Every finding on record at Humboldt House Rehabilitation and Nursing Center

Based on interview and record review conducted during a survey, the facility failed to ensure that all alleged violations involving abuse are reported immediately but not later than two hours after the allegation is made if the events that cause the allegation involve abuse, to the Administrator of the facility and to other officials (including to the State Survey Agency) for one (Resident #1) of three residents reviewed. Specifically, an allegation of staff to resident verbal and physical abuse was not reported to the facility Administrator and to the New York State Department of Health within the required two-hour timeframe. This is identified as past noncompliance. The findings include:Refer to F 600 Freedom from Abuse and Neglect, scope and severity DThe undated facility policy titled Resident Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure documented residents have the right to be free from abuse and associates must not use physical abuse against any resident. In response to any allegations of abuse or mistreatment the facility will ensure all alleged violations involving abuse are reported in the proper timeframe. When the facility has identified abuse, the facility will report the alleged violation within required timeframes pursuant to Federal and State statutes and regulations.Resident #1 had diagnoses including dementia, anxiety, and hypothyroidism (the thyroid gland does not produce enough hormones causing the body's metabolism to slow down). The Minimum Data Set (a resident assessment tool) dated 04/08/2026 documented the resident had severe cognitive impairment, had verbal behavioral symptoms directed towards others, had no physical behavioral symptoms and did not wander.Review of the Internet Quality Improvement and Evaluation System (iQIES) Complaint/Incident Investigation Report dated 06/03/2026 at 10:56 AM revealed an allegation of staff physical abuse involving Resident #1 occurred on 06/02/2026 at 1:00 PM. The Administrator was first made aware of the incident on 06/03/2026 at 8:30 AM.During a telephone interview on 06/09/2026 at 11:22 AM, Housekeeper #1 stated they were on the 4th floor cleaning a room and they saw a nurse push a resident backwards and say, get the (expletive) out of my face. Housekeeper #1 stated they were in the bathroom cleaning the floor at the time and did not see the resident fall but heard them fall. Housekeeper #1 stated they were not sure if the staff member was a nurse or an aide. Resident #2 asked for a nurse so they thought the staff member was a nurse, but they could have been an aide. Housekeeper #1 stated the staff member did not say anything else to Resident #1 before swearing at them. Housekeeper #1 stated they did not see the resident fall but did see the staff member push the resident using two hands like they were hurrying the resident to get out of the room. Housekeeper #1 stated they did not say anything to the staff member because they did not know them, but they should have said something because they felt it was wrong. Housekeeper #1 stated this happened around 2:00 PM. Housekeeper #1 stated they did not tell anyone until after they got home because they were scared. They stated they called their boss (Director of Housekeeping) around 4:00 PM. They did not report it right away because they were kind of fearful. Housekeeper #1 stated their boss told them they wished they would have reported it sooner. Housekeeper #1 stated they got in-service education about reporting incidents when they first started almost a year agoDuring a telephone interview on 06/09/2026 at 2:17 PM, the Director of Housekeeping stated Housekeeper #1 called them at home on [DATE] around 4:00 PM. Housekeeper #1 stated they witnessed something but did not want to say anything because they were afraid of retaliation. The Director of Housekeeping told them they needed to tell them about it. Housekeeper #1 reported they witnessed one of the aides push one of the residents down. The Director of Housekeeping stated they told Housekeeper #1 they would have to go into the facility, but they said they could not go back to the facility then but would go in the next morning. The Director of Housekeeping stated they told the Housekeeper #1 it would have to be reported within 24 hours. The Director of Housekeeping stated they did not notify the Administrator or Director of Nursing because Housekeeper #1 was timid and seemed confused about what they witnessed, what time it happened, and they wanted to talk to them to get the correct information. The Director of Housekeeping stated they reported this to the Director of Nursing the next morning (06/03/2026). They stated they thought it had to be reported within 24 hours but had Housekeeper #1 reported it before they left work that day (06/02/2026), it would have been reported on time. During an interview on 06/09/2026 at 3:06 PM, the Director of Nursing stated the Director of Housekeeping did not report it to the Administrator or themselves because they were not sure about the details. The Director of Nursing stated the Director of Housekeeping should have reported what Housekeeper #1 told them right away to the Administrator or themselves even if the details were unclear as it was their job to do an investigation and determine the timeframe for reporting, two hours versus 24 hours.During an interview on 06/09/2026 at 3:37 PM, the Administrator stated Housekeeper #1 might have felt intimidated/scared to report it, they called the Director of Housekeeping around 4:00 PM and told them what they saw that day. The Director of Housekeeping told them to tell administration about it in the morning. The Administrator stated the Director of Housekeeping did not report it immediately because Housekeeper #1 was not making sense, but they should have reported it right after Housekeeper #1 reported it to them. The Administrator stated they were aware of the incident around 8:30 AM the next morning (06/03/2026) and that abuse allegations were supposed to be reported no later than two hours after the allegation was made.The following corrective actions were implemented by the facility to correct the non-compliance as of 06/06/2026. -Certified Nursing Assistant #1 was removed from resident contact on 06/03/2026.-Resident #1 was assessed by nursing, medical, and social work staff and no ill effects were noted.-During the abbreviated survey completed 06/09/2026 Resident #1 had no signs of abuse observed.-Starting on 06/04/2026 all facility staff were re-educated on resident rights, abuse and abuse reporting.-During the abbreviated survey completed 06/09/2026, it was verified through staff interviews and record review that the facility had re-educated 100% of their staff on abuse which included types of abuse and abuse reporting process including timeframes.-During the abbreviated survey completed 06/09/2026, it was verified through staff interviews and record review that on 06/04/2026 incident reports were reviewed dating back to 03/02/2026 for reporting timeframes and abuse instances by the Director of Strategic Planning. Certified Nurse Aide #1's file was reviewed with no prior discipline or incidents and had the required abuse education. 10 New York Codes, Rules, and Regulations 415.4(b)(2)

Based on observation, interview, and record review conducted during a survey, the facility failed to ensure the resident's right to be free from physical abuse by staff for one (Resident #1) of three residents reviewed. Specifically, based on facility surveillance footage, facility investigation, and an eyewitness account, a certified nurse aide was physically abusive to Resident #1. This is identified as past noncompliance The findings include: The undated facility policy titled Resident Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure documented residents have the right to be free from abuse and associates must not use physical abuse against any resident. The facility explicitly and expressly prohibits and will take steps to prevent any associates from engaging in any behavior or actions that may result in the abuse of residents. In response to any allegations of abuse or mistreatment the facility will ensure all alleged violations involving abuse are reported in the proper timeframe. Resident #1 had diagnoses including dementia, anxiety, and hypothyroidism (the thyroid gland does not produce enough hormones causing the body's metabolism to slow down). The Minimum Data Set (a resident assessment tool) dated 04/08/2026 documented the resident had severe cognitive impairment, had verbal behavioral symptoms directed towards others, had no physical behavioral symptoms and did not wander. The comprehensive care plan dated 04/20/2026 documented Resident #1 was a wanderer and was at risk for victimization related to severe dementia. Interventions included encouraging the resident to attend activities, especially in the afternoons at shift change, moving to a less stimulating environment, and to redirect away from other resident's rooms as needed. The Kardex (a guide used by staff to direct care) dated 06/09/2026 documented staff were to engage the resident in activities as needed and as follows especially at shift change, redirect away from other resident's rooms, move to a less stimulating area as needed. Review of the facility's video footage (no audio available) on 06/09/2026 at 8:50 AM with the Director of Nursing and Administrator present, revealed the footage was timestamped 06/02/2026 and the Administrator stated it was from the short hall on the 4th floor. At 1:11:17 PM, Housekeeper #1 was seen walking from the direction of the nurse's station to Resident #2's room (a private occupied room), they were going into the room as Certified Nurse Aide #1 exited a different room at the end of the hallway and walked toward Resident #2's room. It appeared Housekeeper #1 said something to the Certified Nurse Aide #1 and then went into Resident #2's room. Certified Nurse Aide #1 went into the room after Housekeeper #1 at 1:11:46. While the staff members were entering that room, Resident #1 was seen walking from the direction of the nurse's station toward Resident #2's room. At 1:11:52 PM, Resident #1 stopped at the doorway to Resident #2's room, looked into the room, then entered the room. At 1:12:10 PM, Resident #1 was seen falling backwards from inside Resident #2's room, attempting to brace themselves with their left hand as they fell, landing on their buttocks and then onto their back on the floor in the middle of the hallway. During an interview at this time, the Administrator stated the timestamp on the footage was off by one hour due to daylight savings time and this footage was from the two o'clock hour not the one o'clock hour. The Nursing Home Investigative Report: Submission #24768 submitted on 06/09/2026 at 9:52 AM, documented an incident date of 06/02/2026 at 2:00 PM that Housekeeper #1 witnessed Certified Nurse Aide #1 swear at Resident #1 and push them out of a room causing them to fall. Certified Nurse Aide #1 denied yelling or swearing at the resident and said they tried to redirect the resident out of the room. Certified Nurse Aide #1 said the resident fell and they did not help them up or report the fall. Law enforcement was notified, and an investigation was ongoing at their end. The facility concluded that the findings were verified and there was