/24/2026 at 10:12 AM, the Director of Nursing stated they suspended staff involved who were working on the day of 06/19/2026. They stated Resident #1 looked like a visitor, and for over a year Resident #1 did not attempt to leave. The Director of Nursing stated on the date of the incident, 06/19/2026, Resident #1 was able to walk out of the building without staff noticing. They stated when staff passed the dinner tray at approximately 06:00 PM - 06:30 PM, staff did not see Resident # 1 and reported to the supervisor. Code Orange was initiated, and police were notified.During an interview on 06/25/2026 at 11:19 AM, Social Worker #1 stated they were aware that Resident #1's Representative wanted the resident to transfer to another facility. Social Worker #1 stated Resident #1 had a speech impairment and had mentioned to them during six out of 10 conversations that they wanted to leave the facility. Social Worker #1 stated Resident #1 was ambulatory, frequently went to the basement to get money, and would go to the vending machine in the basement independently. Social Worker #1 stated Resident # 1 was never at risk for elopement. Social Worker #1 stated Resident # 1 had a daily routine which included sitting on a chair by their room, going to the basement and business office, or going to the vending machine for snacks.During a telephone interview on 06/25/26 at 12:10 PM, Registered Nurse #1 stated Resident #1 never verbalized to them that they wanted to leave the facility. Resident #1 was an elopement risk and was supposed to have a wander guard but refused it. They stated if residents were an elopement risk, other interventions were put in place such as head count every hour to check the resident. They stated that 06/10/2026, they arrived at work for the 3:00 PM-11:00 PM shift, did rounds and did not see Resident #1 on initial rounds. They stated they assumed that Resident #1 was off the unit because that was their normal routine. They stated the certified nurse aide assigned to the resident never reported to them that Resident #1 was not accounted for in the head count. They stated they were not made aware that Resident #1 was missing until the dinner tray was passed by Certified Nurse Aide #1. They stated Resident #1's routine was to go throughout the building unsupervised, and they were not concerned about supervision because Resident #1 would return to the unit. They stated the hourly head count was the prevention of elopementDuring a telephone interview on 06/29/2026 at 02:23 PM, the Medical Director stated they were aware of the incident on 06/19/2026 concerning Resident #1's elopement. They stated Registered Nursing Supervisor #1 called them to report Resident #1 was missing from the facility. The Medical Director stated they did not write a note on the elopement for Resident # 1. They stated the facility notified them that the police were called, and they did not know exactly what happened. The Medical Director stated they did not remember if anyone reported to them that the resident was found. The Medical Director stated they were responsible for resident care and addressing clinical needs.2. Resident # 2 had diagnosis that included but were not limited to unspecified dementia, (loss of thinking, remembering and reasoning skills), psychotic disturbance, mood disturbance (loss of contact with reality, disorganized thinking), anxiety (feeling of worry and unease), and bipolar disorder (significant mood swings)The quarterly Minimum Data Set, dated [DATE] documented Resident#2 had severe cognitive impairment with no behaviors. Resident 2 had no impairments to the upper and lower extremities and had a wander/elopement alarm.The Comprehensive Care Plan for Elopement, last revised 02/27/2026, documented Resident #2 was at risk for elopement related to confusion and memory lapses. Wander guard to the right wrist, serial # 8CC1CA expiration date 2/20/2026. Distract resident with another activity when risk is more prevalent. Encourage facility sponsored activities. Ensure all door alarms are working. Ensure interdisciplinary teams are aware of the wandering and elopement risk. Notify provider of resident risks for wandering and elopement. Psychiatric consult as needed. Wandering and elopement risk assessment must be initiated on admission and as needed.The Physician Orders dated 02/20/2026 documented Wander Guard to the right wrist- Check placement every shift and monitor for safety.The Elopement assessment dated [DATE] documented that Resident # 2 had a score of 1, (an elopement risk).During an observation on 06/23/2026 at 02:14 PM, Resident # 2 was in the dayroom on the Behavior Monitoring Unit with no wander guard in place.During an interview on 06/23/2026 at 02:19 PM, Certified Nurse Aide # 8 stated Resident # 2 was on their assignment. They stated five residents on their assignment had wander guards in place. Certified Nurse Aide # 8 stated Resident #2 had a wander guard in place this morning on their left ankle when they assisted Resident #2 with putting on their socks. Certified Nurse Aide #8 stated Resident #2 sometimes takes off the wander guard. Certified Nurse Aide #1 stated the purpose of wander guard, was to sound an alarm if the resident attempted to get on the elevator. They stated this would prevent them from leaving the unit.During an observation on 06/23/2026 at 2:30 PM, Resident's # 2's wander guard was carried over to the elevator, after the elevator door closed surveyors were able to reach the basement with the wander guard in hand. The elevator alarm did not activate.During an interview on 6/23/2026 at 02:40 PM, the Administrator was informed that Resident #2 did not have their wander guard in place and that Resident #2's wander guard was checked for functioning and did not activate the elevator alarm. The Administrator stated that the system was checked and functioning properly. Administrator stated the facility also conducts hourly head counts, and there is binder at the front desk that identified all residents that are an elopement risk.During an interview on 06/23/2026 at 02:40 PM, the Director of Nursing stated when a resident refused to wear a wander guard, the facility conducted hourly monitoring and documented the monitoring on paper. 10 New York Code Rules Regulations 415.12(h)(2)The survey team identified Immediate Jeopardy, and the facility Administrator was notified on 06/25/2026 at 04:15 PM.On 06/26/2026 at 08:43 PM, the survey team determined the Immediate Jeopardy was removed based on the following corrective actions taken by the facility:a. Termination of employees that did not follow the facility's protocol for elopement.b. Elopement Assessments for all ambulating residents reviewed on 06/20/2026 and updated if necessary.c. Nursing department continued to conduct hourly headcount/visual checks for all residentsd. The functionality check audit for the wander guard was updated on 06/23/2026 to be individualized for each resident with a wander guard and will continue to be completed nightly.e. Certified Nurse Aides checked placement of the wander guards every shift.f. Elopement policy was reviewed and revised to include headcount and visual checks. A designated binder will be kept at the security desk for a list of residents at risk for elopement along with their pictures and identifying information regarding each resident.g. Elopement education and lesson plan in-services were conducted. Employee roster received with education sign off sheets. As of 06/26/2026 according to provided roster and education sign off sheets, of employees have been educated as follows: Nursing 174/183=95%, Rehabilitation 31/33=94%, Dietary 29/30= 97%, Maintenance 4/4=100%, Administration 17/22=77%, Social Work- 4/4=100%, Recreation 10/10=100%, Housekeeping 26/26=100%. Total number of staff educated 297/314= 94.6%.

Based on record review and interview the facility failed to ensure that the resident, resident representative, were informed in writing and in a language and manner they understood for one of eight (Resident #1) residents reviewed for discharge. Specifically, there was no documented evidence in the medical record to indicate the facility had ongoing communication and follow up to address the 05/22/2026 Resident Representative's inquiry regarding Resident #1 being transferred to a skilled nursing facility closer to their home in [NAME] New York. Resident #1 eloped and was subsequently discharged unplanned from the facility on 06/19/2026, and there was no documented evidence that a Notice of Discharge was provided as soon as possible to Resident #1, their Resident Representative and the Ombudsman and there was no documented evidence that the facility offered assistance with post discharge care. The findings include:The Policy for transfer and discharge reviewed 12/2025 documented resident-initiated transfer means the resident or representative has provided verbal or written notice of intent to leave the facility. The medical record must contain documentation or evidence of the resident's or resident representative's verbal or written notice of intent to leave the facility. A resident's expression of a general desire or goal to return home or to the community or elopement of a resident who is cognitively impaired should not be taken as notice of intent to leave the facility.Resident #1 had diagnoses including unspecified dementia, aphasia and depression. The comprehensive Care Plan for Discharge initiated on 08/31/2023 and last revised on 08/31/2023 documented Resident # 1 will remain in long term placement. Include Involve family/responsible parties in discharge planning and provide emotional support as needed.The 05/22/2026 Social Worker Note written by Social Worker # 1 documented resident care plan meeting. Resident #1 could not participate due to impaired cognition. Resident's Representative was able to participate via teleconference. All questions answered, no concerns at this time. Resident's Representative inquired about Skilled Nursing Facility transfer closer to their home in [NAME] New York. Social Worker educated the Resident Representative on Skilled Nursing Facility transfer process and details. Social Worker will request Patient Review Instrument and Screen from the Director of Nursing/Director of Social Work and refer to Skilled Nursing Facility closer to the Resident Representative. Will continue to monitor.The quarterly Minimum Data set (assessment tool) dated 05/23/2026 documented Resident #1 had severe cognitive impairment, and no wandering behavior.The 06/02/2026 at 1:24 PM Social Service Note Resident # 1 remains long term. Will continue to monitor for any changes. Continue with Plan of Care.Resident #1 eloped from the facility unsupervised on 06/19/2026.The discharge Minimum Data set (assessment tool) dated 06/19/2026 documented discharge assessment return not anticipated. unplanned discharge. Discharge status to home/community.06/20/2026 at 06:41 AM Nurse Progress Note Documented Resident #1 remains out of the building.The 06/20/2026 at 02:51 PM Nurse Progress Note documented received a call from the [NAME] Detective who reported that they successfully spoke to Resident #1's Representative and confirmed that Resident #1 had gone to the Resident Representatives house and stayed there overnight. The Detective stated that the Resident Representative had been instructed to notify the facility if Resident #1 intends to return, so that appropriate follow up and the proper discharge process can be conducted. This information has been documented for continuity of care and coordination with all parties involved.During a phone interview on 06/23/2026 at 04:57 PM, the Resident Representative stated Resident #1 was with them at home, and that the resident told them they did not want to be in the nursing home. The Resident Representative stated they spoke to the facility Social Worker yesterday to report that Resident #1 was at their house, and they would be going to the facility to pick up Resident #1's belongings. During a subsequent phone interview on 06/25/2026 at 09:35AM, the Resident Representative stated the Social Worker informed them that Resident #1 was not allowed back because of the way Resident #1 left.During an interview on 06/25/2026 at 11:16 AM Social Worker #1 stated six out of 10 conversations with the resident, the resident would verbalize they wanted to leave the facility, to go home. Social Worker #1 reviewed their Care Plan Note dated 05/22/2026 and stated they were in the process of trying to find placement for the Resident. They stated they attempted to have the resident placed in a local assisted living facility, but the resident did not meet the criteria to be placed. Social Worker #1 stated they were aware that the Resident Representative wanted Resident #1 transferred to another facility. Social Worker # 1 stated they could not proceed forward with the discharge because the Resident Representative never provided them with a list of Skilled Nursing Facilities in their areaDuring a telephone interview on 6/29/2026 at 2:23 PM the Medical Director stated they were aware of the incident on 06/19/2026 when Resident # 1 left the facility. The Medical Director stated Resident # 1 had dementia. The Medical Director stated when a resident was to be discharged , they assisted with discharge plans by sending medication requests to the pharmacy, writing discharge summaries, and assessing residents to ensure they were medically stable. They stated they were not aware that Resident # 1 was discharged from the facility. The Medical Director stated their notes are clinical notes therefore; they did not write a note for the elopement incident or discharged uring an interview on 06/29/2026 at 02:55 PM, the Director of Social Work stated Resident #1 was discharged from the facility as an unplanned discharge. They stated they did not send a discharge notification to the ombudsman. They stated for any unplanned discharge, there should be a signed form that education was provided, and that residents were notified about the risk. They stated there should be documentation in the progress note. They stated they were not sure if the process for unplanned discharge was followed for Resident #1. They stated they did not talk to Social Worker #1 about the discharge of Resident #1. They further stated it was never brought to their attention that Resident #1 wanted to leave the facility.During an interview on 06/29/2026 at 04:21 PM the Administrator stated Resident #1 eloped, and their Representative had no intention of bringing them back. They stated the Resident Representative came in on Friday to pick up the resident's belongings. They stated the elopement itself was a discharge. They stated they would double check if there was a discharge note.10 New York Code Rules and Regulations 415.3

Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan was reviewed and/or revised for two of 36 residents (Resident #1, Resident #2) reviewed for care plan. Specifically, 1. for Resident #1 who was assessed on 05/20/2026 to be at risk for elopement and refused to wear a wander guard the comprehensive Care Plan was not reviewed and/or revised to address every one hour head count/visual checks and 2. for Resident #2 there was no documented evidence that the comprehensive Care Plan was reviewed and/or revised to address certified nurse aide reports that Resident #2 did not always wear a wander guard and a 06/23/2026 at 2:14 PM observation of Resident #2 without a wander guard. Additionally, the Care Plan was not updated to reflect the change to the wander guard serial # 8CC1CA after a new wander guard was provided on 06/23/2026. The findings include: The policy for comprehensive Care Plan reviewed 09/20/2025 documented an individualized comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Care Plans are revised as changes in the residents' condition dictate. 1.Resident #1 had diagnoses including unspecified dementia, aphasia and depression. The 05/20/2026 Elopement Assessment indicated Resident #1 had a score of 1.0 (at risk). The comprehensive Care Plan dated 05/20/2026 documented Resident #1 was at risk for elopement and refused the wander guard. Encourage the resident to attend facility sponsored activities, ensure all door alarms are working, ensure Interdisciplinary Team is aware of the wandering and elopement risks, involve family in the plan of care, and a picture of the resident was to be given to the front desk for an additional layer of monitoring. There was no documented evidence in the comprehensive Care Plan to address every one-hour head count/visual checks. The quarterly Minimum Data set (assessment tool) dated 05/23/2626 documented Resident #1 had severe cognitive impairment, no wandering behaviors, no impairment in upper and lower extremities, and ambulated with supervision or touching assistance. 2. Resident #2 was admitted with diagnosis including dementia, bipolar, psychosis, and anxiety. The 02/27/2026 comprehensive Care Plan for risk for elopement related to confusion and memory lapse documented wander guard to the right wrist serial # 8CC1CA, distract resident with another activity when risk is more prevalent, encourage resident to attend facility sponsored activities, ensure all door alarms are working, ensure Interdisciplinary Team is aware of the wandering and elopement risk. The 03/01/2026 comprehensive Care Plan documented poor safety awareness due to attempt to leave the facility, dementia; Wanders with no rational purpose. Approach calmly when redirecting resident, family to inform staff when ending visit, initiate code orange if an elopement occurs, invite and encourage participation in activities program, and place name band. The 05/29/2026 quarterly Minimum Data Sat documented severe cognitive impairment, and no wandering behavior. During observation and interview on 06/23/2026 at 2:14 PM, Resident #2 was observed sitting in the day room, without the wander guard. Certified Nurse Aide #2 stated that Resident #2 had no wander guard on. Certified Nurse Aide #2 stated Resident #2 must have removed the wander guard and stated the wander guard must be in Resident #2's room. Certified Nurse Aide #2 left the day room and upon return stated they found the wander guard in the resident room. During an interview on 06/23/2026 at 2:19 PM, Certified Nurse Aide # 8 stated Resident #2 had their wander guard on that morning. Certified Nurse Aide #8 stated that Resident #2 sometimes removed their wander guard. During an observation on 06/23/2026 at 2:30 PM, Resident's # 2's wander guard was carried over to the elevator, after the elevator door closed surveyors were able to reach the basement with the wander guard in hand. The elevator alarm did not activate.During an interview on 6/24/26 at 4:12 PM Certified Nurse Aide # 6 stated that they are able to monitor the residents on the unit because the door is closed and when someone comes on the unit or leaves the bell will ring. They stated the bell is an alert for them to watch the door to see who is entering the unit and who is leaving the unit. They stated Resident # 2 removed their wander guard at times. They stated if the wander guard was not in place, then they searched the room. They stated Resident # 2 placed the wander guard in their drawer. Certified Nurse Aide # 6 stated if the wander guard was not in place on Resident # 2's they would report it to the nurse. They stated Resident # 2 had the wander guard in place when they arrived on shift today and that they were never told that Resident # 2 removed their wander guard yesterday. There was no documented evidence that the comprehensive Care Plan was updated with measurable goals and interventions to address certified nurse aide reports that Resident #2 did not always have a wander guard on and observation of Resident #2 without the wander guard on 06/23/2026. During an interview on 06/24/226 at 4:18 PM Registered Nurse Supervisor # 1, stated that on 06/23/2026 the Assistant Administrator informed them that Resident # 2 did not have a wander guard. Supervisor # 1 stated the Assistant Administrator gave them a new wander guard for Resident #2. Supervisor #1 stated the care plan was supposed to be updated but it was not. Supervisor #1 stated they were responsible for documentation but stated that they missed it. 10 New York Code Rules Regulations 415.11(c)(2)

Based on observation, record review, and interviews during survey, the facility failed to ensure that the residents' environment remained as free of accident hazards as is possible with the use of assistive device for one (1) (Resident #169) of four (4) residents reviewed for accidents. Specifically, the use of a left-enabler bar (bar attached to the bed designed to facilitate movement, improve safety) was not implemented as per physician order for Resident #169, which resulted in a 04/05/2025 fall from bed when Certified Nurse Aide #8 turned Resident #169 onto their left side during care. Subsequently, Resident #169 was transferred to the hospital and diagnosed with a right intertrochanteric (thigh bone) fracture (broken bone). This resulted in actual harm to Resident #169 that was not Immediately Jeopardy. The findings included: The Assessment for enabler bars dated 01/13/2025 completed by the rehabilitation department documented an enabling device is indicated to promote independence. Left-enabler device recommended. Request made to maintenance to install an enabling device. Nursing notified.Resident #169 had diagnoses including obesity (excessive body fat), paraplegia (inability to voluntarily move legs), and generalized weakness.The Physician Order dated 01/14/2025 documented left-enabler bar for bed mobility to aid in turning and positioning on every shift.The Care Plan for enabler-bar dated 01/14/2025 documented may use enabler bars. There was no documented evidence that goals and interventions were added to the Care Plan to address the use of enabler bars prior to 05/06/2025. The admission Minimum Data Set (a resident assessment tool) dated 01/17/2025 documented Resident #169 was cognitively intact, had functional impairment of one (1) upper extremity (arm) and both lower extremities (legs), was dependent with rolling from their back to side and was not at risk for falls.The Accident and Incident form dated 04/05/2025 at 5:30 AM completed by Registered Nurse #21 documented that Resident #169 slipped off the bed when Certified Nurse Aide #8 was turning the resident. Resident #169 had no visible injury but was holding their head in pain and complaining of pain in their lower extremity. Review of the written statement completed by Certified Nurse Aide #8 dated 04/05/2025 documented that they were giving care to the resident. They turned the resident to the left to clean the resident, and the resident started to shake. The right leg slipped down, and the resident fell out of bed. There was no documented evidence on the 04/05/2025 Accident and Incident form that indicated a left enabler bar was in place. There was no documented evidence on the 04/01/2025 - 04/31/2025 Certified Nurse Aide Follow Up Question Report to address the use of a left enabler bar.The Progress Notes dated 04/05/2025 at 6:12 AM by Registered Nurse Supervisor #21 documented the floor nurse called for assistance. The resident had a fall at 5:30 AM. The resident rolled off the bed during care (as per certified nurse aide). The resident was holding their head in pain, with no change in mental status, and no visible injury was noted. The Medical Doctor was notified and ordered a transfer to the emergency room for an X-ray of the head to rule out a head injury. Emergency Medical Services on its way.The Emergency Department Visit Summary dated 04/05/2025 documented that Resident #169 had a right intertrochanteric fracture.The Progress Note dated 04/11/2025 at 5:17 PM written by Registered Nurse Supervisor #21 documented the resident was readmitted from the hospital at 3:30 PM. The resident was brought in by ambulance and escorted by two (2) staff members. The resident had been treated for a right hip fracture after a fall and had undergone a surgical procedure with right gamma nailing (internal fixation of fracture). The resident was received in stable condition, alert, and oriented times three (3). The resident had a surgical wound on the right hip region. All orders were carried out, the Medical Doctor was notified, and the resident was made comfortable. The resident was to be continually monitored.The Summary of Investigation dated 04/15/2025 documented Resident #169 was on skilled physical and occupational therapy for therapeutic exercises and activities for activities of daily living training secondary to deconditioning. The resident used a left-enabler bar for bed mobility and was dependent on staff in most areas of activities of daily living. Certified Nurse Aide #8 was interviewed and recounted that they were providing care to the resident when, upon turning the resident to the left side, the resident started to shake, which led to the resident's right leg slipping off the bed, dragging the resident's whole body down to the floor. The resident was sent to the hospital for evaluation. The resident was care planned for one (1)-assist for bed mobility. There was no documented evidence on the 04/15/2026 Summary of Investigation that indicated a left enabler bar was in place. During an interview on 04/10/2026 at 1:43 PM, Physical Therapist #22 stated Resident #169 required substantial/maximum assistance (required 75 percent assistance; could only do a little for themselves). They stated Resident #169 required one (1) assist for bed mobility.During an interview on 04/14/2026 at 3:12 PM, the Director of Nursing stated Resident #169 had a left-enabler bar since January 2025. They stated they signed off on the accident/incident report completed on 04/05/2025 but were not aware if the left-enabler bar was in the up position. They stated they could not say if the left-enabler bar in the up position would have prevented the fall.During a telephone interview on 04/14/2026 at 3:40 PM, the Medical Director/Primary Physician stated they were familiar with Resident #169's condition and they were notified that Resident #169 had a fall that resulted in a hip fracture. They stated the left-enabler bar would have helped Resident #169, but when the resident slid off the bed, their motion was strong, and the resident kept falling.During an interview on 04/13/2026 at 9:34 AM, Resident #169 stated Certified Nurse Aide #8 turned and pushed them over too far. Resident #169 stated they fell on their right hip. They had surgery and had rods/screws placed in the right hip. They stated now they could help with turning because they have side rails, but before the fall they did not have enablers. Resident #169 stated that their condition caused spasms and prevented movement from their waist down. They stated they did not have spasms when they fell.During a telephone interview on 04/13/2026 at 11:49 AM, Certified Nurse Aide #8 stated they were giving Resident #169 peri care and turned the resident to wipe them. Resident #169's leg started to shake, and the resident slid out of the bed very quickly and fell on their right side on the floor. They stated the resident was on their assignment and this was not the first time they had taken care of the resident. They stated the resident needed one (1) assist for care, turning, and positioning.During an interview on 04/13/2026 at 1:20 PM, Registered Nurse #9 stated they were called to Resident #169's room by Certified Nurse Aide #8. They stated Resident #169 was on the floor complaining of a little back pain; no injury was observed, no bleeding, no mental status changes. They stated they called the nursing supervisor. They stated they took the resident's vital signs. They stated they could not recall Resident #169 having bed enablers. They stated the resident fell on the left side of the bed.During an interview on 04/14/2026 at 5:02 PM, the Administrator stated that the enablers on the second-floor beds could not be lowered/raised. They stated that all beds on the second floor were new in April 2025, and those are the same beds currently on the second floor. All enablers that were in place were fixed and could not be moved without tools. They stated that former Registered Nurse Supervisor #21, who completed the Accident/Incident report form, may not have seen the enabler at the time of the resident's fall, and that it may have been obscured by the mattress. The Administrator stated they reviewed the Accident/Incident Report and signed off on it but did not notice the discrepancy in the documentation regarding the enabler bar.10 NY CRR 415.12 (h)(2)

Based on observation and interviews during recertification survey and abbreviated survey (# 649776), the facility failed to ensure that food was stored and prepared in accordance with professional standards for food service safety. Specifically, 1) Resident #153 had complaint of expired milk in July 2025 2) the kitchen refrigerator/freezer and unit 4/unit 5 pantries contained unlabeled and undated food, 3) the unit 4 pantry and the kitchen contained expired foods and 4) milk was not maintained at the proper temperature. The findings include: The policy and procedure titled Storage of Perishable Goods reviewed 05/2025 documented, prepared foods are covered before storage and container must be labeled indicating content and date stored.The policy and procedure titled Dietary /Food Handling reviewed 06/2025 documented, guidelines for the safe preparation, handling and storage of perishable food: all potentially hazardous food must be maintained at 40 degrees Fahrenheit or less.The policy and procedure titled Staff Pantry Refrigerator Use reviewed 09/2025 dated 2025 documented, the facility provides the bottom drawer of the unit pantry refrigerator for staff use. All food items must be labeled with staff name and date, food must be in sealed containers, items unlabeled, and expired or older than 72 hours will be discarded.The policy and procedure titled Food Brought from the Outside reviewed 09/2025 documented, Food or beverage brought in from the outside will be labeled with the resident's name, room number and dated by nursing with the current date the item that was brought to the facility.1) Resident #153 reported that on 07/05/2025, they were provided milk for their cereal. The milk was added to the cereal and tasted off, as they drank the milk it was curdled and they noticed the date on the carton of milk was 07/03/2025.2) During the initial tour of the kitchen on 04/07/2026 at 9:44 AM the following was observed: a pan of cooked vegan chicken cutlets and veggie burgers unlabeled and undated, an opened brick of [NAME] cheese undated, two (2) open packages of shredded mozzarella cheese undated, pan of frozen peppers thawing in the refrigerator unlabeled and undated, pan of frozen waffles and muffins in freezer unlabeled and undated, and a pan of frozen chicken necks undated. During an observation of the unit 4 pantry on 04/07/2026 at 1:11 PM the refrigerator contained three (3) bags of undated and unlabeled food, unwrapped brick of cheese unlabeled and undated, a stick of butter in a plastic bag unlabeled and undated, and what appeared to be pickle slices in a specimen cup, unlabeled and undated.During an observation of the Unit 5 pantry on 04/14/2026 at 9:41 AM the refrigerator door contained a cut lemon in a plastic cup uncovered, undated and unlabeled, and the freezer contained two (2) fast food drinks with uncovered straws, one (1) undated and one (1) unlabeled.3) During the initial tour of the kitchen on 04/07/2026 at 9:44 AM the refrigerator contained eight (8) cartons of 8-ounce fat free milk with a 03/04/2026 expiration date, and a pan of cooked turkey breasts that expired 03/28/2026.During the observation of the Unit 4 pantry on 04/06/2026 at 1:11 PM the refrigerator contained a container of expired food dated 02/14/2026 and a bag of expired food dated 03/06/2026.4) During the initial tour of the kitchen on 04/07/2026 at 9:44 AM a diet aide assembled a rack of individual juice cups and some individual four (4) ounce portions of milk. The Food Service Director stated the racks were being prepared for the lunch tray line. The milk cups did not feel cold/cool to touch. The Food Service Director obtained a temperature of the milk at 69 degrees Fahrenheit.During an observation and interview on 04/07/2026 at 1:48 PM three (3) residents (Resident #98, #109, and #229) were heard stating the milk tasted sour. All milk cartons were checked for date and were dated 04/09/2026. Temperature of the milk was obtained at 58 degrees Fahrenheit. Registered Nurse Unit Manager #20 stated maybe the milk was warm because the lunch trays were delivered to the unit 30 minutes late. During an observation of the lunch tray assembly in the kitchen on 04/14/2026 at 11:42 AM temperatures were taken by the Food Service Director. The temperature of the milk was 47 degrees Fahrenheit. They stated the milk had not been delivered that long ago and possibly had not been in the refrigerator long enough before tray line started.During an interview on 04/07/2026 at 9:44 AM the Food Service Director stated staff had been educated on labeling and dating items that have been opened, and anyone can discard expired foods. They stated they were not sure why the eight (8) cartons of milk were expired when they had just received a delivery. They stated stock was rotated by the stocking staff person, and everything was dated when it was delivered. The Food Service Director stated they were not aware the diet aide was leaving the rack of juice and milk out of the refrigerator while preparing the rack for the tray line. During an interview on 04/07/2026 at 1:11 PM Registered Nurse Unit Manager #20 stated nursing staff was allowed to put their personal food and drinks in the unit pantry refrigerator, but they must be labeled and dated. They stated nursing staff was responsible for logging the refrigerator temperatures, and disposal of expired, unlabeled, and undated food. They stated they were not sure why there were items in the refrigerator that were expired, unlabeled and undated.10 New York Code Rules Regulations 415.14(h)