reasonable cause to believe that abuse, neglect, or mistreatment occurred. Review of a written statement signed by Housekeeper #1 dated 06/03/2026 revealed they were cleaning in Resident #2's room and Resident #2 asked to see a nurse, so they went to the front desk, and a staff member who was short and skinny went to the room to see the resident. Before they were done cleaning the room the resident asked to see a nurse again. They came and a resident came in behind them. The resident had curly greyish/black hair. The aide pushed them backward and said, get the (expletive) out of my face and pushed them backward. The resident fell and hit the floor. Clarification: they heard the resident hit the floor, they were cleaning from the bathroom and did not witness the fall, but they saw the staff member pushing the resident. Review of a written statement signed by Certified Nurse Aide #1 and dated 06/03/2026 revealed they saw Resident #1 in a resident's room, and they entered the room to redirect the resident. Resident #1 became combative, and they directed the resident by their arm to the doorway and then Resident #1 threw themselves on the floor outside the door. While the resident was on the floor, they were going to reapproach but the resident was still being combative and so they continued to walk up the hall. The only people in attendance were Certified Nurse Aide #1 and Resident #1. During an observation on 06/09/2026 at 10:02 AM, Resident #1 was in the unit lounge area sitting in a chair by the television. They were alert and able to tell me their name but could not answer any other questions. The resident was wearing shorts and a T-shirt and had no visible injuries. During an interview on 06/09/2026 at 10:09 AM, Resident #2 was in their room lying in bed watching television. They stated they think a staff member was in their room and that Resident #1 was trying to come into their room. The staff member did not want the other resident in their room. The resident stated they did not know if the staff member pushed or cursed at Resident #1 or if the resident fell as they were not paying attention. Resident #2 could not remember when this occurred. During a telephone interview on 06/09/2026 at 10:26 AM, Certified Nurse Aide #1 stated they worked on 06/02/2026 on the 4th floor and had just left a resident's room and saw Resident #1 in the room across the hallway standing near a resident's dresser. They did not know the exact room number, but they did know it was Resident #3's room. They went into the room to direct Resident #1 out and the resident threw themselves out of the room. Certified Nurse Aide #1 stated she had grabbed the resident's arm and directed them toward the door and as they put Resident #1 toward the door, the resident threw themselves out of the room backwards and went ah ah with their hands up. The Certified Nurse Aide #1 stated they saw the resident land on the floor on their bottom like as they sat down. Certified Nurse Aide #1 stated the resident was not hurt and they did not help the resident up because they were being combative, but they did see Resident #1 attempt to get up but did not actually see them get up because they were walking away from the resident. The Certified Nurse Aide #1 stated they were not in Resident #2's room, they were in the room behind it toward the fire door direction which was Resident #3's room. The Certified Nurse Aide #1 stated before they directed Resident #1 out of the room, they told the resident to get out of (Resident #3's) room, they did not yell or swear at the resident. Then they had Resident #1's arm and directed them toward the door. Certified Nurse Aide #1 stated there was no resident in the room at the time of this incident. Certified Nurse Aide #1 stated they did not push Resident #1, and they would not do that to a resident. During further telephone interview on 06/09/2026 at 2:41 PM, Certified Nurse Aide #1 stated they did not report to anyone that Resident #1 fell because they knew the resident was not injured and was getting themselves up off the floor. Resident #1 was moving by themselves and did not have any injuries, so they did not think they needed to get a nurse. Certified Nurse Aide #1 stated they did not see any video footage and was unaware there was footage. Certified Nurse Aide #1 stated this incident happened in Resident #3's room and it was not in Resident #2's room. They stated Resident #2 never left their room, that's how they knew it was Resident #3's room because nobody was in the room during the time of this incident. During a telephone interview on 06/09/2026 at 11:22 AM, Housekeeper #1 stated they were on the 4th floor cleaning a room. The resident (#2) in the room asked them to get a nurse, so they went to the front desk to ask for a nurse. A short, skinny brown skinned lady came into the room and saw the resident and left the room. Housekeeper #1 went out to their cart and the resident (#2) asked for a nurse again. The housekeeper went back to the desk, and the same person came to the room, and a resident (#1) followed them. The nurse pushed that resident backwards and said, get the (expletive) out of my face. Housekeeper #1 stated they were in the bathroom cleaning the floor at the time and did not see the resident (#1) fall but heard them fall. Resident (#2) was in their bed at this time. Housekeeper #1 stated they were not sure if the staff member was a nurse or an aide. Resident #2 asked for a nurse so they thought the staff member was a nurse, but they could have been an aide. Housekeeper #1 stated the staff member did not say anything else to the resident (#1) before swearing at them. Housekeeper #1 stated they did not see the resident (#1) fall but did see the staff member push the resident (#1) using two hands like they were hurrying the resident to get out of the room. After it happened the staff member talked to Resident #2 but then left the room. Housekeeper #1 stated they did not say anything to the staff member because they did not know them, but they should have said something because they felt it was wrong. Housekeeper #1 stated this happened around 2:00 PM. Housekeeper #1 stated they did not tell anyone until after they got home because they were scared. They stated they called their boss (Director of Housekeeping) around 4:00 PM. They did not report it right away because they were kind of fearful. Housekeeper #1 stated their boss told them they wished they would have reported it sooner. Housekeeper #1 stated they got in-service education about reporting incidents when they first started almost a year ago. During an interview on 06/09/2026 at 1:09 PM, Certified Nurse Aide #2 stated they were assigned to Resident #1 on 06/02/2026 and were not aware that someone pushed the resident or that the resident fell on the floor. They found out about it when they were asked for a statement. They stated Resident #1 could sometimes flail their arms during incontinent care and they had a staggered walk but did not throw themselves on the floor. The Certified Nurse Aide #2 stated pushing a resident was considered abuse. During an interview on 06/09/2026 at 1:17 PM, the Registered Nurse Unit Manager #1 stated they were not aware Resident #1 was pushed or that they fell on the floor. They stated they assessed the resident the day after the incident, and they had no injuries or no change in behavior. They stated they saw the video footage and felt there was some force there, lets be honest. They considered a staff member pushing a resident physical abuse. The Registered Nurse Unit Manager #1 stated they were not sure if Resident #1 had any history of throwing themselves on the floor, but they were a little unsteady. The Registered Nurse Unit Manager #1 stated if a staff member witnessed a push or any abuse, they were supposed to notify the Administrator or their department head so that they can tell administration. The timeframe to report was two (2) hours. During a telephone interview on 06/09/2026 at 2:17 PM, the Director of Housekeeping stated Housekeeper #1 called them at home on [DATE] around 4:00 PM. Housekeeper #1 stated they witnessed something but did not want to say anything because they were afraid of retaliation. The Director of Housekeeping told Housekeeper #1 they needed to tell them about it. Housekeeper #1 reported they witnessed one of the aides push one of the residents down. Housekeeper #1 did not know the name of the staff member or the resident involved as they were not on their usual floor. The Director of Housekeeping stated they told Housekeeper #1 they would have to go into the facility, but they said they could not go back to the facility but would go in the next morning. The Director of Housekeeping stated they told the Housekeeper #1 it would have to be reported within 24 hours. The Director of Housekeeping stated they did not notify the Administrator or Director of Nursing at that time because Housekeeper #1 was timid and seemed confused about what they witnessed and what time it happened and wanted to talk to them to get the correct information. The Director of Housekeeping stated they reported this to the Director of Nursing the next morning. They stated they thought it had to be reported within 24 hours but had Housekeeper #1 reported it before they left work that day, it would have been reported on time. During an interview on 06/09/2026 at 3:06 PM, the Director of Nursing stated on the morning of 06/03/2026 the Director of Housekeeping told them that Housekeeper #1 said a resident was pushed the day before but that the housekeeper was confused and did not have their facts straight and was supposed to come into the facility that day. The Director of Nursing called Housekeeper #1, and they told them when they were cleaning in a resident room, the resident had asked for a nurse twice. The same staff member went into the room both times. The second time a resident wandered into the room behind them. Housekeeper #1 reported that while they were cleaning the bathroom the 'nurse' swore at the resident and pushed them. The Director of Nursing stated Housekeeper #1 did not know the staff member's name or the resident's name, but they had a thought on which resident it was based on the housekeeper's description of them. The Director of Nursing reported it to the Administrator right away and started an investigation. They assessed Resident #1 who was sitting in their bed, appeared to have no pain and no distress. They checked the resident's skin for bruises or markings, and they had none. Then they checked the video footage to confirm it was Resident #1 involved. The footage also confirmed it was Housekeeper #1 and Certified Nurse Aide #1 involved. Their investigation concluded that abuse occurred, that the Certified Nurse Aide #1 pushed the resident and they fell to the ground. The Certified Nurse Aide #1 did not report the fall either. The Director of Nursing stated Resident #1's right to be free from abuse was not followed by Certified Nurse Aide #1 and when they questioned the involved aide they got loud and defensive and immediately responded that Resident #1 was being dramatic and threw themselves on the floor. The Certified Nurse Aide #1 insisted nobody else was in the room when this happened and that they were in a different room from what the video showed. During an interview on 06/09/2026 at 3:37 PM, the Administrator stated they concluded that the Housekeeper #1's statement of Certified Nurse Aide #1 pushing Resident #1 seemed very factual and that abuse did occur. They had law enforcement involved, so yes, they believed abuse occurred. They stated the residents' right to remain free from abuse was not maintained and every mandated reporter should be ensuring residents remained free from abuse. The staff involved did not have any record of disciplinary actions, was not overworking, and staffing was good that day, but maybe they had a short fuse. The following corrective actions were implemented by the facility to correct the non-compliance as of 06/06/2026. -Certified Nursing Assistant #1 was removed from resident contact on 06/03/2026.