Based on observation, interview, and record review the facility failed to ensure that care and services were provided in accordance with resident preference and professional standards of practice that met physical and psychosocial needs for one (1) of one (1) resident (Resident #74) reviewed for rehabilitation and restorative. Specifically, a prosthetic fitting was not completed as per the 08/06/2025 vascular consultation recommendation for Resident #74 with a left below knee amputation. The findings included: Resident #74 was admitted to the facility with diagnoses including status post below knee amputation from diabetic ulcer and gangrene, diabetes mellitus and legally blind. The Vascular Consultation report dated 08/06/2025 documented left below knee amputation is healed, ready for prosthesis fitting. The facility's attending physician signed the consultation report. The Nursing Progress note dated 08/06/2025 documented the resident returned to the unit in a wheelchair with the following recommendation, left below knee amputation is healed and ready for prosthesis fitting. Physician notified. The Physician Order dated 08/06/2025 documented physical therapy screen, evaluation, and treat. There was no documented evidence of a physician order to address the prosthetic fitting as per vascular consultation recommendation. The Care Plan for rehabilitation initiated 03/11/2026 documented activity of daily living rehabilitation program for decreased endurance, decreased performance in activities of daily living, bed mobility, transfers, generalized weakness, and impaired balance with a goal to maintain current level of function and an intervention to praise all efforts at self-care. The quarterly Minimum Data Set (resident assessment tool) dated 03/23/2026 documented Resident #74 had moderate cognitive impairment.During an observation and interview on 04/08/2026 at 9:27 AM, Resident #74 was sitting on the side of the bed. Resident #74 stated the facility refused to get a prosthesis for their left below knee amputation. They stated they were told their insurance did not allow for a prosthesis. They stated they wanted to learn how to use a prosthesis to be able to be discharged . During an interview on 04/13/2026 at 11:08 AM, the Director of Rehabilitation stated Resident #74 received therapy upon admission and was discharged from therapy 10/2025 when they reached maximum potential. The Director of Rehabilitation stated that due to Resident #74's impaired vision they felt it would not be safe for Resident #74 to have a prosthetic leg. During an interview on 04/14/2026 at 9:18 AM, Licensed Practical Nurse #23 stated they recalled a vendor from the rehabilitation department visiting Resident #74 to evaluate for a prosthesis but were not sure of the outcome. Licensed Practical Nurse #23 stated they did not see any reason why Resident #74 should not have a prosthetic leg. During an interview on 04/14/2026 at 10:16 AM, the Director of Rehabilitation stated Resident #74 was seen on 06/26/2025 but the resident's insurance was out of network and did not qualify for a prosthetic leg. The Director of Rehabilitation stated it was an oversight that a referral was not made to another vendor to evaluate Resident #74 for a prosthesis. During an interview on 04/14/2026 at 2:36 PM the Medical Director/Primary Physician stated they observed Resident #74 perform a transfer from the wheelchair to the bed and stated Resident #74 should have a prosthesis. 10 New York Code Rules Regulations 415.12

Based on observation, record review, and interview, the facility failed to ensure an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infection for two (2) of five (5) residents (Resident #14 and Resident #56) reviewed for infection control. 1) Specifically, Physical Therapist Assistant #15 provided range of motion without the use of a gown for Resident #14 with a physician order for contact precautions. Additionally, the precaution sign on Resident #14's door indicated enhanced barrier precautions and 2) Certified Nurse Aide #7 provided cares without the use of a gown for Resident #56 with an indwelling supra-pubic catheter who had a physician order for enhanced barrier precautions.The findings included: The policy titled Infection Prevention and Control Program, revised 01/2025, documented that the infection prevention and control program was a facility-wide effort involving all disciplines and individuals and was an integral part of the quality assurance and performance improvement program. It included educating staff and ensuring that they adhered to proper techniques and procedures. The policy titled Enhanced Barrier Policy, revised 01/2026, documented Enhanced Barrier Precautions was to prevent opportunities for transfer of multidrug-resistant organisms to employees' hands and clothing during care, beyond situations in which staff anticipated exposure to blood or body fluids. In high-contact resident care activities such as dressing, bathing/showering, transferring, and providing hygiene, staff were required to wear gloves and gowns. 1) Resident #14 was admitted with diagnoses including osteomyelitis of the vertebra sacral and sacrococcygeal region, tropical spastic paraplegia and methicillin resistant staphylococcus aureus infection. The admission Minimum Data Set (a resident assessment tool) dated 01/20/2026 documented Resident #14 had moderate cognitive impairment, was incontinent of bowel and bladder, and had one (1) stage three (3) and one (1) stage 4 (four) pressure ulcer and two (2) venous/arterial ulcers present upon admission. The Physician Order dated 01/20/2026 documented contact precautions due to methicillin resistant staphylococcus aureus infection in synovial fluid. The Care Plan for contact precautions due to methicillin resistant staphylococcus aureus infection in synovial fluid dated 01/25/2026 obtain physician order for precautions. Place precaution alert signs on resident's door. Wear gown and gloves when providing care. During an observation on 04/08/2026 at 1:04 P.M., Resident #14's room had an enhanced barrier precaution sign at the doorway. During an observation and interview on 04/09/2026 at 3:39 P.M., Physical Therapy Assistant #15 provided bilateral leg passive range of motion with the use of gloves and a mask and did not wear a gown. Physical Therapy Assistant #15 stated they forgot to wear a gown. During an interview on 04/09/2026 at 5:00 P.M., Registered Nurse #19 stated Resident #14 had an active physician order and resident care plan for contact precautions. They stated the sign on Resident #14's door indicated the resident was on enhanced barrier precautions. Registered Nurse #19 stated they provided medication and wound care for Resident #14 and followed enhanced barrier precautions. During interview on 04/09/2026 at 5:24 P.M., and 04/10/2026 at 12:33 P.M., the Director of Nursing stated Resident #14 was on enhanced barrier precautions as per the sign at the door for wounds and was not on contact precautions. The Director of Nursing stated there was an active physician order and resident care plan for contact precautions and were unsure exactly when contact precautions ended. They stated Resident #14 would have been removed from contact precaution when their white blood count returned to within normal limits. After reviewing the electronic medical record, they stated Resident #14's white blood count was 8.83 on 01/22/2026 and increased to 10.99 on 03/20/2026. The Director of Nursing stated they were unsure if Resident #14 would have been removed from contact precautions with the increase in white blood count. 2. Resident # 56 had diagnoses including neurogenic bladder, Parkinson's disease, and bipolar disorder. The Care Plan initiated 07/17/2024 documented enhanced barrier precautions to reduce the risk of infection, use personal protective equipment, and ensure proper signage was posted on the resident's door. The Physician Order dated 07/17/2024 documented enhanced barrier precaution every shift for infection prevention. The quarterly Minimum Data Set, dated [DATE] documented Resident #56 had severe cognitive impairment and had an indwelling supra-pubic catheter in place. During an observation/interview on 04/07/2026 at 4:45 P.M., Certified Nurse Aide #7 changed Resident #56's brief and emptied and closed the indwelling catheter leg bag without the use of a gown. There was no enhanced barrier precautions sign in place and no personal protective equipment cart outside Resident #56's room. Certified Nurse Aide #7 stated they did not have to wear a gown because the resident was not on contact precautions. During an interview on 04/07/2026 at 5:18 P.M., Registered Nurse Unit Manager #6 stated the enhanced barrier precautions sign on the door to Resident #56's room was probably removed by a resident. They stated they educated the Certified Nurse Aides regarding the enhanced barrier precaution sign but had no documentation of the education. During an interview on 04/14/2026 at 10:46 A.M., the Nurse Educator stated all Certified Nurse Aides were in-serviced on infection control and prevention, including enhanced barrier precautions. They stated Certified Nurse Aide #7 was in-serviced on enhanced barrier precautions. They stated they observed staff as they performed their tasks for enhanced barrier precautions, to ensure they followed proper infection control protocols. Documentation showed that Certified Nurse Aide #7 received in-service training on enhanced barrier precautions dated 06/18/2025. 10 New York Code Rules Regulations 415.19(a) (1-3)

Based on observation, record review and interview the facility failed to ensure proper disposal of garbage and refuse. Specifically, 1) the recycling dumpster lid was left open and there were cardboard boxes spilling over the top and other debris was observed behind and to the side of the dumpster, and 2) the garbage compactor had food debris puddled in front of the compactor door and litter on the ground surrounding the compactor. Findings Include:A review of the policy and procedure titled Garbage Removal Policy reviewed 09/2025 documented, the facility shall ensure safe, sanitary, and compliant management of all waste in accordance with federal, state, and local regulations to maintain a clean and safe environment. Waste shall be stored in designated areas and must be clean and well-maintained, pest-resistant and not accumulated beyond acceptable limits.During an observation of the garbage area and interview on 04/07/2026 at 10:43 AM the recycling dumpster was open with cardboard boxes spilling over the top. There were boxes and other debris behind and to the side of the dumpster. The garbage compactor had food debris that had spilled down the front of the compactor door and was puddled at the base of the compactor. There were used gloves, plastic utensils, and an empty ice cream cup on the ground surrounding the compactor. There was a bag of garbage sitting on the top of the compactor. The Food Service Director stated the lid on the recycling dumpster should be closed. The garbage was used by the whole facility; everyone was responsible for keeping the area clean.During an interview on 04/13/2026 at 11:29 AM, the Housekeeping Supervisor stated the dumpster lid should be closed. They stated they checked every morning when they arrived to make sure the dumpster lid was closed, and they were not sure why the dumpster lid was open on 04/07/2026. They stated all staff were educated about closing the lid and cleaning the area when waste was not in the dumpster or compactor. They stated the garbage pick-up schedule was once or twice a week, but three (3) weeks ago they requested a more frequent pick up to prevent waste overflow.During an observation on 04/14/2026 at 10:28 AM the recycling dumpster lid was open with boxes spilling over the top. 10 New York Code Rules Regulations 415.14(h)

Based on observation, record review, and interview the facility failed to ensure that all drugs and biologicals were stored in accordance with the manufacturer's specifications and professional standard of practice for one (1) of one (1) resident (Resident #116) reviewed for medication storage. Specifically, Resident #116 room was observed to have physician ordered medications / treatments on the bedside table that included two (2) opened packets of maximum strength lidocaine pain relief gel patch 4%, each pouch contained one (1) patch.The findings included:A policy titled Medication Administration, revised 11/2025, documented nursing personnel shall ensure the safe and effective administration of medications. Medication should not be left at the bedside for the resident to take later. Resident #116 diagnoses included low back pain, type two (2) diabetes mellitus without complications, and pain in the left knee. The quarterly Minimum Data Set (a resident assessment tool) dated 03/29/2026 documented Resident #116 was cognitively intact.The Physician order dated 06/19/2025 documented lidocaine external gel 4 % (lidocaine) apply to left thigh topically in the morning for thigh pain.The Physician order dated 06/19/2025 documented lidocaine external patch 4 % (lidocaine), apply to left shoulder topically one time a day for pain. Remove after 12 hours. There was no documented evidence that Resident #116 was assessed, and care planned for medication self-administration.During an observation and interview on 04/08/2026 at 9:40 AM two (2) opened pouches of maximum strength lidocaine pain relief gel patch 4%, one patch per pouch were present on Resident #116's bedside table. Resident #116 stated Unit Manager Registered Nurse #3 left the lidocaine patches earlier in morning and they independently applied patches after they showered/bathed. They stated Unit Manager Registered Nurse #3 frequently left the lidocaine patches for self-administration. During an observation and interview on 04/08/2026 at 9:54 AM, Unit Manager Registered Nurse #3 stated they presented to Resident #116's room earlier with lidocaine patches and that Resident #116 stated they were washing up and not ready for the patches. They stated they left the lidocaine patches at the bedside because they were distracted by another resident. They stated they usually informed Resident #116 to let them know when they were ready for lidocaine patches to be placed and would then return to place the patches.During an interview on 04/14/2026 12:22 PM, the Director of Nursing stated medications, including lidocaine patches, should not be left at bedside/in room for resident self- administer unless the resident was care planned and assessed in safe medication administration. 10 New York Code Rules Regulations 415.18(e)(1-4)