-Resident #1 was assessed by nursing, medical, and social work staff and no ill effects were noted. The resident's care plan was reviewed.-During the abbreviated survey completed 06/09/2026 Resident #1 had no signs of abuse observed.-Starting on 06/04/2026 all facility staff were re-educated on resident rights, abuse and abuse reporting.-During the abbreviated survey completed 06/09/2026, it was verified through staff interviews and record review that the facility had re-educated 100% of their staff on abuse which included types of abuse and abuse reporting process including timeframes.-During the abbreviated survey completed 06/09/2026, it was verified through staff interviews and record review that on 06/04/2026 incident reports were reviewed dating back to 03/02/2026 for reporting timeframes and abuse instances by the Director of Strategic Planning. Certified Nurse Aide #1's file was reviewed with no prior discipline or incidents and had the required abuse education. 10 New York Codes, Rules, and Regulations 415.3(d)(1)(vii)

Based on observations, interviews, and record review conducted during the survey the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, observations of one (1) of one (1) kitchen revealed an active ceiling leak in front of the walk-in refrigeration and freezer units, several missing and broken wall tiles, the commercial oven range was soiled with grease and food debris, the wall behind the stove, oven, and two (2) bay sink was heavily soiled with grease, the drain pipe underneath the hand wash sink leaked, the paper towel dispenser by the hand wash sink was non-working, and ceiling pipes were covered with dust. Additionally, the walk-in freezer had black debris around the window, a broken gasket, and accumulated condensation and ice buildup on the exterior and interior door surfaces, the floor, and ceiling. The findings include: The policy titled Sanitation dated October 2008 documented the food service area shall be maintained in a clean and sanitary manner. All equipment, food contact surfaces and utensils must be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water or chemical sanitizing chemicals. Kitchen surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. The policy titled Food Receiving and Storage dated October 2017 documented foods shall be received and stored in a manner that complies with safe food handling practices. Food services, or other designated staff, will maintain clean food storage areas at all times. Durning intermittent observations on 03/23/2026 at 9:15 AM, 03/23/2026 at 11:46 AM, 03/25/2026 at 11:19 AM, and 03/26/2026 at 9:01 AM of the kitchen, the following was revealed: -the walk-in freezer and cooler area adjacent to the air conditioning ventilation duct contained an approximate three (3) foot by two (2) foot opening in the plaster ceiling. Below the opening was an approximate four (4) foot by four (4) foot tarp suspended from the ceiling by the tarp's four (4) eyelet holes. The tarp had a water drain hose from its center that directed water into the drain on the floor. -the air conditioner ventilation unit, approximately two (2) foot by two (2) foot wide adjacent to the tarp, was actively leaking water onto the floor. The floor in front of the walk-in freezer and cooler units had approximately one-sixteenth (1/16) of an inch of standing water pooled in an approximate ten (10) foot by eight (8) foot wide area. -(3/23/26) a tray catty with approximately (13) food covers and plate warmers on top of the catty was stationed under the tarp connected to the ceiling and the actively dripping air conditioning ventilation unit. -(3/25/26) two (2) tray catties with approximately forty (40) food covers on top of the catties stationed under the tarp connected to the ceiling and the actively dripping air conditioning ventilation unit. -a four (4) tier metal shelf extended underneath the tarp and contained multiple uncovered condiments, salt packets, pepper packets, sugar packets, creamer packets, and four (4) containers of peanut butter. -there was approximately one-half (0.5) of an inch of gray dusty debris on the pipes attached to the ceiling throughout the kitchen, including areas above food preparation stations and food serving stations. -the hand wash sink next to the kitchen entry door had an active drainpipe leak when in-use. The hand wash sink contained an approximate six (6) inch stack of paper towels that were partially wet and above the sink was a non-working paper towel dispenser. -the wall behind the stove, oven, and two (2) bay sink was soiled with dark black thick grease and food debris and contained pieces of broken wall tile. -all exterior surfaces of the commercial oven range were heavily coated with grease and food debris. - the walk-in freezer door gasket was not securely attached and protruded through the space between the door and the freezer unit. Additionally, the walk-in freezer had black debris on the window, condensation and ice buildup on the lower exterior and interior sides of the door, and an approximate two (2) foot by one (1) foot accumulation of ice inside the unit on the floor and ceiling. - the wall behind the stove and oven, and the window above the two (2) bay sink, had broken and missing wall tiles. The damaged area behind the stove and oven measured approximately three (3) foot by two (2) foot and included peeled plaster. The damaged area above the two (2) bay sink had approximately seven (7) missing tiles and peeled plaster. During an interview on 03/23/2026 at 10:10 AM, the Food Service Director stated they worked with the facility for about one (1) year. The ceiling in the kitchen had leaked since they started and became worse since the snow started. The Food Service Director stated they reported the leak to administration and believed estimates were made but were unsure if anything had been done to fix it. The Food Service Director also stated the leak was worse today with the rain. Durning an interview on 03/23/2026 at 10:23 AM, the Administrator stated the issues with the ceiling in the kitchen started with the heavy snow and were patched by the facility two (2) times prior. Additionally, the Administrator stated the leak was located on the single-story part of the roof above the kitchen around the air conditioning unit, it looked like someone patched the area in the past, and they tore part of the ceiling down in the kitchen to see what was going on. The Administrator further stated the facility obtained estimates sometime in October 2025 and they were waiting for the weather to break before they could repair it. During an interview on 03/25/2026 at 1:01 PM, the [NAME] stated the stove should be cleaned after each meal including the top and all sides. The stove did not look like it was cleaned after breakfast as there was still pancake batter on the side of the stove. They were unaware of the missing tiles behind the stove and window. Additionally, the [NAME] stated the leak in the ceiling near the walk-in freezer and cooler units had been that way since they started at the facility in December 2025 and leaked more when it rained or snowed. The [NAME] also stated they did not notice the dust on the pipes connected to the ceiling and the pipes should be cleaned as they were over food prepping stations and could fall on prep surfaces. The [NAME] further stated they were unsure how long the paper towel dispenser was not working near the hand wash sink and the paper towels on the sink were wet and should not be used to dry staff hands. During an additional interview on 03/26/2026 at 1:09 PM, the Food Service Director stated the condiments, open boxes, and containers should be closed, covered, and not stored under the tarp and leaking air conditioning ventilation unit. Additionally, they stated the catties should not be stored under the leaking ceiling, it was an ongoing problem, and staff were reminded about the issue. Furthermore, they stated the gasket on freezer door needed to be replaced because it had a tear and the door did not seal properly. The Food Service Director stated the freezer had been fixed at least three (3) to four (4) times in the past year because of condensation and ice buildup inside the freezer. They stated the tiles on the back wall of the kitchen fell off as they were being cleaned today, and the Administrator was notified of the issue and stated the tiles would be fixed. Finally, the Food Service Director stated the stove should be cleaned after each meal, the evening cook had a problem with cleaning it correctly, and the front and sides were dirty and needed to be cleaned. During an interview on 03/27/2026 at 10:03 AM, the Maintenance Supervisor stated the roof was leaking for about the last six (6) months near the air conditioning unit above the kitchen. Additionally, they stated they pulled down part of the ceiling in the kitchen in September last year to identify the problem. Furthermore, they stated the roof was patched in September and again in November because the area continued to leak, and the facility planned on having the roof repaired when the weather broke. The Maintenance Supervisor stated they were aware of the broken and missing wall tiles, there had been an issue since the middle of 2025, and more tiles fell off behind the oven yesterday. They also stated they were unaware of the broken gasket on the walk-in freezer, and it should be replaced. The Maintenance Supervisor further stated the freezer door was worked on about 3 months ago and they were unsure if the broken gasket was causing the condensation and ice buildup inside and outside of the unit. Durning an interview on 03/27/2026 at 1:24 PM, the Administrator stated they were aware of the current and ongoing issues in the kitchen. They stated the facility planned to fix the ceiling in the kitchen and roof leak when the weather broke. Additionally, the Administrator stated they were unaware the tray catties and condiments were stored in the area of the leaking ceiling, and the wall tiles would be fixed. 10 New York Code Rules Regulations 415.14(h)

Based on observations, interviews, and record review conducted during the survey the facility failed to ensure that each resident had the right to be treated with respect and dignity for one (1) (Resident # 20) of three (3) residents reviewed. Specifically, Resident #20 was served their lunch meal when they were visibly incontinent. In addition, there were soiled linens, a large amount of fecal matter, and soiled briefs and linens on the floor between their bed and wall.The findings include:The policy and procedure titled Dignity dated 2/21 documented each resident shall be cared for in a manner that promotes their sense of well-being, and feelings of self-esteem. The residents are always to be treated with dignity and respect.Resident #20 had diagnoses that included cerebral vascular accident (stroke) Schizophrenia (a chronic severe brain disorder characterized by hallucinations and delusions) and intellectual disability. The Minimum Data Set (a resident assessment tool) dated 02/18/2026 documented Resident #20 was understood, understands and was severely cognitively impaired. There were no behaviors documented during the assessment period. Resident #20 required total assist of one (1) for personal hygiene and total assist of two (2) for toileting and was incontinent of bowel and bladder.The care plan report dated 03/03/2026 documented Resident #20 had a self-care deficit related to cerebral vascular accident and intellectual disability. Interventions included Resident #20 was independent with eating, total assistance of one (1) staff for personal hygiene and total assistance of two (2) staff for toileting. There was no care plan developed to address bowel and bladder incontinence.The Kardex (a guide used by staff to provide care) dated 03/27/2026 documented Resident #20 required total assistance of one (1) staff for personal hygiene and total assistance of two (2) staff for toileting. The Kardex did not give staff instructions regarding incontinent care needs.The following was observed on 03/25/2026:-12:29 PM Resident #20 was observed in bed with just an incontinent brief, a small blanket and a flat sheet covering the mattress. The flat sheet was visibly soaked/soiled with urine from their shoulders to the foot of their bed. Between the bed and the wall were three (3) soiled flat sheets and a soiled brief. There was a large amount of feces and dried food debris on the floor. Resident #20 was awake and did not respond when spoken to. -1:09 PM Resident #20 remained in bed and was still laying on the heavily soiled sheet. Between the bed and the wall on the floor the soiled linens and brief remained, as well as the large amount of feces and dried food debris. Resident #20's lunch tray was on the over bed table with hundred percent (100%) consumed. During an observation and interview on 03/25/2026 at 1:12 PM, Certified Nurse Aide #2 stated Resident #20 was on their assignment today, and that they had washed and provided incontinent care to the resident around 7:30 AM. Certified Nurse Aide #2 stated Resident #20 should be provided incontinent care every two (2) hours, they had not been back in the resident's room since this morning, and did not provide them their lunch tray. At this time, Resident #20 remained in bed laying on the heavily soiled sheet. Certified Nurse Aide #2 stated Resident #20 would remove their brief and pee and poop on the bed and put the soiled sheets and brief on the floor. Certified Nurse Aide #2 removed the soiled sheets and brief from behind the bed and stated they would get a housekeeper to clean up the floor. They said it was not like this when they washed Resident #20 up this morning. Resident #20 must have pushed them onto the floor. Certified Nurse Aide #2 also stated that Resident #20 should have been cleaned up before receiving their lunch.- 2:15 PM Resident #20 was sleeping in bed, the linens on the bed were changed but the dried food debris and large amount of feces remained on the floor behind the bed.Review of the video surveillance footage provided by the facility on 03/26/2026 at 9:51 AM revealed Certified Nurse Aide #2 entered Resident #20's room with the resident's lunch tray on 3/25/2026 at 12:50 PM, exited the room at 12:51 PM and closed the door.During a follow- up interview on 03/26/2026 at 12:47 PM, Certified Nurse Aide #2 stated they could not recall if they gave Resident #20 their lunch tray yesterday (03/25/26), but Resident #20 should have been cleaned up and linens change prior to receiving their lunch tray. No resident should be left that way to eat and it was a dignity issue. Durning an interview on 03/26/2026 at 1:44 PM, Registered Nurse Unit Manager #2 stated Resident #20 should have been provided care prior to receiving their lunch tray, and it was undignified. Durning a telephone interview on 03/27/2026 at 11:03 AM, Resident #20's family member stated Resident #20 was always soiled with feces and urine when they come in to visit. It's not right Resident #20 should not be treated or cared for that way. The staff don't care, and they have complained to the social workers and the nurses, but nothing ever changes. It's terrible. Durning an interview on 03/27/2026 at 1:04 PM, the Corporate Director of Nursing stated incontinent care should be completed every 2-3 hours. Resident #20 should have been provided with care and their room cleaned before the resident was served their lunch. 10 New York Code Rules Regulations 415.3 (a)

Based on observations, interviews, and record review conducted during the survey the facility failed to ensure that each resident who was unable to carry out Activities of Daily Living (ADL's) received the necessary services to maintain grooming and personal hygiene for one (1) (Residents #20) of three (3) residents reviewed. Specifically, Resident #20 was not provided with incontinent care every two (2) to three (3) hours and was not provided with timely incontinent care prior to lunch being served. Additionally, a care plan was not developed for bowel and bladder incontinence. The findings include:The policy and procedure titled Perineal Care dated 2/2018 documented the purpose of this procedure was to provide cleanliness and comfort to the residents, to prevent infection and skin irritation.Resident #20 had diagnoses that included cerebral vascular accident (stroke) Schizophrenia (a chronic severe brain disorder characterized by hallucinations and delusions) and intellectual disability. The Minimum Data Set (a resident assessment tool) dated 02/18/2026 documented Resident #20 was understood, understands and was severely cognitively impaired. There were no behaviors documented during the assessment period. Resident #20 required total assist of one (1) for personal hygiene and total assist of two (2) for toileting and was incontinent of bowel and bladder.The care plan report dated 03/03/2026 documented Resident #20 had a self-care deficit related to cerebral vascular accident and intellectual disability. Interventions included that Resident #20 was independent with eating, total assist of one (1) staff for personal hygiene and total assistance of two (2) staff for toileting. There was no care plan developed to address bowel and bladder incontinence.The Kardex (a guide used by staff to provide care) dated 03/27/2026 documented Resident #20 required total assistance of one (1) staff for personal hygiene and total assistance of two (2) staff for toileting. The Kardex did not give staff instructions regarding incontinent care needs. Review of the Progress Notes dated 3/25/2026 revealed there was no documented evidence Resident #20 refused care.The following was observed on 03/25/2026:-12:29 PM Resident #20 was observed in bed with just an incontinent brief, a small blanket and a flat sheet covering the mattress. The flat sheet was visibly soaked/soiled with urine from their shoulders to the foot of their bed. Between the bed and the wall were three (3) soiled flat sheets and a soiled brief. There was a large amount of feces and dried food debris on the floor. Resident #20 was awake and did not respond when spoken to. -1:09 PM Resident #20 remained in bed and was still laying on the heavily soiled sheet. Between the bed and the wall on the floor the soiled linens and brief remained, as well as the large amount of feces and dried food debris. Resident #20's lunch tray was on the over bed table with hundred percent (100%) consumed. During an observation and interview on 03/25/2026 at 1:12 PM, Certified Nurse Aide #2 stated Resident #20 was on their assignment today, and that they had washed and provided incontinent care to the resident around 7:30 AM. Certified Nurse Aide #2 stated Resident #20 should be provided incontinent care every two (2) hours, they had not been back in the resident's room since this morning, and did not provide them their lunch tray. At this time, Resident #20 remained in bed laying on the heavily soiled sheet. Certified Nurse Aide #2 stated Resident #20 would remove their brief and pee and poop on the bed and put the soiled sheets and brief on the floor. Certified Nurse Aide #2 removed the soiled sheets and brief from behind the bed and stated they would get a housekeeper to clean up the floor. They said it was not like this when they washed Resident #20 up this morning. Resident #20 must have pushed them onto the floor. Certified Nurse Aide #2 also stated that Resident #20 should have been cleaned up before receiving their lunch.- 2:15 PM Resident #20 was sleeping in bed, the linens on the bed were changed but the dried food debris and large amount of feces remained on the floor behind the bed.Review of the video surveillance footage provided by the facility on 03/26/2026 at 9:51 AM revealed Certified Nurse Aide #2 entered Resident #20's room with the resident's lunch tray on 3/25/2026 at 12:50 PM, exited the room at 12:51 PM and closed the door.During a follow- up interview on 03/26/2026 at 12:47 PM, Certified Nurse Aide #2 stated they could not recall if they gave Resident #20 their lunch tray yesterday (03/25/26), but Resident #20 should have been cleaned up and linens change prior to receiving their lunch tray. Durning an interview on 03/26/2026 at 1:44 PM, Registered Nurse Unit Manager #2 stated Resident #20 was incontinent of bowel and bladder and required total assist for care. Resident #20 could be resistive with care, and they were not aware Resident #20 was incontinent. Resident #20 should be provided with incontinent care every two (2) to three (3) hours. Registered Nurse Unit Manager #2 stated they were unsure if Resident #20 was care planned for bowel and bladder incontinence/care and they were trying to catch up on all the residents' care plan documentation. Resident #20 should have been provided care prior to receiving their lunch tray.Durning a telephone interview on 03/27/2026 at 11:03 AM, Resident #20's family member stated Resident #20 was always soiled with feces and urine when they come in to visit. Durning an interview on 03/27/2026 at 1:04 PM, the Corporate Director of Nursing stated incontinent care should be completed every two (2) to three (3) hours. Resident #20 should have been cleaned up and their room cleaned before they were served their lunch. It's an infection control issue. The Corporate Director of Nursing stated the facility does not document ADL (activities of daily living) completion. 10 New York Code Rules Regulations 415.12 (a)(3)