Based on record review, observation and interview the facility failed to ensure that residents were seen by a Physician at least once every thirty days for the first ninety days after being admitted to the facility for one (1) of five (5) residents (Resident #14) reviewed for infection control. Specifically, there was no documented evidence that Resident #14 who was admitted to the facility 01/2026 was seen by a medical provider after 02/14/2026.The findings included:The undated facility policy titled Physician Services documented the attending physician will perform pertinent, timely medical assessments; prescribe an appropriate medical regimen; provide adequate, timely information about the resident's condition and medical needs; visit the resident at appropriate intervals; and ensure adequate alternative coverage. Review of orders are provided during monthly physician visits and documentation in physician's notes.Resident #14 was admitted with diagnoses including osteomyelitis of vertebra sacral and sacrococcygeal region, arthritis due to other bacteria, right knee, tropical spastic paraplegia and methicillin resistant staphylococcus aureus infection, unspecified site. The admission Minimum Data Set (a resident assessment tool) dated 01/20/2026 documented Resident #14 had moderate cognitive impairment, one (1) stage three (3) and one (1) stage 4 (four) pressure ulcer and two (2) venous/arterial ulcers present upon admission. The electronic medical record documented Resident #14 was assessed by the facility physician on 01/20/2026, 01/21/2026, 01/26/2026, 02/04/2026 and 02/14/2026. There was no documented evidence that Resident #14 was assessed after 02/14/2026 by facility physician. The Nurse Practitioner note dated 01/20/2026 documented Resident #14 had a face-to-face visit. The Nurse Practitioner note dated 01/21/2026 documented Resident #14 received an on-call telemedicine visit and a face-to-face physician visit.The Physician note dated 01/26/2026 documented Resident #14 had a face-to face visit with the facility physician.The Physician note dated 02/04/2026 documented Resident #14 had a face-face visit with facility physician for a blister and rash concern.The Physician noted dated 02/14/2025 documented Resident #14 received a face-to-face follow-up visit by the facility physician. There was no documented evidence that Resident #14 was assessed by the facility physician after 02/14/2026.During an interview and observation on 04/09/2026 at 5:24 PM the Director of Nursing stated they were unaware as to why Resident #14 had not been assessed by the facility primary care physician since 02/14/2026 and not assessed at least monthly since admission as per facility policy and regulations. During an interview on 04/10/2026 at 3:09 PM, Unit Manager Registered Nurse #3 stated newly admitted residents should have a physician visit after admission, monthly thereafter and as needed for acute developments. They stated physicians could run a report to view residents who were due for an assessment. During an interview on 04/13/2026 at 5:37 PM Primary Physician #2 stated Resident #14 was assessed upon admission and again in 02/2026. They stated new admission residents, including Resident #14, should be assessed monthly for the first 90 days. They stated they were aware there was no documented evidence of an assessment in 03/2026 for Resident #14. 10 New York Codes Rules Regulations 415.15(b)(2)(ii)

Based on observation, interview and record review the facility failed to ensure residents who needed respiratory care were provided such care consistent with professional standards of practice for one (1) of three (3) residents reviewed for respiratory care. Specifically, Resident #85 had a physician order for oxygen to be delivered at two to three liters per minute via nasal cannula and was administered 4.5 liters of oxygen.The findings included:The Policy for oxygen administration last updated 05/2025 documented adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.Resident #85 was admitted with diagnoses including end stage renal disease, chronic obstructive pulmonary disease and hypertension.The Physician Order dated 01/26/2026 documented oxygen two to three liters per minute via nasal cannula every shift for chronic obstructive pulmonary disease.The 02/02/2026 admission Minimum Data Set (assessment tool) documented Resident #85 had intact cognition and received oxygen therapy.The Care Plan for oxygen therapy dated 02/04/2026 documented give oxygen as ordered.During observations on 04/08/2026 at 11:30 AM and 04/09/2026 at 3:52 PM, Resident #85 was receiving 4.5 liters of oxygen via nasal cannula.During an interview on 4/09/2026 at 3:56 PM, Registered Nurse #17 stated Resident #85 was receiving 4.5 liters of oxygen. They stated Resident #85 should receive 2 to 3 liters of oxygen per minute as per physician order. They stated nurses were responsible for checking the flow rate on the oxygen concentrator.During an interview on 4/09/2026 at 4:02 PM, Registered Nurse Unit Manager #16 stated they did not know why Resident #85's oxygen flow rate was set and administered so high. They stated the nurses were responsible for administering the oxygen as per the doctor's order.10 New York Code Rules Regulations 415.12 (a) (3)

Based on observation, interview, and record review the facility did not ensure that the call bell system was accessible for one (1) (Resident #74) of seven (7) residents reviewed for environment. Specifically, the facility did not ensure that Resident's #74's call bell was within reach. Findings include:The policy and procedure titled Call Bell System reviewed 07/2025 documented the facility will ensure that all residents shall have a call bell within reach while in their room. Provide a call bell with long extension to reach the resident's bed. Check to see that call bell is within reach before leaving the room.Resident #74 had diagnoses including legally blind, below knee amputation, and diabetes mellitus.The quarterly Minimum Data Set assessment dated [DATE] documented Resident #74 had moderately impaired cognition. Resident #74 required supervision with rolling left to right and lying to sitting on side of bed; and partial assistance for toileting, personal hygiene, sit to stand and transfers.A review of the comprehensive pare Plan for Falls dated 06/15/2026 documented ensure the call light is within reach and encourage the resident to use it for assistance as needed.During observations on 04/08/2026 at 9:27 AM, 04/09/2026 at 1:03 PM, and 04/10/2026 at 12:07 PM, Resident #74 was sitting on their bed. The call bell was on the floor at the head of the bed and out of the resident's reach. Resident #74 stated they used the call bell to call for assistance but had not had the call bell in a month. Resident #74 stated they just waited for the nursing staff to come into the room and would ask for help. During observation on 04/10/2026 at 12:07 PM Resident #74 was sitting on their bed and asked for a urinal. They stated they knew they had one but could not locate it. The call bell was on the floor at the head of the bed, out of the resident's reach. The surveyor activated the call bell for Resident #74, and Registered Nurse #5 came across the hall and went into Resident #74's room.During an interview and observation on 04/10/2026 at 12:18 PM, Certified Nurse Aide #4 stated they provided cares for Resident #74 that day and had assisted them to get washed and dressed. When the location of the call bell was pointed out to Certified Nurse Aide #4, they stated they typically gave the call bell to Resident #74 and clipped it to the bed sheet by their pillow, but they had been dealing with a lot that morning and must have forgotten to do it. Certified Nurse Aide #4 stated they knew they should always put the resident's call bell within their reach.During an interview on 04/10/2026 at 12:30 PM, Registered Nurse Unit Manager #6 stated call bells should be clipped to the bed sheet by the pillow and checked every shift. They stated they were not sure why Resident #74's call bell was out of reach for three (3) days. They stated they did not notice it when they rounded. During an interview on 04/13/2026 at 11:40 AM the Director of Nursing stated Certified Nurse Aides should make sure call bells were in reach before they left resident rooms. 10 New York Codes Rules and Regulations 415.5(e)(1)

Based on interview and record review the facility failed to ensure prompt efforts to resolve grievances for one (1) of five (5) residents (Resident #116) reviewed for personal property. Specifically, there was no documented evidence that a thorough investigation was conducted, and that Resident #116 was compensated for lost clothing that was reported to the facility on [DATE] and 03/02/2026.The findings included:The undated policy titled Grievance, Reporting and Response documented investigate and respond to all Residents' grievances in a timely manner. The Grievance Official or designee will notify the Resident and complainant of the final disposition of the complaint, in writing.Resident #116's diagnoses included other low back pain, type two (2) diabetes mellitus without complications, and pain in the left knee. Review of the Resident Inventory reports dated 06/22/2025, 10/28/2025, 11/06/2025 revealed they were completed by Resident #116.A Grievance Report dated 12/23/2025 documented that the resident made numerous complaints about things missing from their room, clothing going to laundry and not returning, and lack of communication. The resident still has not received any of their belongings or compensation for the losses. Social Worker #14 received the report. Room and floor were searched. Will continue to look. Resident aware. Signed by the Administrator on 12/28/2025.A follow up report dated 03/02/2026 documented the resident reports the following belongings have gone missing since date of admission and other recent items that were collected from their room and taken to laundry. See attached list of belongings. Continue to look for items. Family aware. Signed by the Director of Social Services/Grievance Officer on 03/02/2026. There was no documented evidence that a thorough investigation was conducted and that Resident #116 was compensated for the lost items after the 12/23/2025 and 03/02/2026 report of missing items.There was no documented evidence that Resident #116 was provided written notification of grievance resolution.A quarterly Minimum Data Set (a resident assessment tool) dated 03/29/2026 documented Resident #116 was cognitively intact.During an interview on 04/07/2026 at 12:18 PM, Resident #116 stated Social Worker #14 had been given grievance forms with missing items and that Registered Nurse Unit Manager #3 was also aware of missing items including underwear, bras, night gowns, sweaters, sweatpants and socks. Resident #116 stated when clothing items went to laundry, only some items returned. They stated they did not receive reimbursement for the missing items. They stated they met with the Assistant Administrator and informed them that missing items totaled approximately $125. They stated the Assistant Administrator told them they could not reimburse for the clothing but could offer Resident #116 some donated clothing. Resident #116 stated they were never shown/provided replacement clothing, reimbursed or provided a written grievance outcome.During an interview on 04/10/2026 at 3:02 PM, Unit Manager Registered Nurse #3 stated they were aware that Resident #116 reported missing clothing that was not returned from laundry. They stated they also reached out to the Housekeeping Director, provided Resident #116 with reassurance and provided Resident #116 with inventory forms.They stated they believe Resident #116's socks and possibly a pair of pants were returned. During an interview of 04/10/2026 at 5:17 PM, the Director of Social Work/Grievance Officer stated that the grievance reports dated 12/23/2025 and 03/02/2026 were incomplete. They stated they did not believe items were found or replaced or that Resident #116 was reimbursed for any of the missing items. They stated they did not have written documentation that Resident #116 received a grievance resolution. During an interview on 04/13/2026 at 11:07 AM, the Assistant Administrator stated they did not recall conversation with Resident #116 regarding missing property/clothing.They stated they did not recall that Resident #116 was offered reimbursement or offered donated clothing as replacement. During an interview on 04/13/2026 at 11:13 AM, the Director of Housekeeping stated they believe Resident #116 reported missing items and that some items were returned.They stated they did not recall informing Administration or the Concierge of missing items for Resident #116 but may have. During an interview on 04/14/2026 at 1:57 PM, Social Worker #14 stated for the 12/23/2025 grievance, they filled out the first page and gave it to the Director of Social Work/Grievance Officer and were unaware if anyone investigated or followed up with Resident #116. For the 03/02/2026 follow up grievance, they filled out the first page of Resident #116' s grievance and obtained a list of missing items. They searched Resident #116's room and no items were found. They stated Housekeeping was notified and they discussed the missing items with the Director of Social Work/Grievance Officer. Social Worker #14 stated they could not answer why the investigation or resolution sections of the grievance were not complete. They stated there was one item (socks) that matched Resident #116's inventory sheet and the resident was offered new socks or reimbursement. Resident #116 took the socks and continued to want reimbursement for other missing clothing. 10 New York Codes Rules and Regulations 415.3 (d)(1)(ii)