Based on observations, interviews, and record review conducted during the survey, the facility failed to ensure that residents who had an indwelling Foley catheter (tube inserted into the bladder to drain urine) received the appropriate care and services to manage catheters for one (1) (Resident #19) of three (3) residents reviewed for Foley catheters. Specifically, Resident #19 had a history of urinary tract infections, and the urine collection bag was observed lying directly on the floor on multiple occasions. Additionally, infection control practices were not maintained while emptying the urine collection bag and staff did not utilize enhanced barrier precautions (interventions designed to reduce transmission of multi-drug-resistant organisms including gown and glove use during high contact resident care activities) when providing direct hands-on care.The findings include: The policy and procedure titled Urinary Catheter Care dated 8/2022 documented that catheter tubing and drainage bag were to be kept off the floor, the collection bag was to be emptied at least every eight (8) hours, to avoid splashing, and to prevent contact of the drainage spigot with the non-sterile container. The policy and procedure titled Enhanced Barrier Precautions dated 12/2024 documented enhanced barrier precautions were utilized to prevent the spread of multi-drug-resistant organisms to residents during high contact resident care. Furthermore, the policy and procedure documented examples of high contact resident care activities that required the use of gown and gloves or enhanced barrier precautions included central lines, urinary catheters, and feeding tubes. Resident #19 had diagnoses that included quadriplegia (paralysis of all four limbs), chronic kidney disease, and depression. The Minimum Data Set (a resident assessment tool) dated 12/01/2025 documented that resident was cognitively intact and had an indwelling catheter. The Care Plan Report dated 11/29/2024 documented Resident #19 had a Foley catheter. Documented interventions included monitoring for signs and symptoms of urinary tract infection and report to the Doctor of Medicine, and to position the drainage bag and tubing below the level of the bladder. The Kardex (a guide used by staff to provide care) dated 03/27/2026 documented to provide Foley catheter care every shift and monitor/document Foley output every shift. Observations of Resident #19 on 03/26/2026 revealed the following: - 8:55 AM, the Resident was sleeping in bed, and their breakfast tray was untouched on the bedside table. The Resident's urinary drainage bag had approximately one thousand (1,000) milliliters of amber colored urine and was lying on directly on floor under the bed. The drainage tubing contained urine and a large amount of white mucous. Licensed Practical Nurse #1 entered the Resident's room to administer their medications and exited the room. Their urinary drainage bag remained on the floor. - 9:10 AM, Licensed Practical Nurse #1 entered the Resident's room, fed the Resident breakfast, and exited the room when the task was completed. Their urine drainage bag remained on the floor. - 10:16 AM and 11:26 AM, their urinary drainage bag remained on the floor. During an interview on 03/26/2026 at 11:31 AM, Certified Nurse Aide #3 stated Resident #19's urinary drainage bag should not have been on the floor as it was an infection control issue and should have been emptied because it was full. During an interview on 03/26/2026 at 11:48 AM, Licensed Practical Nurse #1 stated they were Resident #19's nurse today. They stated hey gave the Resident their medications and fed the Resident their breakfast this morning. Licensed Practical Nurse #1 stated they did not recall if the urinary drainage bag was on the floor when they gave the Resident their medications and fed the Resident their breakfast at the time. Licensed Practical Nurse #1 further stated the urinary drainage bag should not have been on the floor as it was an infection control issue and the Resident was prone to having urinary tract infections. During an observation on 03/26/2026 at 11:50 AM there was a sign posted on the door that Resident #19 required enhanced barrier precautions, and it was noted that supplies where nearby and available. Certified Nurse Aide #3 entered Resident #19's room, donned (put on) gloves, picked up the urinary drainage bag off the floor, and placed the clean urinal they brought into the room directly on the floor with no barrier. Certified Nurse Aide #3 subsequently opened the urinary drainage bag spigot and filled the urinal to the top. Certified Nurse Aide #3 then placed the urinary drainage bag with the spigot opened back on the floor, proceeded to the Resident's bathroom, and emptied the urine in the urinal into the toilet. Certified Nurse Aide #3 then placed the urinal back directly on the floor and finished emptying the urine from the urine drainage bag into the urinal and replaced the spigot into the bag holder without cleaning the spigot tip with alcohol. Certified Nurse Aide #3 was not wearing a protective gown while emptying the urinary drainage bag. During an interview at the time of the observation, Certified Nurse Aide #3 stated the Resident had eighteen hundred (1,800) milliliters emptied from the urinary drainage bag and was on enhanced barrier precautions because they had a Foley catheter. During an interview on 03/26/2026 at 1:21 PM, the Registered Nurse Infection Preventionist stated they had been with the facility for approximately two (2) weeks and were not familiar with the facility policy and procedures or the residents. The Registered Nurse Infection Preventionist stated urinary drainage bags should never be on the floor as it was an infection control issue and put the resident at risk for urinary tract infections. During an interview on 03/26/2026 at 1:30 PM, the Director of Nursing stated they would expect staff to follow enhanced barrier precautions for a resident with a Foley catheter. Precaution signs were on the residents' room doors to remined staff. The urinary drainage bag should never be on the floor, the bag should be emptied every shift, and staff should document the output. During an interview on 03/27/2026 at 1:05 PM, Registered Nurse Unit Manager #1 stated Resident #19 had a Foley catheter related to neurogenic problems. The Resident had a history of urinary tract infections and was just treated in February. The urinary drainage bag should never be on the floor, and they would expect the staff to wear a gown and gloves when emptying the urinary drainage bag per enhanced barrier precautions protocol. During an interview on 03/27/2026 at 1:15 PM, the Corporate Director of Nursing stated they would have expected the staff to follow enhanced barrier precautions, and don (put on) gloves and a gown when emptying the urinary drainage bag. The urinary drainage bag should not be on the floor as it was an infection control issue, and a barrier should have been used. 10 New York Code Rules and Regulations 415.12(d)(1)

Based on interviews and record review conducted during an Extended Recertification Survey and complaint investigations (#NY00385595 - 574018, #NY00381410 - 574678) completed on 10/10/2025, the facility failed to protect residents' right to be free from physical abuse, mistreatment, and neglect for five (5) (Residents #15, #29, #34, #91, #135) of eight (8) residents reviewed for abuse. Specifically, the facility failed to implement sufficient interventions to protect and prevent resident-to-resident abuse resulting in Resident #155 hitting four (4) residents between 02/15/2025 to 07/02/2025. Administration and medical staff failed to recognize abuse and neglect. This resulted in, or had the likelihood for, psychosocial harm and physical harm that is Immediate Jeopardy and Substandard Quality of Care for Residents #15, #29, #34, and #91 with the likelihood to affect all residents (census 145) in the facility. In addition, Certified Nurse Aide #7 used profanity and spoke to Resident #135 in a demeaning manner, then neglected to provide incontinence care and left the resident sitting in a soiled brief in their wheelchair with their pants down to their knees.The findings are:The policy titled Abuse and Neglect - Clinical Protocol with a revised date of March 2018 documented that abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. Willful as defined and as used in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.The policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program with a revised date of April 2021, documented residents had the right to be free from abuse and neglect, misappropriation of resident property and exploitation. That included but was not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, physical or chemical restraint to treat the resident's symptoms1. Resident #155 had diagnoses including frontotemporal neurocognitive disorder (brain disorder that affects personality, behavior, and language), dementia without behavioral disturbances, and adult failure to thrive. The Minimum Data Set (a resident assessment tool) dated 05/16/2025 documented Resident #155 was severely cognitively impaired, was understood, and usually understands.The Comprehensive Care Plan initiated 11/24/2024 documented Resident #155 exhibited self-directed harm or harm directed at others. Interventions included to allow resident personal space if safe wandering or pacing, initiate visual supervision during acute episode, maintain consistent schedule with daily routine, minimize environmental stimuli, monitor for signs or symptoms of agitation, provide clear simple instructions, engage in activities, offer food or snack, offer to toilet, and/or redirect as needed. On 03/30/2024, a focus was initiated that documented Resident #155 had the potential to be physically aggressive when redirected. Interventions included to adjust voice tone, approach from the front, assess and anticipate resident's needs, administer meds as ordered, analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document, provide calm environment, engage in conversation. Additionally, on 07/03/2025 an intervention to provide resident with calm environment in their room when noted behaviors of aggression/agitation arise was initiated. Review of the care plan revealed there were no changes made to the resident's plan of care after the 02/15/2025 or the 06/07/2025 altercations. a. Resident #91 had diagnoses including dementia with behavioral disturbances, schizoaffective disorder bipolar type (mental health disorder characterized by a persistent and significant disturbances in thought, perception, emotion, and behavior), and major depressive disorder. The Minimum Data Set, dated [DATE] documented Resident #91 was severely cognitively impaired, understands, and was understood by others.The Comprehensive Care Plan dated 03/14/2022 (current) documented Resident #91 was dependent on staff for meeting emotional, intellectual, physical, and social needs and had impaired cognitive function and/or impaired thought processes related to dementia. The Nursing Home Facility Investigation Summary dated 02/15/2025 at 2:45 PM, completed by Director of Nursing documented that Activities Aide #1 witnessed Resident #155 walk over to Resident #91 and ask for their Pepsi. Resident #91 said no and blocked Resident #155 from taking it. Resident #155 attempted to hit Resident #91 to get their attention. Resident #91 backed up and Resident #155 made contact with Resident #91's right cheek. Activities Aide #1 separated the residents. Activities Aide #1 was interviewed and stated, Resident #155 may have touched Resident #91, but it could not have been hard as it did not phase Resident #91. Resident #91 was assessed, had no bruising or discoloration, and did not recall the incident. Resident #155 was redirected and provided a drink. Both residents were placed on behavior monitoring for seventy-two (72) hours.The 24-hour Nursing Reports dated 02/15/2025 to 02/18/2025 documented Resident #155 and Resident #91 were to be monitored for behaviors. Review of the nursing reports revealed Resident #91 had incomplete