Based on observation, interview, and record review the facility failed to ensure that residents are free from restraints for one (1) of one (1) resident (Resident #10) reviewed for restraints. Specifically, there was no documented evidence that a physician order, assessment, consent, and a care plan were in place to address the use of an abdominal binder for Resident #10. The findings included:Resident # 10 had diagnoses including Alzheimer's disease, depression, and adult failure to thrive.The 02/04/2026 Nursing Progress note written by Registered Nurse Manager #6 documented a transfer to hospital summary. The resident was noted to be without their gastrotomy tube in place. The writer and another Registered Nurse attempted reinsertion but were unable to maintain stoma patency. The Nurse Practitioner was notified and ordered that the resident be transferred to the hospital for reinsertion of the gastrostomy tube. The Physician Order dated 02/12/2026 documented 120 mL water flush three times a day (total 360 mL) by gastrostomy tube and enhanced barrier precautions every shift for the gastrostomy tube.The quarterly Minimum Data Set (assessment tool) dated 02/17/2026 documented that Resident #10 had severe cognitive impairment, was dependent on staff to perform their daily living activities and did not use a restraint.There was no documented evidence in the electronic medical record that a physician order, assessment, consent, and a care plan were in place to address the use of an abdominal binder.During an observation on 04/07/2026 at 11:56 A.M., 04/08/2026 at 1:15 P.M., and 04/10/2026 at 8:04 A.M., Resident #10 was resting in bed with an abdominal binder in place.During an interview on 04/10/2026 at 11:45 A.M., Certified Nurse Aide #10 stated they provided care for the resident that morning and had gotten the resident dressed. They stated they put the abdominal binder back on the resident because the resident kept pulling out the gastrostomy tube. They stated the resident had an abdominal binder since they returned from the hospital.During an interview on 04/10/2026 at 11:48 A.M., Licensed Practical Nurse #11 stated the resident had an abdominal binder on, but they did not see a physician's order for the abdominal binder. They stated they did not document it because it was not on the residents' Medication Administration Record.During an interview on 04/10/2026 at 1:08 P.M., the Director of Nursing stated that the facility did not have a restraint policy because it was restraint-free. They stated they were not aware that the resident had an abdominal binder, and if they were aware they would have notified the physician and evaluated whether it was necessary. They stated when the resident removed the gastrostomy tube, the resident was ill. They stated the resident did not need an abdominal binder.During an interview on 04/10/2026 at 3:01 PM, Registered Nurse Supervisor #12 stated that on 02/12/2026 when the resident returned from the hospital, they had an abdominal binder on. They stated there was no physician order for the abdominal binder. They stated the nurse in the hospital informed them to keep the abdominal binder on because the resident might pull out the gastrostomy tube. They stated they were told to remove it after 24 hours. They stated that on 02/13/2026, they removed the abdominal binder and placed it in the resident's closet. They stated they did not want to discard the resident's abdominal binder because it was the resident's personal property. They stated the resident was transferred to the fifth floor on 02/19/2026.10 New York Code Rules and Regulations 415.4(a) (2-7)

Based on record review and interview the facility failed to ensure that the Minimum Data Set assessment 3.0 accurately reflected the resident's status for one (1) of one (Resident #7) reviewed for smoking. Specifically, the 08/28/2025 comprehensive Minimum Data Set assessment was not coded to reflect Resident #7's use of tobacco. The findings included:The policy and procedure titled Minimum Data Set 3.0, revised 10/2024, documented all members of the interdisciplinary team were responsible for reviewing the Minimum Data Set and completing the assigned care area assessments. Additionally, the interdisciplinary team was responsible for reviewing all residents' strengths, problems, needs, and plans of care to ensure the delivery of appropriate and quality care in accordance with facility policies and federal and state guidelines.Resident # 7 had diagnoses including Parkinson's disease, seizure disorder, and chronic obstructive pulmonary disease.The Care Plan for psychosocial history dated 01/05/2025 revealed the resident was a known smoker. The plan directed staff to review the smoking policy with the residents as needed and to allow the resident to smoke in the designated smoking area with supervision.The 08/28/2025 comprehensive Minimum Data Set (an assessment tool) documented that Resident #7 had intact cognition and did not use tobacco.During an observation/interview on 04/09/2026 at 8:30 AM, Resident #7 stated they smoked tobacco, had no issues when smoking, and could hold the cigarettes. During an observation/interview on 4/10/2026 at 10:18 AM, Resident #7 was in the smoking area wearing an apron. The resident was holding a cigarette without difficulty.During an interview on 4/13/2026 at 03:55 PM, Minimum Data Set Coordinator #1 stated the resident's annual Minimum Data Set was completed on 08/28/2025; they also stated that section J was not captured for tobacco use. They stated they did not receive the smoking list from the activities department and missed coding the tobacco use section as yes.10 New York Code Rules Regulations 415.11(b)

Based on record review and interview the facility failed to ensure that comprehensive care plans were reviewed and revised to reflect the current code status for two (2) of two (2) residents (Resident #7 and Resident #101) reviewed for advance directives. Specifically, 1) there was no documented evidence that advance directive care plans were reviewed and care plan interventions updated to accurately reflect cardiopulmonary resuscitation status for Resident #7 as per physician order and 2) there was no documented evidence that advance directive care plans were reviewed and care plan interventions updated to accurately reflect cardiopulmonary resuscitation status for Resident #101 as per physician order. The findings included: The Policy and Procedure for advanced directive, revised 05/2025 documented the facility will honor the wishes of the resident/representative regarding medical concern, by honoring the existing advanced directives of the residents. Physicians' orders are required for advanced directives, including full code; Social Services will evaluate and create a care plan for advanced directives. 1.Resident # 7 had diagnoses including Parkinson's disease, depression, and chronic obstructive pulmonary disease. The Care Plan for advanced directive dated 08/31/2023 documented full code with interventions to ensure a copy of do not resuscitate is on the resident's chart, ensure a do not resuscitate sticker is prominently displayed in the chart, and ensure that a do not resuscitate/non-hospital/do not resuscitate form is transferred with resident to hospital/clinic offices/out on pass. The Physician Order dated 10/21/2025 documented cardiopulmonary resuscitation The quarterly Minimum Data Set (an assessment tool) dated 12/30/2025 documented that Resident # 7 had intact cognition. 2. Resident #101 had diagnoses including schizoaffective disorder, depression, and anemia. The Physician Order dated 05/16/2022 documented cardiopulmonary resuscitation. The Care Plan for advanced directive dated 06/20/2023 documented full code with interventions to ensure a copy of do not resuscitate is on the resident's chart, ensure a do not resuscitate sticker is prominently displayed in chart, and ensure that a do not resuscitate/non-hospital do not resuscitate form is transferred with the resident to hospital/clinic offices/out on pass. The quarterly Minimum Data Set, dated [DATE] documented Resident #101 had moderate cognitive impairment. During an interview on 04/09/2026 at 1:25 P.M., Social Worker #14 stated the advanced directive care plans for Resident #7 and Resident #101 included interventions implemented by the previous Social Worker. They stated that the interventions had remained unchanged, even though they should have been updated. They stated that Social Services should have revised the interventions to accurately reflect the residents' code status as Full Code (cardiopulmonary resuscitation) During an interview on 04/10/2026 at 12:30 P.M., the Director of Social Services stated that when a resident had a Full Code status, interventions were to be put in place to reflect the code status. They stated that there should not have been any interventions for a do not resuscitate when residents were designated as Full Code status. 10 New York Code Rules Regulations 415.11(c)(2) (i-iii)

Based on observation, record review and interview the facility failed to ensure each resident who was unable to carry out activities of daily living received the necessary care and services for one (1) of eight (8) residents (Resident #145) reviewed for activities of daily living. Specifically, 1) toileting assistance was not provided every two (2) hours as per comprehensive care plan for Resident #145, who required assistance with toileting. The findings include:The policy and procedure for activities of daily living last reviewed on 5/2025, documented established guidelines for providing comprehensive assistance with Activities of Daily Living to residents. It aims to ensure that each individual's basic needs are met while promoting dignity, independence, and comfort. This policy applies to all caregivers, nurses, and staff involved in the direct care of residents who require assistance with Activities of Daily Living, including but not limited to toileting, mobility and transferring. Supervisors/Managers to oversee the implementation of care plans.1)Resident #145 was admitted to the facility with diagnoses including overactive blader, muscle weakness and localized swelling, mass and lump, unspecified lower limb. The Minimum Data Set (resident assessment) dated 12/27/2024 documented Resident #145 had moderately impaired cognition and was dependent on staff for chair to bed transfer and required substantial assistance with toileting and personal hygiene. The Care Plan for bowel incontinence dated 12/21/2024, documented check resident every two hours and assist with toileting as needed, provide a bedpan or bedside commode.The Care Plan for dependance on staff in meeting activities of daily living needs last reviewed on 12/27/2024, documented Resident #145 required partial to moderate assistance with toilet transfer, toileting and personal hygiene. The Kardex Report dated 4/9/2026, documented toileting, check the resident every two (2) hours and assist with toileting as needed, provide bedpan or bedside commode, and provide peri care after each incontinent episode.During observation and interview on 4/7/2026 at 9:46 A.M., Resident #145 was sitting on the edge of the bed watching a laptop.The resident stated the night shift changed their brief at approximately 6:30 A.M.During observation and interview on 4/07/2026 at 2:48 P.M., Resident #145 stated their brief was wet for approximately two (2) hours and stated they expected that staff would come back and change them. They stated no staff offered toileting assistance since the morning care provided by the night shift. During observation and interview on 4/08/2026 at 11:35 A.M., Resident #145 stated that they were assisted with toileting at approximately 9:00 A.M., and no staff had offered toileting assistance since then.During observation and interview on 4/09/2026 at 11:30 A.M., Resident #145 stated they had been incontinent about hour ago and expected that the staff would come and change them, but no staff had offered toileting assistance.During observation and interview on 4/09/2026 at 1:07 P.M., Resident #145 was in their wheelchair. The resident stated they had been incontinent since approximately 10:30 A.M. and nobody offered them assistance with toileting. During an interview on 4/9/2026 at 1:09 P.M., Certified Nurse Aide #1 stated Resident #145 required two-person assistance for transfers and was toileted in bed due to safety concerns with transfers. Certified Nurse Aide #1 stated toileting should occur every two (2) hours, however, they stated that on 4/7/2026 they did not provide toileting assistance to Resident #145 until approximately 1:00 P.M. due to being busy with documentation at the end of the shift. Certified Nurse Aide #1 stated that on 4/9/2026, the last time Resident #145 was toileted was around 9:00 A.M., during morning care and that no additional toileting checks had been performed as of the time of the interview. During an interview on 4/9/2026 at 2:12 P.M., Licensed Practical Nurse # 2 stated the resident required two-person assistance with transfers and believed the resident should be toileted approximately every two (2) hours. Licensed Practical Nurse #2 was unable to state the frequency of toileting provided. During an interview on 04/10/2026 at 9:40 A.M., the Registered Nurse Supervisor # 3 stated although Resident #145 could be transferred with two-person assistance to the bathroom or commode posed safety and privacy concerns due to the tight space in the bathroom, which requires both doors to remain open during transfers and toileting. Registered Nurse Supervisor #3 stated that the most appropriate and safe intervention for the resident was to provide frequent toileting in bed at a minimum of every two (2) hours. Registered Nurse Supervisor #3 stated they were not aware of how often staff were actually checking or toileting the resident. 10 New York Code Rules Regulations 415.12 (a)(3)

Based on observations, record review, and staff interviews conducted during the Abbreviated Surveys (649784 and 649783), the facility did not ensure that residents at risk for elopement received adequate supervision to prevent accidents for 2 (Resident #1 and #2) of 3 residents reviewed. Specifically, 1) On 1/26/2025, Resident #1 who had documented evidence of elopement attempts and was on one-to-one supervision was left unattended by Patient care Assistant #1 to go on their dinner break. Resident #1 exited the facility without their wheelchair and without detection from staff. The Facility wander guard system did not alarm. Resident #1 was later found at the bus station in front of the building. 2) Resident #2 who had been assessed as an elopement risk exited the facility on 03/23/2025 at 5:48PM without staff detection. Resident #2 was found at a hospital emergency department and returned to the facility with an order for 30minute visual checks for three (3) days and was also placed on a one-to-one supervision at night. On 4/14/2025, at approximately 4:45 AM, a Code Orange was announced for Resident #2. The resident had eloped from the facility and was later located by police walking on a nearby street. Police transported the resident to the emergency room for evaluation. The Facility's wander guard system did not alarm during Resident #1 & #2's exit from the facility. There was no documented evidence that the interventions put in place were implemented.The findings are:The 04/15/2025 policy titled Elopement Prevention/Wandering Behavior Management documented that it is the policy of the facility to utilize all possible measures to maintain the safety and well being of all residents. To have system and tools in place to do all that is reasonable to identify and prevent unsafe wandering and/or elopement and to act quickly and prudently should either occur. The Facility Policy titled One to One Supervision reviewed on 05/2025 documented that staff must maintain visual contact and always be within arm's reach at all times. 1. Resident #1 was admitted with diagnosis including but not limited to anxiety disorder, cerebral infarction, and psychoactive substance-induced psychotic disorder with delusions, and schizoaffective disorder.The 11/05/2024 Annual Minimum Data Set (an assessment tool) documented that Resident #1 had moderately impaired cognition.The 03/17/2024 Physicians Orders documented that Resident #1 had a Wander guard to their left wrist.The 01/26/2025 Investigative Summary documented that on 01/26/2025 at 8:30 PM, Resident #1 was on one-to-one supervision, left unsupervised, was able to breach an exit door and was later found at the bus station in front of the facility.The Elopement Care Plan dated 01/11/2024 documented that Resident #1 was at risk for elopement related to agitation, change of environment, and wandering behavior. Interventions included ensuring that all door alarms are working and may initiate 1:1 as needed.The 12/02/2024 Comprehensive Care Plan Meeting Note documented that Resident #1 will continue one to one supervision due to disruptive behaviors. During an interview on 09/04/22025 at 1:49 PM, Front Desk Personnel #1 stated that their regular work hours are 8:00 AM to 4:00 PM. They explained that they are familiar with residents who wander by referencing the wander guard book kept at the front desk where they are stationed. Front Desk Personnel #1 when asked to provide the wander guard book, they were unable to do so, stating it was in the possession of the Administrator. Front Desk Personnel #1 further stated that the only door equipped to trigger a wander guard alarm is the main entrance door of the facility. During an interview on 09/04/2025 at 11:55 AM, the Director of Nursing stated that Resident #1 activated the fire alarm on the 5th floor. The Director of Nursing stated that when staff responded to the alarm, Resident #1 must have exited the facility through an exit door, but the Director of Nursing was unable to identify which door or exit was used. The Director of Nursing further stated that at the time of the incident, Resident #1 was on a one-to-one supervision, but the assigned Patient Care Assistant #1 was on her break and not with the resident. During an interview on 09/05/2025 at 11:44 AM, Patient Care Assistant #1, stated that they were assigned to provide one to one supervision for Resident #1. They stated that after putting the resident to bed, they informed the nurse to take a break and left the resident unattended to eat dinner. They reported that by the time they sat down to eat at the nurse's station, they heard the door alarm sounding. Patient Care Assistant #1 stated that they went back to the resident's room and Resident #1 was not there. Patient Care Assistant #1 stated that they were aware of the resident's background of wandering and elopement attempts and that Resident #1 was awake when they left the room to go on their dinner break. Patient Care Assistant #1 stated that they were always assigned to Resident #1 for one to one supervision, who often expressed wanting to go home. Patient Care Assistant #1 stated that Residents on one to one supervision are not supposed to be left alone. During an interview on 09/05/2025 at 11:54 AM, Registered Nurse #1 stated that during the evening shift they were aware Resident #1 was on one-to-one supervision. Registered Nurse #1 reported that while they were exiting the medication room, they observed Patient Care Assistant #1 and asked what they were doing. Patient Care Assistant #1 responded that they were going on their break, and Registered Nurse #1 stated that they gave Patient Care Assistant #1 permission to do so, although no one was in the room with Resident #1 at the time. As a result, the resident was left unsupervised while on one to one supervision and was able to elope out of the building. Registered Nurse #1 stated that during a one-to-one supervision, a resident should never be left unattended and that prior to leaving a Resident's room, staff should have obtained relief coverage for safety. During an interview on 09/19/2025 at 12:58 PM, the Director of Nursing stated that Resident #1 was placed on one-to-one supervision because they were known to wander and had multiple prior elopement attempts. The Director of Nursing stated that staff assigned to provide one-to-one supervision should never leave a resident alone, and if they must leave the room, another staff member should be present to cover and monitor and provide oversight/supervision. The Director of Nursing further stated that the Patient Care Assistant #1 should not have left the room without another staff member present to assume responsibility for the resident. In addition, the Director of Nursing stated that Registered Nurse #1 was responsible for ensure that coverage was provided before giving the Patient Care Assistant #1 permission to take a break, so that Resident #1 was never left unattended.2. Resident #2 was admitted with diagnoses including but not limited to adjustment disorder, Dementia with mood disturbance and agitation, and Parkinson's disease.The 01/14/2025 admission Minimum Data Set documented that Resident #2 had severely impaired cognition and exhibited wandering behaviors occurring one to three days during the assessment period. The 01/07/2025 Physicians Orders documented that Resident #1 had a Wander guard in place their left wrist.The 01/17/2025 poor safety awareness care plan documented that Resident #2 has poor safety awareness due to diagnosis of dementia and wanders with no rational purpose. Interventions included initiating a wander guard bracelet. The 03/23/2025 Accident/Incident Report and nursing documentation revealed that at approximately 5:45 PM staff discovered Resident #2 was not in their bed. The resident's room was searched, and the resident could not be found. A Code Orange was activated and 911 was called. Police officers responded to the facility to gather information regarding the resident. Shortly thereafter, the facility received a call from the hospital that the resident was in the emergency department. Review of the facility's investigation summary dated 03/23/2025 documented that Resident #2 was to be monitored every 30 minutes for three days and placed on one-to-one supervision at night. However, there was no documented evidence that these interventions were implemented. On 04/14/2025, Resident #2 again eloped and was found by local police wandering on a nearby street.The 03/23/2025 at 11:50 PM Incident Note documented that Resident #2 had an elopement episode at 6:10 PM. A Code Orange was activated, and 911 was called. Police officers responded and subsequently received a call that the resident had been located at the Emergency Room.The 04/13/2025 Behavior Note at 11:36 PM documented that Resident #2 attempted to exit the facility by using the elevator and tried to open the stairwell door seven times during the evening shift while stating, I want to go home. The note documented that the resident was very difficult to redirect.The 04/14/2025 at 4:45 AM Investigative Summary documented that a Code Orange was announced. Staff immediately responded to the lobby, where front desk staff reported that Resident #2 had walked through the front entrance. Staff dispersed into the parking lot and surrounding streets to search for the resident. 911 was called and the incident was reported. Resident #2 was subsequently located by police and transported by Emergency Medical Services to the emergency department for evaluation. The 04/14/2025 at 8:01 AM Accident/Incident Note documented that at approximately 4:45 AM a Code Orange was announced. The writer immediately responded to the lobby, where front desk staff reported that Resident #2 had walked out through the front entrance. Staff dispersed into the parking lot and surrounding streets to search for the resident. 911 was called and the incident was reported. Resident #2 was found by Police and transported to the Hospital by Emergency Medical Services(EMS)The 04/14/2025 Nurse's Progress Note at 10:12 AM documented that at approximately 4:45 AM the nurse heard Code Orange(Facility code to search for an eloped resident) announced. The nurse called the front desk and confirmed it was Resident #2. The nurse, along with another nurse and two Certified Nurse Aides, went to the lobby and were informed by the front desk clerk that Resident #2 had gone through the front entrance. Staff and police initiated a neighborhood search, and Resident #2 was subsequently located by the police unsupervised and transferred them to the emergency room for further evaluation.During an interview on 09/05/2025 at 12:56 PM, Certified Nurse Aide #2 stated that they arrived late to their scheduled evening shift. Certified Nurse Aide #2 stated while performing rounds, they realized Resident #2 was not in their room and informed the nurse. When the resident could not be located, a Code Orange (code to search for eloped resident) was called.During an interview on 09/05/2025 at 2:00 PM, the Administrator stated that prior to the end of March 2025, the facility's elevator did not alarm and there was no system in place to connect the wander guard to secure the exits besides the front entrance. The Administrator confirmed that the wander guard system did not alarm or lock the elevators or exit doors if a resident wearing a wander guard attempted to elope. The Administrator stated that there are no cameras inside of the building but they had exterior cameras installed sometime in May 2025During an interview on 09/05/2025 at 3:53 PM, Certified Nurse Aide #3 stated they were assigned to provide 1:1 supervision to Resident #2 on 4/14/2025. Certified Aide #3 stated when they left for their break, Resident #2 was in bed sleeping and they found out about the elopement when they were informed by another Certified Nurse Assistant that Resident #2 was not in their room. Certified Nurse Aide #3 stated they were unsure how the resident left the buildingDuring an interview on 09/19/2025 at 12:58 PM, the Director of Nursing stated that Resident #2 was consistently exit-seeking, and the Resident's wife had reported a history of such behaviors. The Director of Nursing stated that when Resident #2 eloped on 03/23/2025, they were supposed to be placed on one-to-one supervision. The Director of Nursing stated that the facility could not determine how Resident #2 exited the facility because at the time of the incident there were no sensors on the exit doors or the elevators to alert staff when residents with wander guards attempt to leave the unit The Director of Nursing stated that following the second incident on 4/14/205, the volume on the facility alarms were made louder and sensors were placed on both elevators and doors. During an interview on 09/05/2025 at 2:56 PM, the Administrator stated that on March 27, 2025, the facility completed work on the four elevators (two service and two main), installing wander guard integration so that if a resident with a wander guard attempted to use the elevator, the elevator would not leave the unit. The Administrator stated that prior to the upgrades in March, a resident with a wander guard could access the elevators without triggering an alarm. The Administrator further stated that as of April 2025, all exit doors on the 5th floor are now equipped to delay egress meaning the doors only opens with a code or if pushed for 15 seconds. When pushed for 15 seconds, the alarm would sound, giving staff time to respond. The Administrator stated that they were out on leave on 03/13/2025, and while they were notified of the incident, they could not recall how the resident exited the building. They also confirmed that the facility did not have exterior cameras at the time of the elopement.10NYCRR 415.12(h)(1)

Based on observations, record review, and interviews conducted during the Abbreviated Survey (649783), the facility did not ensure that the comprehensive care plan was revised to include measurable interventions to address an identified elopement risk for 1 (Resident #2) of 3 residents reviewed. Specifically, review of the facility's investigation summary dated 03/23/2025 documented that Resident #2 was to be placed on one-to-one supervision at night following an elopement incident. Review of Resident #2's care plan showed that one-to-one supervision intervention was not incorporated into the plan of care. As a result, the resident's comprehensive care plan did not reflect all identified interventions necessary to address their assessed elopement risk. Subsequently on 04/14/2025, Resident #2 eloped again from the facility and was found by local police wandering on a nearby street. The Resident was brought to the emergency room for further evaluation.The findings are:The Facility policy titled Care Plan-Comprehensive revised 06/2025 documented that assessments of residents are ongoing, and care plans are revised as information about the residents' condition change. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes.Resident #2 was admitted with diagnoses including but not limited to adjustment disorder, Dementia with mood disturbance and agitation, and Parkinson's disease.The 01/14/2025 admission Minimum Data Set documented that Resident #2 had severely impaired cognition and exhibited wandering behaviors occurring one to three days during the assessment period. The 03/23/2025 Accident/Incident Report documented that at approximately 5:45 PM, staff discovered Resident #2 was not in their bed. The resident's room was searched, and the resident could not be found. A Code Orange was activated and 911 was called. Police officers responded to the facility to gather information regarding the resident. Shortly thereafter, the facility received a call from the hospital emergency department that Resident #2 had been located and was brought there. Review of the facility's investigation summary dated 03/23/2025 documented that Resident #2 was to be monitored every 30 minutes for three days and placed on one-to-one supervision at night. However, review of the resident's care plan revealed it was not revised to reflect these interventions, and documentation showed the interventions were not implemented, and on 04/14/2025, Resident #2 again eloped from the facility.During an interview on 09/05/2025 at 11:54 AM, Registered Nurse #1 stated that Resident #2's care plan should have been updated to reflect the new interventions indicated after the elopement. Registered Nurse #1 stated that the Care Plans are implemented and revised by the Registered Nurses and that the staff member responsible for the investigation should have updated the care plan to ensure the interventions were reflected.During an interview on 09/05/2025 at 2:52 PM, the Director of Nursing stated that when new care plan interventions are required, the nurse completing an incident/accident report or investigative summary is responsible for revising the care plan to reflect the new interventions. The Director of Nursing further stated that Resident #2's care plan should have been updated to certify and reflect the intervention of one-to-one supervision following the elopement. Registered Nurse #1 explained that revising the care plan to include new interventions is very important because Certified Nurse Aide tasks are generated directly from the care plan, and without revisions, staff would not receive updated directives to implement the required interventions.10 NYCRR 415.11(c)(1)

Based on observations, record review, and interviews conducted during the Abbreviated Surveys (#649784 and #649783), the facility did not ensure that a comprehensive care plan was timely developed to address elopement risk for 1 (Resident #3) of 3 residents reviewed for accidents. Specifically, Resident #3 was assessed as an elopement risk on 09/02/2025 and had a wander guard placed on 09/02/2025 but the elopement care plan was not initiated until 09/04/2025. Review of the Care Plan and the Certified Nurse Aide Assignment/Accountability Record showed that wander guard monitoring instructions were not updated until 09/04/2025.The findings are:The facility policy titled Elopement Prevention and Wandering Behavior Management last reviewed 04/15/2025 documented that if a resident is identified at risk for elopement or unsafe wandering, the registered nurse supervisor must develop or update the elopement prevention care plan, document in the progress notes, ensure the resident is carried on the 24-hour report, and update the Certified Nurse Aide Assignment/Accountability Record (CNAAR) /Nursing Instructions. The policy further stated that the Certified Nurse Aide Assignment/Accountability Record Nursing Instructions must include the body location of the wander guard, notification of the resident's family, and documentation of wander guard placement to ensure Certified Nurse Aide monitoring every shift.Resident #3 was admitted with diagnoses including but not limited to dementia, cerebral infarction and spondylosis of the cervical region.Review of Resident #3's care plan dated 09/02/2025 revealed no documented evidence that a wander guard device was initiated. Nursing progress note dated 09/04/2025 documented a wander guard device was applied to the resident on 09/02/2025.The 09/02/2025 Elopement/Unsafe Wandering Screen documented that Resident #3 wanders, apply a wander guard device, and notify staff of elopement risk/wandering risk.During an interview on 09/04/2025 at 2:14PM, Registered Nurse #2 stated that Certified Nurse Aides are expected to document wander guard checks in a binder at the nurses' station. When the binder was requested, Registered Nurse #2 was unable to provide it, and Registered Nurse #2 stated that staff just know which residents have wander guards.During an interview on 09/05/2025 at 2:52 PM, the Director of Nursing stated that the resident's care plan should have been updated at the time the wander guard was applied, and that it was the nurse completing the assessment or investigation who was responsible for ensuring the care plan was revised to reflect the initiation of the wander guard and the new intervention.During an interview on 09/05/2025 at 4:36 PM, the Director of Nursing stated that they did not know why the registered nurse who completed Resident #3's admission did not initiate the elopement care plan and include the wander guard intervention. The Director of Nursing stated it is the expectation that when a resident is admitted or re-admitted , the admitting nurse develops or revises the care plan to include all interventions and links those interventions to the Certified Nurse Aide Accountability Record so that Certified Nurse Aides are aware of the resident's needs. The Director of Nursing further stated that all registered nurses have been in-serviced and instructed to always implement care plans or revise them to include new interventions. The Director of Nursing confirmed they noticed the Elopement/Wander Guard was missing from Resident #3's care plans and that they initiated the elopement care plan on 09/04/2025 and included the wander guard placement. [10 NYCRR 415.11(c)(1)]