documentation on 02/15/2025, from 3:00 PM through 7:00 AM on 02/16/2025, and during 3:00 PM to 11:00 PM on 02/16/2025. Resident #155 had incomplete documentation on 02/16/2025 during 7:00 AM to 11:00 PM and 02/18/2025 during 7:00 AM to 3:00 PM.b. Resident #34 had diagnoses including syncope (fainting), hypertension (high blood pressure), and cataracts (clouding of the eyes lens). The Minimum Data Set, dated [DATE] documented Resident #34 was moderately cognitively impaired, was understood, and understands others.The Comprehensive Care Plan dated 10/11/2022 (current), documented Resident #34 was independent with ambulation, was dependent on staff for meeting their emotional, intellectual, physical, and social needs, was not an independent decision maker, but was able to make their needs known.Review of the Nursing Home Facility Investigation Summary dated 03/30/2025 at 1:00 PM, completed by the Director of Nursing, documented Licensed Practical Nurse #9 heard Resident #34 yelling, and they went to their room. Resident #34 informed Licensed Practical Nurse #9 that Resident #155 walked into their room, and Resident #155 made physical contact with their hand to their face, then walked out of the room. Resident #34 was assessed and had redness noted to their face. Resident #34 stated they were not bothered by the incident. Following the incident, a stop sign was placed on Resident #34's door to prevent further unwanted guests, and both residents were placed on behavior monitoring for 72 hours. Resident #34's documented statement in the investigation documented that Resident #155 hit them.The 24-hour Nursing Reports dated 03/30/2025 to 04/03/2025, documented Resident #155 was to be monitored for behaviors. The reports were incomplete and had incomplete documentation on 03/31/2025 during the 3:00 PM to 7:00 AM shift, and on 04/01/2025 during the 3:00 PM to 11:00 PM shift. There was no documented evidence that Resident #34 was placed on the 24-hour Nursing Report for behavior monitoring from 03/30/2025 to 04/03/2025, as per the investigation summary.c. Resident #29 had diagnoses including Wernicke's encephalopathy (neurological emergency caused by the lack of thiamine (vitamin B1)/alcohol induced persisting dementia), history of trans ischemic attack (temporary interruption of blood flow to the brain, causing stroke like symptoms), and cerebral infarction (stroke). The Minimum Data Set, dated [DATE] documented Resident #29 was severely cognitively impaired, was understood, and usually understands others.The Comprehensive Care Plan dated 08/31/2023 (current), documented Resident #29 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to mild cognitive impairment. The resident was independent with wheelchair mobility. On 05/22/2024 an addition to the comprehensive care plan documented Resident #29 was at risk for victimization due to being involved in a resident-to-resident altercation where they were the victim (involved a threat of being harmed by another resident with sharp scissors).Review of the Nursing Home Facility Investigation Summary dated 06/07/2025 at 12:30 PM, completed by the Director of Nursing, documented Certified Nurse Aide #13 saw Resident #29 sitting in their wheelchair outside of their room and Resident #155 was approaching Resident #29's room. Resident #29 tried to redirect Resident #155 by saying turn around and go back that way. Resident #155 threw a box of gloves they were holding at Resident #29 and hit Resident #29 in the face with the box of gloves. Resident #155 then walked up to Resident #29, and with a closed fist punched them on their left cheek. The residents were separated. Resident #29 was assessed and had no injuries, their room was moved immediately following the incident to an area closer to the nurses' station, where Resident #155 did not frequent. Resident #29 was thrilled with the room change. Resident #155 was redirected by staff to the other end of the unit and was assessed and found to have no injuries. Resident #155 was calm and redirectable.Review of 24-Hour Nursing Reports, dated 06/07/2025 to 06/10/2025, revealed there was no documented evidence that Resident #29 and Resident #155 were placed on the 24-hour Nursing Report for behavior monitoring, until 06/09/2025 at 7:00 AM.d. Resident #15 had diagnoses including dementia without behavioral disturbances, anxiety, and arthritis (joint inflammation that causes pain). The Minimum Data Set, dated [DATE] documented Resident #15 was severely cognitively impaired, was understood and understands others.The Comprehensive Care Plan dated 05/22/2025 documented Resident #15 had impaired cognitive function related to dementia and to cue, reorient and supervise as needed. Resident #15 had poor safety awareness and staff were to anticipate and meet the resident's needs.The Nursing Home Facility Investigation Summary dated 07/02/2025 at 4:40 PM completed by the Director of Nursing documented the Minimum Data Set Nurse/Nursing Supervisor #1 heard Certified Nurse Aide #9 yell, They just hit them! At that time, Resident #15 was observed ambulating down the hallway crying and holding their left cheek and head with both of their hands. Resident #155 was also observed ambulating down the hallway. Resident #15 approached the nurses' station and there was an abrasion to their left cheek measuring 2.5 centimeters with redness extending up to the temple area. Resident #15 was asked to demonstrate what had happened. They made a fist with their right hand and made a hitting motion. Resident #155 was asked to describe what happened. They closed their right hand into a fist and struck the palm of their hand twice. It was determined that Resident #155 walked up to Resident #15 and struck them in the face with their hand. Resident #15 was upset and afraid of Resident #155 at the time of the incident. Immediately after the incident, Resident #15 had a room change to the second floor. Resident #155 was monitored for changes in behavior and was placed on the 24-hour nursing report. The Resident-to-Resident Incident Report for Resident #15 dated 07/02/2025, completed by Minimum Data Set Nurse/Nursing Supervisor #1, documented that after Resident #15 was struck in the face, the resident was afraid of Resident #155. Resident #15 was taken behind the nurses' station to ensure their safety and to provide comfort. Ice was applied to Resident #15's cheek/temple area and Tylenol (pain reliever) was administered for complaints of throbbing pain to the left side of their head.Review of the Vitals and Pain Evaluations form dated 07/02/2025 at 4:55 PM, documented Resident #15 had sharp, severe (level eight (8) out of 10, non-radiating pain to their head, and was exhibiting facial expressions of discomfort. A cool compress was applied, and Resident #15 received as needed pain medication.The 24-hour Nursing Report dated 07/02/2025 to 07/05/2025 revealed behavior next to Resident #155's name. There was no evidence of behaviors being monitored and documented throughout the day (7:00 AM to 7:00 PM). The 24-hour Nursing Report dated 07/03/2025 revealed Resident #155 was being monitored for behavior on one (1) day (07/03/2025 3:00 PM to 11:00 PM) out of 35 days.There is no documented evidence interventions put in place for Resident #155 were evaluated for effectiveness or to assure the safety of residents following each incident.Review of a progress note dated 07/08/2025 revealed Nurse Practitioner #2 documented that Resident #155 was seen for follow up after a resident-to-resident negative altercation where Resident #155 was the aggressor. Both residents were separated. Resident #155 is managed on Depakote (mood stabilizer) and Lexapro (medication used to treat depression and anxiety). The note documented to follow up with psych services as indicated.Review of a psychiatric consult note dated 09/18/2025 revealed Psychiatric Nurse Practitioner #1 documented that Resident #155 was seen for a psychiatric follow up visit. Staff and the Health Care Proxy (agent, person to make health care decisions) stated that Resident #155 had no recent physical aggression or behavioral disturbances on the unit. The Health Care Proxy Agent stated that Resident #155 made rash decisions. Based on observations, it was determined Resident #155 was alert, minimally verbal, and impulsive. Based on patient evaluation, symptoms, staff reports and collaboration, recent medical chart history reviewed, and current medications were reviewed. Psychiatric Nurse Practitioner #1 recommended no new medication changes; to provide non-pharmacological interventions; continue to monitor for changes in mood and behavior; and to monitor psychiatric changes. Behavioral symptoms are being actively monitored and continue to provide non-pharmacological interventions and monitor for changes in mood and behavior.During an interview on 09/11/2025 at 10:28 AM, the Director of Strategic Planning stated there were no behavior monitoring sheets for Resident #155, only what was documented on the 24-hour Nursing Reports.During an interview on 09/11/2025 at 12:54 PM, Minimum Data Set Nurse/Nursing Supervisor #1 stated Resident #155 was impulsive and did not understand the consequences of their actions. Minimum Data Set Nurse/Nursing Supervisor #1 stated Resident #15 was moved to another floor, but they could not recall any specific interventions put into place to keep other residents safe from Resident #155 following the incident on 07/02/2025.During an interview on 09/11/2025 at 3:18 PM, Certified Nurse Aide #9 stated on 07/02/2025 after the incident, Resident #15 was upset, in pain, and stated Resident #15 was afraid of Resident #155. They took Resident #15 to the nurses' station, and they immediately told Minimum Data Set Nurse/Nursing Supervisor #1 because they felt Resident #155 physically abused Resident #15.During a telephone interview on 09/12/2025 at 9:56 AM, Certified Nurse Aide #3 stated they were Resident #155's assigned aide on 07/02/2025 from 3:00 PM to 11:00 PM, and they were not told to increase their monitoring of Resident #155 following the incident.During a telephone interview on 09/12/2025 at 10:05 AM, Licensed Practical Nurse #5 stated they were Resident #155's assigned nurse 3:00 PM to 11:00 PM on 07/02/2025 and were not told to increase the monitoring of Resident #155. Licensed Practical Nurse #5 stated if they did do any increased monitoring, it would have been documented in the nursing progress notes or on the 24-hour Nursing Report. They added, if it was not documented, then the increased monitoring did not occur.During an interview on 09/15/2025 at 9:48 AM, the Director of Social Work stated they were informed of the incident between Resident #15 and Resident #155 the next day. They interviewed both residents and stated neither resident recalled the incident. The Director of Social Work stated the incident was abuse because Resident #155 caused physical harm to Resident #15. During an interview on 09/15/2025 at 10:46 AM, the Director of Nursing stated Resident #155 did not like other people in their personal space, so they assumed Resident #15 got into Resident #155's personal space causing Resident #155 to react. The Director of Nursing stated following the incident, Resident #15 was moved to a different floor, and behavior monitoring was started for Resident #155, which should have been documented on the 24-hour Nursing Report. The Director of Nursing stated the incident on 