Based on observation, record review, and interviews conducted during an abbreviated survey (2621561), the facility failed to ensure that the residents' environment remained as free of accident hazards as possible for one (1) of three (3) residents reviewed for accidents. Specifically, on 09/02/2025 Resident #1 who had a history of being combative with care and required two (2) staff assistance for bed mobility, fell out of bed and sustained a laceration to the left eyebrow when Certified Nurse Aide # 1 turned around to retrieve a mechanical lift pad from the resident's chair. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy.Resident #1 had diagnoses including Parkinson's disease (a progressive neuro-degenerative disorder that primarily affects movement), impaired mobility, and falls. The quarterly Minimum Data Set (a resident assessment tool) dated 08/18/2025 documented Resident #1 had severe cognitive impairment, was dependent (helper does all the effort and the resident does none of the effort to complete the activity, or the assistance of two (2) or more helpers is required for the resident to complete the activity) for all activities of daily living, including rolling left and right and transfers. Resident #1 had upper and lower extremity impairments on both sides and no falls or behaviors. During an observation on 10/14/2025 at 2:52 PM, Resident #1 was awake and, in their room, sitting in the Geri-chair with a mechanical lift pad observed in the chair behind the resident. The resident was placed back to bed by Certified Nurse Aide #2 and Certified Nurse Aide #4 via mechanical lift. Resident #1's left side of the bed was against the wall during the resident's transfer. The 09/01/2025 Certified Nurse Aide Kardex documented Resident #1's bed mobility status as dependent on staff to roll left and right.The 09/02/2025 statement written by Certified Nurse Aide #1 documented after they cleaned and dressed the resident, they turned around to pick up the mechanical lift pad and heard the resident hit the floor. The 09/02/2025 Investigative Summary written by Registered Nurse Unit Manager/Supervisor #5 documented that at around 11:30 AM, Registered Nurse Unit Manager/Supervisor #5 was told by Certified Nurse Aide #1 that Resident #1 had fallen and was on the floor. A full body and skin assessment revealed a 2.5-centimeter laceration on the left forehead. A pressure dressing was applied to control minimal bleeding, and the resident's level of consciousness and range of motion remained at baseline. The resident was non-verbal and could not state what happened and was sent to the Emergency Department for a computed tomography scan (an imaging method that uses x-rays) and further evaluation. Certified Nurse Aide #1 stated that after cleaning and dressing the resident, they turned to pick up the mechanical lift pad and heard the resident hit the floor. A reenactment showed that fall precautions were in place: the room was well-lit, the floor was dry and clutter-free, the bed was at the lowest position, and the call bell was within reach while the resident wore non-skid socks. Impaired mobility was identified as a contributing factor. Certified Nurse Aide #1 received a three (3) day suspension (09/16/2025-09/18/2025) as part of corrective action and underwent ongoing in-service re-education on activities of daily living. The facility ruled out abuse, neglect, and mistreatment of the resident. The 09/03/2025 Emergency Department Physician's visit summary documented that Resident #1 did not require hospitalization related to no evidence of traumatic injuries, acute infections, metabolic conditions, or emergencies. They documented the resident can address any urgent needs on an outpatient basis. The discharge plan included continuing prescribed medications/treatment, wound care, and a follow-up with the primary care physician for left eye suture removal in seven (7) days.The 09/03/2025 at 9:19 PM Medical Visit note by Physician #1 documented the resident was sent to the emergency room on [DATE], status post-fall and had a laceration to the left eyebrow. The resident's computed tomography scan was reviewed, and the workup in the hospital was negative; the computed tomography scan had no internal injury or bleeding. The resident's vital signs were stable.During a telephone interview on 10/06/2025 at 8:49 AM, Resident #1's health care proxy stated that the resident cannot move independently and cannot turn over on their own. They stated they were concerned about how the resident fell out of bed when the aide turned away. They stated the resident injured their left eyebrow and was sent to the hospital on [DATE].During a telephone interview on 10/06/2025 at 12:41 PM, Certified Nurse Aide #1 stated that after they finished cleaning the resident following breakfast, they dressed the resident, who was resting in bed against the wall. Certified Nurse Aide #1 stated that the resident was positioned in the bed with their body against the wall, and the bed was in a low position. Certified Nurse Aide #1 stated they turned around to retrieve the resident's mechanical lift pad from their Geri chair to place it under the resident. They stated while they were doing this, they heard a thump on the floor and turned around to see the resident lying on their left side on the floor. They stated that the resident required one (1) person for assistance with cleaning, but transferring required two (2)person assistance using the mechanical lift. Certified Nurse Aide #1 stated they observed bleeding from the resident's eyebrow, they called for help, and Registered Nurse # 6 came to assist the resident. During an interview on 10/06/2025, at 1:36 PM, Certified Nurse Aide #2 stated that Resident #1 was often combative, requiring the presence of two (2) persons, as they would kick and hit staff. They stated that the resident was fragile and that they would request help when providing care for the resident.During an interview on 10/06/2025, at 1:46 PM, Certified Nurse Aide # 3 stated that the resident is completely dependent on staff for all cares. They stated that the resident tends to kick and reach for items.During an interview on 10/06/2025, at 1:50 PM, Certified Nurse Aide # 4 stated that the resident can be combative; there was even an incident where the resident grabbed their shirt and tore it. The resident is capable of movement and often reaches for objects.During an interview on 10/06/2025, at 1:55 PM, Registered Nurse Unit Manager #5 stated that when they assessed the resident on 09/02/2025, there was no bruising on the leg; only a cut above the left eye was observed. They stated the resident was sent to the hospital. During an interview on 10/06/2025, at 3:09 PM, the Director of Nursing stated that Certified Nurse Aide #1 was suspended because they were getting ready to place the mechanical lift pad under the resident and they should have had another staff in the room at that time. The Director of Nursing stated upon the resident's return from the hospital, staff observed the resident who had no signs of discomfort related to pain. During a telephone interview on 10/07/2025 at 12:01 PM, Assistant Director of Nursing #2 stated Certified Nurse Aide #1 reenacted the incident, explaining the resident was positioned in bed against the wall. The aide did not change their statement about the resident's position. The Assistant Director stated it would take two (2) rolls for the resident to fall out of bed, but the aide insisted the resident was against the wall.During a follow-up interview on 10/14/2025 at 3:10 PM with Registered Nurse Unit Manager #5, they stated the certified nurse aides reported off to the on-coming certified nurse aide on the residents related to their care and that the nurses give report on residents to the certified nurse aides.During an interview on 10/14/2025 at 3:32 PM, the Director of Rehabilitation/Assistant Administrator stated the resident required total assistance with their activities of daily living and does not have any trunk control and required assistance with their mobility.During a telephone interview on 10/16/2025 at 3:38 PM, Resident #1's primary care physician stated they were informed the resident fell and had a laceration above the left eyebrow. They stated the nurse was told to send the resident to the Emergency Room. Upon the resident's return, the physician examined the resident and found no swelling or edema. During an interview on 10/31/2025, at 8:46 AM, Certified Nurse Aide #1 stated that on 09/02/2025, they worked alone to dress the resident and move them from side to side using a draw sheet. During a telephone interview on 11/03/2025 at 2:01 PM, the Minimum Data Set Coordinator stated that assessors collaborate with nursing and rehabilitation staff when a resident comes from the hospital. admission nurses assessed residents on the date of admission and enter the assessment in the activities of daily living tracker, which generates tasks for certified nurse aides related to residents' activities of daily living. After three (3) days in the activities of daily living tracker, nurses observe on the fourth day and collaborate with the assessors to determine usual performance based on certified nurse aides' tasks. Nurses start the residents' assessment on admission and have 14 days to complete it. They stated that for Resident #1, where it is documented that a helper provides all care, it means that Resident #1 requires a two (2) person assist with bed mobility.10 NYCRR 415.12 (h)(1)