07/02/2025 was resident-to-resident physical abuse that caused harm to Resident #15. During a telephone interview on 09/15/2025 at 11:34 AM, Nurse Practitioner #1 stated following the incident, they evaluated both residents and neither resident was cognitively intact. They stated it was a situational reaction and stated they did not feel abuse occurred between the residents, but Resident #155 had caused harm to Resident #15. Nurse Practitioner #1 stated they would have expected an immediate intervention to have been put into place to keep all other residents on the fourth floor safe. During a telephone interview on 10/08/2025 at 1:11 PM, Psychiatric Nurse Practitioner #1 stated they were asked to see Resident #155 due to their diagnoses. When they approached the unit, they started talking to staff who do direct care and they explained Resident #155's behaviors. They stated they also had a conversation with Resident #155's Health Care Proxy Agent. Psychiatric Nurse Practitioner #1 stated Resident #155 was intrusive because while they were talking to Resident #155's Health Care Proxy Agent, Resident #155 came up to them (Psychiatric Nurse Practitioner #1) and almost kissed them on the lips. Resident #155's Health Care Proxy Agent stated Resident #155 was only aggressive if someone got in their personal space. Psychiatric Nurse Practitioner #1 stated they reviewed Resident #155's progress notes and saw that they hit someone and was under the assumption this other person got into Resident #155's personal space causing Resident #155 to react. They also stated they were unaware of any other incidents involving Resident #155. Psychiatric Nurse Practitioner #1 stated they were unsure of what Resident #155's triggers were. They stated they had spoken with Director of Nursing on 09/18/2025 and educated them that an in-service on de-escalation would be beneficial for facility staff, and education was needed on Resident #155s ' triggers and how to approach them. Due to their condition, Resident #155 was impulsive, and may get agitated and strike out. Additionally, Psychiatric Nurse Practitioner #1 stated they informed the Director of Nursing they needed to have something in Resident #155's plan of care related to de-escalation techniques, have them more involved and keep them busy. Psychiatric Nurse Practitioner #1 stated these incidents were humiliating, and degrading for all residents involved. The resident-to-resident incident between Resident #15 and Resident #155 on 07/02/2025 was harm.During a telephone interview on 10/08/2025 at 1:40 PM, Nurse Practitioner #2 stated they saw Resident #155 following the incident on 07/02/2025 and referred them to see psych because the resident had been recommended for an increase in their Depakote. Nurse Practitioner #2 stated they did not feel the incident on 07/02/2025 between Resident #15 and Resident #155 was abuse, because Resident #155 did not have the cognitive ability to do it. Nurse Practitioner #2 stated they were unaware of Resident #155's previous incidents, but there were other providers who worked with Resident #155 as well. Nurse Practitioner #2 stated they would have expected the psych consult to have been scheduled in a timely manner and July to September was not timely. During a telephone interview on 10/08/2025 at 2:23 PM, the Medical Director stated they were informed that Resident #155 punched Resident #15 because Resident #15 got into Resident #155's space and Resident #155 was trying to defend themselves. It was just two demented patients fighting. The Medical Director stated, they did not feel as though the incident was abuse, or any of the incidents with Resident #155, because they have dementia, and you cannot really control what people with dementia will do. The Medical Director stated there should have been monitoring of all residents involved following the incidents. A reasonable person would not be accepting of being punched in the face. That population is going to hit each other and sometimes that is just how it is going to be. The Medical Director stated they did not feel as though there was harm when Resident #155 punched Resident #15. Someone could be hurt, but that does not mean there was harm.During an interview on 10/08/2025 at 3:07 PM, the Director of Nursing, with the Director of Strategic Planning present, stated they felt all interventions put into place following each incident involving Resident #155 (02/15/2025, 03/30/2025, 06/07/2025, and 07/02/2025) were appropriate interventions. Resident #155 had a Depakote increase on 07/24/2025 and had no behaviors against other residents since then. The Director of Nursing stated they were planning on talking about some de-escalation techniques but had not yet met again with Psychiatric Nurse Practitioner #1.During an interview on 10/09/2025 at 11:14 AM, the Director of Strategic Planning stated they felt all their interventions were appropriate that were put into place after each incident involving Resident #155. The Director of Strategic Planning stated they would have expected Nurse Practitioner #2 to have been aware of all Resident #155's incidents. The Director of Strategic Planning stated if there was an order or recommendation made by a provider, they would have expected the unit manager to follow through with the recommendation. A recommendation made in July should have been carried out before September as there was a brief lapse in psychiatric providers in facility. The Director of Strategic Planning stated they did not know why de-escalation techniques training had not been completed. They had an educator who was very knowledgeable and was able and willing to do any sort of in servicing on de-escalation techniques, however the Director of Nursing was coordinating with Psychiatric Nurse Practitioner #1 before that happened. During an interview on 10/09/2025 at 12:27 PM, the Administrator stated they felt the interventions put into place for Resident #155 and the other residents involved in each incident were appropriate. They stated they would have expected Nurse Practitioner #2 to be familiar with all Resident #155's incidents and know their history. The Administrator stated there was a lapse in time when the facility did not have a psych provider and that could have been why Resident #155 did not see psych sooner. However, an appointment could have been made at an outside facility. The Administrator stated they were present for the conversation between the Director of Nursing and Psychiatric Nurse Practitioner #1, and it was more of a generalized statement made regarding de-escalation techniques for Resident #155, they felt it was not a formal conversation and had time to come up with a plan to implement.During an interview on 10/10/2025 at 11:04 AM, the Director of Strategic Planning stated they would expect for the Medical Director to be knowledgeable in the dementia diagnosis and what comes along with it. The Director of Strategic Planning stated nurse managers were responsible for reviewing all physician notes and following up with the necessary disciplines. If the physician note was reviewed, then the consult should have been put into place. When asked what as indicated meant, Director of Strategic Planning stated, I am not sure, I am confused as well and will ask for guidance. Nurse Practitioner #2 documented consult as indicated, but there was never an order put into place, and there should have been. Resident #155 saw psych services on 09/18/2025.2. Resident #135 had diagnoses including hypertension (high blood pressure), deep vein thrombosis (blood clot in the vein) of the right lower extremity, and anemia (not enough red blood cells to carry oxygen throughout the body). The Minimum Data Set documented that Resident #135 was moderately cognitively impaired, was always understood and always understands others. They required substantial maximum assistance from staff for toileting, transferring from the bed to their wheelchair, and for upper and lower body dressing.The Comprehensive Care Plan initiated 03/06/2025, documented Resident #135 had an Activities of Daily Living self-care performance deficit. The care plan documented the resident was occasionally incontinent, wore an adult brief and required extensive assistance from one (1) staff for dressing and toileting, and required setup for eating.The facility incident report Verbal Aggression Received dated 05/20/2025 at 1:00 PM completed by the Director of Nursing, documented that Resident #135 reported when they requested Certified Nurse Aide #7 to cut their pancakes and complained they were cold, Certified Nurse Aide #7 used profanity and told them they didn't care if they ate it or not. It was also reported that when the resident requested to be changed, dressed and taken out of bed for therapy, Certified Nurse Aide #7 told them they would not be getting them up. Resident #135 stated Certified Nurse Aide #7 did return and got them out of bed, but did not change their brief, left their pants down to mid-thigh, unbuttoned and unzipped.Physical Therapist #1's statement, dated 05/20/2025, documented at approximately 1:20 PM when they saw Resident #135, the resident was seated in their wheelchair with their pants down to just above their knees, and they were soiled with urine and feces. The resident told them they had wanted to get up earlier for therapy, but their aide refused to get them up. Physical Therapist #1 documented Resident #135 expressed sadness and frustration at the situation.Certified Nurse Aide #7's statement dated 05/20/2025, documented they did not use profanity but told the resident they did not have to eat. They stated they got them up and left their pants down so they would not get wet because they had no more clothes.The Investigation Summary/QA (quality assurance) Privilege report dated 05/29/2025 completed by the Director of Nursing, documented it was determined the incident was not abuse because Resident #135 did not suffer physical or psychological harm.During an interview on 09/15/2025 at 10:07 AM, the Director of Social Work stated that on 05/20/2025, they were called by Physical Therapist #1 to come see Resident #135 in therapy. Resident #135 was seated in their wheelchair, in a soiled brief with their pants down by their knees. The resident did not have a blanket over their lap, and they were unable to pull their pants up independently. They took the resident's statement and reported the incident to the Director of Nursing. The Director of Social Work stated the incident could be abuse, but the resident did not express that they were harmed.During an interview on 09/15/2025 at 11:05 AM, Resident #135 stated they recalled the incident with Certified Nurse Aide #7. They stated Certified Nurse Aide #7 was very rude at breakfast and used foul, profane language. Then they did not want to get them up for therapy, so they hurried them up into their chair and left them dirty with their pants halfway down. The resident stated they did not feel they were abused but felt undignified.During an interview on 09/15/2025 at 11:14 AM, Licensed Practical Nurse #4 stated they entered Resident #135's room shortly after breakfast and the resident had reported to them Certified Nurse Aide #7 had been rude. About an hour later, they observed Resident #135 wheeling back from the therapy room with their pants down by their knees. Physical Therapist #1 stated to them they had already notified Social Work. Licensed