Based on record review and interviews during an abbreviated survey (NY00372408) the facility failed to ensure the resident environment remains free of accident hazards as is possible and each resident receives adequate supervision to prevent accidents for one (1) of three (3) residents (Resident #1) reviewed for safety and supervision. Specifically, on 1/5/2025, Resident #1 obtained hot water from the hot liquid cart, filled their basin and carried it to a room and immersed their feet without the knowledge or detection of unit staff. Resident #1 was found with blisters to bilateral feet and sustained second- and third-degree burns. On 1/15/2025, Resident #1 was transferred to the hospital with a fever and for burn evaluation. On admission to the hospital, Resident #1 was determined to have third degree burns and underwent a skin graft on 1/21/2025. There was no facility policy that addressed the monitoring of hot water carts when they are on the resident units. Furthermore, the monitoring of the hot water cart was sporadic and arranged by word of mouth and monitoring was not consistently in place for the period when the hot water carts are on the units. This resulted in actual harm for Resident #1 which was Immediate Jeopardy with the likelihood of risk for harm to the health and safety of other residents. The Findings are: Review of the facility Hot Liquids Safety Policy last reviewed 6/20/2024 documented hot liquids are to be served at proper (safe and appetizing) temperatures using appropriate safety precautions. The temperature of hot liquids will be checked in the dietary department prior to distribution to the nursing units. If the temperature is greater than 140 degrees Fahrenheit, hold the liquid in the dietary department until it reaches appropriate temperature. General safety precautions when serving hot liquids include but are not limited to regulate temperature of hot liquids to which residents have direct access. Resident #1 was admitted with diagnoses including but not limited to diabetes mellitus, peripheral vascular disease, polyneuropathy (a condition that damages multiple peripheral nerves affecting sensation, movement or both). A Quarterly Minimum Data Set (an assessment that measures health status) dated 11/17/2024 documented the resident was cognitively intact with no behaviors noted. Resident #1 used a walker for locomotion and had no impairments to their upper and lower extremities. Resident #1 required set-up assistance with eating and supervision with toileting, bed mobility, transfers, and ambulation. Resident #1 had an infection of their foot and was receiving surgical wound care with the application of dressings to their feet. Review of a diabetes mellitus care plan initiated 4/13/2024 documented the following interventions: avoid exposure to extreme heat and cold, assess feet daily for any open areas, sores, pressure areas, blisters or redness and monitor/document/report as needed any signs and symptoms of infection to any open areas. Review of an activities of daily living care plan initiated 10/15/2024 and revised on 2/15/2025 with no changes documented Resident #1 was dependent on staff daily for meeting activity of daily living needs. The resident required set-up assistance with eating, supervision with showering/bathing, and putting on and removing their shoes. Facility Summary of Investigation dated 1/5/2025 documented Registered Nurse Supervisor #1 was summoned to see Resident #1 for the presence of blisters to bilateral (both) feet. Resident #1 was noted with fluid filled blisters on dorsal (top) aspect of bilateral feet. On interview, the resident admitted they sneaked out to get water from the tea cart without anybody seeing to intentionally wash their feet with the warm water; I soaked my feet in the water for about 30 minutes in another resident's room. I didn't feel anything, but it felt weird because my feet turned white, so I reported it to the nurse. Medical Doctor was notified and ordered treatment with a topical antimicrobial cream every shift for five (5) days and to monitor site for symptoms of infection. Family notified and agreed with plan of care. Review of the coffee and hot water temperature chart for January 2025 documented the following temperatures: January 4, 2025 4:45 PM 119 degrees Fahrenheit; January 5, 2025, 4:45 PM 122 degrees Fahrenheit. Review of an accident/incident report dated 1/5/2025 documented Resident #1 was assessed for a change in skin condition by Registered Nurse #2 at 10:00 PM. The accident/incident was reported by Licensed Practical Nurse #1 on 1/5/2025 at 10:00 PM. Resident #1 was ambulatory and the incident occurred in the resident's room. The Attending Physician was notified on 1/5/2025 at 10:02 PM and Resident #1's representative was notified on 1/5/2025 at 10:05 PM. Actions taken to prevent reoccurrence included educating Resident #1 to not poke the blisters, and how to properly care for the blisters. Review of Registered Nurse #2's incident note dated 1/5/2025 at 10:00 PM documented they were called to assess Resident #1 regarding the presence of blisters to bilateral feet which started from a small blister on 1/4/2025. Resident #1 reported on interview that they washed their feet with warm water during dinner time. On assessment, Resident #1 was noted with fluid-filled blisters on bilateral dorsal feet. No redness was noted between Resident #1's toes. The Attending Physician was notified and ordered to start a topical antimicrobial cream for five (5) days to bilateral feet blisters. Resident #1 was to be monitored for signs of infection and their family made aware. Review of a Nurse Practitioner #1 medical progress note dated 1/6/2025 at 2:01 PM documented they were asked to see Resident #1 for burns on both feet. Resident #1 was noted to have huge blisters covering both feet. As per Resident #1, they soaked their feet in hot water yesterday from their tea container. Documentation revealed Resident #1 has no feeling in their feet due to neuropathy and did not notice that their feet got burned. Safety was reinforced with Resident #1 and communicated with nursing staff and administration regarding Resident #1's access to hot water. The Assessment/Plan documented second degree burn, do not pop blisters, continue to monitor, reinforce safety with Resident #1, if blisters pop, apply a topical antimicrobial cream two (2) times daily and schedule wound consult. Review of the Attending Physicians medical visit note dated 1/8/2025 at 3:49 PM documented Resident #1 was seen for follow-up regarding second degree burns on bilateral feet. Resident #1 was noted to have huge blisters popped up on both feet, wound treatment applied. Safety was reinforced with Resident #1. The Attending Physician documented they communicated with nursing staff and Administration regarding Resident #1's access to hot water and resident's safety. The assessment/plan documented second degree burns-do not pop blisters, continue to monitor, reinforce safety to resident. The Plan continued: Resident #1's blisters are popped at this time, no need for antibiotic but will continue antibiotic skin cream or topical antimicrobial cream to sites. Review of an actual skin impairment care plan initiated 1/5/2025 documented Resident #1 had skin impairment to their bilateral dorsal feet related to burns. Interventions listed included follow facility protocols for treatment of injury and identify/document and eliminate/resolve where possible. Review of wound care notes dated 1/10/2025 documented Wound 1 with date of onset 1/5/25, etiology: 3rd degree burns on right dorsal foot measuring length: 9.0 centimeters width: 18.0 centimeters Depth: 0.1 centimeters. wound bed: 100% collapsed blister, scant exudate (drainage) with no odor. Recommended primary dressing of Xeroform + Calcium alginate + gauze + Kerlix daily and as needed Wound 2 with onset date 1/5/2025, etiology: 3rd degree burns of right plantar foot measuring: length: 5.0 centimeters width: 6.0 centimeters depth: 0.1 centimeters, wound bed: 100% collapsed blister and scant exudate with no odor. Recommendation for primary dressing to apply Xeroform + Calcium alginate + gauze + Kerlix daily and as needed. Wound 3 with onset date 5/2025, etiology: 3rd degree burns of left foot measuring: length: 9.0 centimeters with width: 18.0 centimeters and depth: 0.1 centimeters. Wound Bed is 100% collapsed blister. Moisture with scant exudate, serous (yellowish colored drainage) with no odor. Recommended primary dressing of Xeroform + Calcium alginate + gauze + Kerlix daily and as needed There is no documented evidence of the wound progression. Resident #1 was discharged to the hospital on 1/15/2025 for fever and evaluation of burns. Resident #1 was admitted to the hospital with second- and third-degree scald burns to bilateral feet with cellulitis. Resident #1 had a surgical technique where a surgeon removes burned or damaged skin layer by layer until they reach healthy tissue, and then covers the resulting wound with a thin layer of skin taken from another part of the body (split thickness skin graft) to the left foot and application of a mesh structure to help cells attach to the right foot on 1/21/2025 during the admission. Hospital discharge notes documented Resident #1 returned to the facility on 2/3/2025 On 2/10/2025 following an out-patient burn clinic post-operative follow-up appointment, it was decided Resident #1 needed to be admitted back to the hospital for possible wound infection. Review of hospital Discharge summary dated [DATE] documented Resident #1 had failure of skin graft and cellulitis of the fifth toe on the left foot. Resident #1 was treated for wound management, intravenous antibiotics, and pain control. During an interview on 2/19/2025 at 12:32 AM, Resident #1 stated they went to the tea kettle that came to the unit with the meal truck for tea or coffee. Resident #1 stated they filled up their basin with the hot water from the tea kettle and went to Resident #2's room. Certified Nurse Assistant #1 asked what they were doing, and they told Certified Nurse Assistant #1 they were soaking their feet. Resident #1 stated they put their feet in the water for 25 to 30 minutes and did not feel anything because they have had neuropathy for the last 19 years. Resident #1 stated when they removed their feet from the basin their feet were two big bubbles. Resident #1 stated they did not check the temperature of the water. Resident #1 stated they figured the water was hot or warm but did not know that it was scalding. During an interview on 2/19/2025 at 1:30 PM, Certified Nurse Assistant #1 stated during the evening shift on 1/5/2025 they went to give care to a resident in room [ROOM NUMBER]. Resident #1 usually goes to room [ROOM NUMBER] because they know the residents in that room. Certified Nurse Assistant #1 stated they saw Resident #1 in the room sitting in the chair with their feet soaking in water. Certified Nurse Assistant #1 stated when Resident #1 saw them they stated they had soaked their feet in hot water, and they are popping. Certified Nurse Assistant #1 stated they told Resident #1 they are not supposed to do that because they are diabetic, and they may not feel if they are getting burned. Certified Nurse Assistant #1 stated Resident #1 then took their feet out of the water, and they saw blisters on their feet. Certified Nurse Assistant #1 stated Resident #1 then stated they were in pain and could not walk. Certified Nurse Assistant #1 stated they do not know where Resident #1 got the water, and the resident already had their feet in the bucket of water when they saw them. Certified Nurse Assistant #1 stated they saw blisters to Resident #1's feet when they removed their feet from the water and reported it to Licensed Practical Nurse #1. During interview on 2/19/2025 at 1:56 PM, Registered Nurse #1 stated the hot liquid cart comes up with each meal. The residents know not to touch this cart. Registered Nurse #1 stated the incident happened on the weekend, so they are not sure why no staff saw Resident #1 getting the water from the hot liquid cart. Registered Nurse #1 stated they have now instituted that on the day and evening shift a nurse or certified nurse assistant remains in the area by the hot liquid cart. Registered Nurse #1 stated the hot water cart is now out of the dining room and is monitored. Registered Nurse #1 stated the nurses on the west side are responsible to be in the dining room when the trucks arrive to the unit and if there are residents in the dining room, a nurse needs to remain in the dining room. During an interview on 2/19/2025 at 2:29 PM, Registered Nurse #2 stated they are not sure how Resident #1 got enough hot water to fill a basin. The certified nurse assistants may have been busy. Registered Nurse #2 stated they were approached by Licensed Practical Nurse #1 who asked them to assist with Resident #1. Registered Nurse #2 stated they were told at 10:00 PM that Resident #1, at 7:00 PM during dinner, had washed their feet with the water from the hot liquid cart. Registered Nurse #2 stated Licensed Practical Nurse #1 stated they were just informed about the incident at 10:00 PM by Certified Nurse Assistant #1. Registered Nurse #2 stated Certified Nurse Assistant #1 had reported to Licensed Practical Nurse #1 that they saw Resident #1 soak their feet with warm water. Registered Nurse #2 stated Licensed Practical Nurse #1 was the medication nurse for Resident #1 at the time of the incident. Registered Nurse #2 stated they were not informed by any staff that they saw Resident #1 getting the hot water. The kettle for tea on the hot liquid cart has a faucet drain and it would take about 20 minutes to fill a bucket. Registered Nurse #2 stated after the incident occurred there is now one certified nurse assistant assigned to stay by the hot liquid cart and they also spoke with dietary to ensure the water brought to the units is warm and not scalding hot anymore. Registered Nurse #2 stated there is an assignment sheet now to monitor the hot liquid cart. During an interview on 2/19/2024 at 3:11 PM, the Director of Nursing stated after the incident on 1/5/2025 they provided an in-service to the staff. The facility now designates an aide to be to be near the hot water cart but there is no sign-in sheet. They have one (1) nurse always assigned to the dining room. Director of Nursing stated they are not aware of a policy change since the incident. It is possible the facility could have updated a policy without them being aware, since they were out for one (1) month. During an interview on 2/19/2025 at 4:02 PM, Dietary Supervisor Weekends stated the hot liquid carts are picked up from the unit about 45 minutes to an hour after meals are served. The Dietary Supervisor Weekends stated the hot liquids are left outside of the dining room by the dietary staff when delivered to the units. Dinner begins at 4:45 PM and is supposed to end at 5:45 PM, but sometimes it ends at 6:10 PM. The Dietary Supervisor Weekends stated it will be unusual for the hot liquid truck to be on a unit at 7:00 PM. The Dietary Supervisor Weekends stated in January the facility only had one (1) elevator in service, so it may have been possible for the hot liquid truck to be on the unit until 7:00 PM. The Dietary Supervisor Weekends stated they were not informed of any changes to the policy regarding hot liquids. During an interview on 2/20/2025 at 10:38 AM, Resident #2 stated Resident #1 came into their room to wash their feet in some warm water. Resident #2 stated they assumed Resident #1 got the water to wash their feet from where they get the water for coffee and tea by the dining room. Resident #2 stated the water in the sink is never warm enough, and this was the first time they've known Resident #1 to get the water from the kettle. Resident #2 stated Resident #1's feet were very dark, so they felt they were dirty and said they were going to clean their feet themself. Resident #2 stated Resident #1 then put their feet in the water and their feet started to bubble and blister up. Resident #2 stated the hot liquid cart is kept right outside the dining room on the unit and is always accessible to the residents. During a telephone interview on 2/20/2025 at 2:11 PM, the Attending Physician stated they have serviced the facility for three (3) years now. The Attending Physician stated they were informed by Registered Nurse #2 on 1/5/2025 that Resident #1 got hot water from the hot liquid cart, and it dropped on their foot and had sustained blisters on both feet. The Attending Physician stated they instructed Registered Nurse #2 to apply ointment to Resident #1's feet and they saw and evaluated Resident #1 the next day. The Attending Physician stated after they saw Resident #1's feet they instructed the resident and the nurses not to pop the blisters, because if they are not popped there will be no infection. The Attending Physician stated they did not order a wound care consult at that time because the blisters were intact. The resident was already on pain medication and their pain has been managed therefore no additional pain medications were ordered. The Attending Physician stated they and the Nurse Practitioner saw Resident #1 again when the blisters were popped, and a wound care consult was ordered at that time. The Attending Physician stated after the burns occurred, they saw Resident #1 within the next 2-3 days after the incident and they were alternating with the Nurse Practitioner making visits to see the resident. The Attending Physician stated they do not believe that the blisters Resident #1 sustained were from submerging their feet in hot water. Resident #1 sustained blisters only to the dorsum of their feet. The Attending Physician stated when they evaluated Resident #1, they only saw the blisters on the top of their feet. The Attending Physician stated the plantar surface of the foot skin is thicker and would take longer to develop blisters. The Attending Physician stated they had a discussion with the Administrator regarding not having the hot liquid carts on the unit and limiting the residents access to the hot water and they stated they would take care of this no problem. The Attending Physician stated they were not sure if a there is a policy about reporting these types of injures like burns. Maybe the Medical Director might know. They will ask and find out if one exists. During an interview on 2/20/2025 at 4:09 PM the Administrator stated they do not remember who informed them, but they were informed Resident #1 got a hold of some water somehow and had a blister on their foot. The Administrator stated they were further informed Resident #1 got the water from the hot liquid cart on the unit and instructed the staff to continue their investigation. The Administrator stated they were told Resident #1 called one of the staff to the room and informed them they got the hot water from the urn and put the water in a basin, placed their feet in the water and got a burn or blister or something like that. The Administrator stated they told the supervisor to treat Resident #1 and inform the physician. The Administrator stated they were not in the building when the incident occurred on 1/5/2025, but when they returned to the facility, they spoke about the details of the event in morning report and the investigation was taken over by the Assistant Director of Nursing. Since the incident, the steps they have implemented to prevent reoccurrence are they have a temperature log of when the hot liquid cart leaves the kitchen, the hot liquid cart are monitored by staff when they are in the dining room, and they have ongoing staff education on hot liquids. During an interview on 2/21/2025 at 1:15 PM the Director of Dietary Services stated the hot liquids get temperature tested, and they complete the testing three (3) times day as they are in the building for all three (3) meals throughout the day during the week. The Director of Dietary Services stated the hot liquids do not go to the units unless the temperature is between 115 and 125 degrees. The Director of Dietary Services stated most of the time the liquids are sent to the units at 120 degrees. The Director of Dietary Services stated the dietary aides place the hot liquid carts by the nurse's station when they deliver the truck to the units. The dietary aides do not leave the hot liquids on the unit until they locate a nurse to sign off on the delivery truck sheet. The Director of Dietary Services stated if a nurse is busy, a certified nurse assistant will assume the responsibility and sign for the carts. 10 NYCRR 415.12(h)(1)