Practical Nurse #4 stated the incident was a form of abuse.During an interview on 09/15/2025 at 11:34 AM, Physical Therapist #1 stated Resident #135 was in their wheelchair with their pants down by their knees. They asked the resident why their pants were down, and the resident responded the aide did not want to do it and never came back. Physical Therapist #1 stated Resident #135 was very upset and emotional about the situation. Physical Therapist #1 stated the incident was abuse and a violation of the resident's right to dignity.During an interview on 09/15/2025 at 11:40 AM, Registered Nurse #4 stated they recalled there was an incident with Certified Nurse Aide #7, and they sent the aide home. Registered Nurse #4 stated the incident was abuse and a violation of Resident #135's right to dignity.During an interview on 09/16/2025 at 9:18 AM, Director of Nursing stated they ruled out abuse because Resident #135 stated they were happy with their care, and they were not psychologically harmed or upset by the incident. They stated it could be an issue with dignity, but Resident #135 did not express to them that they were very upset about it.During an interview on 09/16/2025 at 9:52 AM, the Administrator stated they ruled out abuse because it was determined that there was no physical or psychological harm to Resident #135.During a telephone interview on 10/09/2025 at 1:11 PM, Psychiatric Mental Health Nurse Practitioner stated they did not feel as though Resident #135 experienced any psychosocial harm from the incident as the resident was happy after the incident knowing Certified Nurse [NAME] #7 was removed from their care. During an interview on 10/08/2025 at 3:07 PM, the Director of Nursing stated they did not feel that the incident was neglect, and they only sent it in to the Department of Health because they wanted to fire the accused Certified Nurse Aide or else we wouldn't have reported it as they did not feel it was any kind of abuse. 10NYCRR 415.4(b)(1)(i)

Based on interviews and record review conducted during Complaint investigations (#NY00365084-574660, #NY00385595-574018, NY00381410- 574678) completed during an Extended recertification survey completed on 10/10/2025, the facility did not ensure that all alleged violations involving abuse, neglect, mistreatment, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) for five (5) (Resident #8, #15, #131, #135 and #155) of five (5) residents reviewed. Specifically, the results of an abuse allegation investigation were not sent to the State Agency within five (5) working days of the incident (Residents #15, #135 and #155). Additionally, an allegation of abuse was not reported to the State Agency within the 2-hour required time frame (Residents #8, #131, and #135). This resulted in no actual harm with the potential to affect all residents that is substandard quality of care.The findings are:The policy and procedure titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised April 2021 documented if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to the state law. Immediately is defined as: within two (2) hours of an allegation involving abuse or result in serious bodily injury. The administrator, or his/her designee, provide the appropriate agencies or individuals listed with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. 1. Resident #15 had diagnoses including dementia without behavioral disturbances, anxiety disorder, and arthritis (joint inflammation that causes pain). The Minimum Data Set (a resident assessment tool) dated 05/29/2025 documented Resident #15 was severely cognitively impaired, was understood and understands. Resident #155 had diagnoses including frontotemporal neurocognitive disorder (brain disorder that affects personality, behavior, and language), dementia without behavioral disturbances, and adult failure to thrive. The Minimum Data Set, dated [DATE] documented Resident #155 was severely cognitively impaired, was understood, and usually understands.The nursing home facility investigation report submitted successfully to the State Agency completed by the Administrator documented an allegation of physical abuse had occurred at 4:40 PM on 07/02/2025. The Administrator was first made aware on 07/02/2025 at 4:47 PM. The incident was submitted to the State Agency on 07/02/2025 at 6:08 PM. There was no documented evidence that the full/results of the abuse investigation was sent to the State Agency within five (5) working business days.The undated facility Investigation Summary documented the date and time of the event was 07/02/2025 at 4:40 PM, and time Director of Nursing #2 notified was 07/02/2025 at 4:45 PM. The Investigation Summary documented Certified Nurse Aide #9 heard a loud thud and saw Resident #15 walking away from Resident #155, holding their left cheek with both hands, visibly upset and fearful of Resident #155. Minimum Data Set Nurse/Nursing Supervisor #1 heard Certified Nurse Aide #9 yell they just hit them, and saw Resident #15 ambulating down the hallway coming from the main dining room with a quick steady pace approaching the nurses station crying and holding both of their hands up to their left cheek/side of their head, a 2.5 centimeter abrasion with redness and swelling extending up to their temple was noted. Minimum Data Set Nurse/Nursing Supervisor #1 immediately notified Director of Nursing #1, and the incident was reported to the New York State Department of Health on 07/02/2025 at 6:08 PM.During an interview on 09/15/2025 at 10:46 AM, Director of Nursing #1 stated they completed the investigation, but Director of Nursing #3 was responsible for sending the information into the New York State Department of Health for review, and they did not know why it was never sent. Director of Nursing #1 stated it was regulation to send in the investigation within five (5) working business days after the initial submission, and the investigation should have been submitted.During a telephone interview on 09/15/2025 at 11:54 AM, Director of Nursing #3 stated they were made aware of the incident on 07/02/2025 and immediately made the Administrator aware so the investigation could begin. Director of Nursing #3 stated they obtained witness statement and gave them to Director of Nursing #1 who they thought submitted the five-day investigation information.During an interview on 09/15/2025 at 2:25 PM, the Administrator stated if Director of Nursing #1 or Director of Nursing #3 failed to submit the full investigation, the Administrator was ultimately responsible for ensuring that the full investigation was successfully uploaded and sent to the State Agency within five business days. The Administrator stated they typically would receive a call asking about the investigation but had not; so, it got away from them; the full investigation should have been submitted within five working business days.During a follow up interview on 09/16/2025 at 9:32 AM, Director of Nursing #1 stated ultimately the Administrator was responsible for ensuring the full investigation was sent into the State Agency within five working business days, and it was not.2. Resident #135 had diagnoses including hypertension (high blood pressure), deep vein thrombosis (blood clot in the vein) of the right lower extremity, and anemia (not enough red blood cells to carry oxygen throughout the body). The Minimum Data Set, dated [DATE], documented they were always understood and always understands others, and they were moderately cognitively impaired. The comprehensive care plan, initiated 03/06/2025, documented Resident #135 had an Activities of Daily Living self-care performance deficit. They required extensive assistance from one (1) staff for dressing and toileting and required setup for eating. Resident #135 was occasionally incontinent and wore a brief.Review of the New York State Department of Health Complaint Tracking System Complaint/Incident Investigation Report revealed the date/time of the alleged incident was 05/20/2025 at 11:00 AM. The date/time the Administrator was first made aware of the incident was 05/20/2025 at 3:45 PM. It was submitted by the facility to the New York State Department of Health on 05/21/2025 at 8:23 PM. Review of the Nursing Home Investigative Report revealed the facility submitted their investigation results on 05/28/2025 at 12:56 PM. There was no documented evidence that the results of the abuse investigation were sent to the State Agency within five (5) working business days.The facility incident report Verbal Aggression Received, prepared by Director of Nursing #1, dated 05/20/2025 at 1:00PM, documented Resident #135 stated when they requested Certified Nurse Aide #7 to cut their pancakes, and then complained they were cold, Certified Nurse Aide #7 used profanity and told them they didn't care if they ate it or not. When they requested to get out of bed, changed and dressed for therapy, Certified Nurse Aide #7 told them they would not be getting them up. Certified Nurse Aide #7 did return, got them out of bed to their wheelchair, did not change their brief and left their pants only pulled up to their mid-thigh, unbuttoned and unzipped.The Investigation Summary/QA Privilege report dated 05/29/2025, completed by Director of Nursing #1, documented it was determined the incident was not abuse because Resident #135 did not suffer physical or psychological harm.During an interview on 09/15/2025 at 10:07 AM, the Director of Social Work stated on 05/20/2025 they were called by Physical Therapist #1 to come see Resident #135 in therapy. Resident #135 was in their wheelchair, in a soiled brief with their pants down by their knees. They were unable to pull them up themselves. They did not have a blanket over their lap. They took their statement and reported the incident to the Director of Nursing.During an interview on 09/15/2025 at 11:05 AM, Resident #135 stated they recalled the incident with Certified Nurse Aide #7. They stated Certified Nurse Aide #7 was very rude at breakfast and used foul language. Then they didn't want to get them up for therapy, so they hurried them up into their chair and left them dirty with their pants halfway down. Resident #135 stated they shouldn't be treated that way and it made them feel terrible to be left that way when they were not strong enough to lift their butt up to pull up their pants.During an interview on 09/15/2025 at 11:34 AM, Physical Therapist #1 stated they saw Resident #135 in their wheelchair with their pants down by their knees. Physical Therapist #1 stated Resident #135 was very upset and emotional about the situation. They immediately notified the Director of Social Work, their manager and Registered Nurse #4. Physical Therapist #1 stated Resident #135 expressed gratitude for sitting with them and actually caring about what happened. Physical Therapist #1 stated the incident was abuse and a violation of the resident's right to dignity.During an interview on 09/16/2025 at 9:18 AM, Director of Nursing #1 stated they spoke with Resident #135 on 05/20/2025 and they ruled out abuse because the resident did not appear psychologically harmed by the incident. Director of Nursing #1 stated the incident was reported to the New York State Department of Health on 05/21/2025 around 8:00 PM. They stated the incident did not need to be reported within two (2) hours because the resident was not physically or psychologically harmed. Director of Nursing #1 stated the incident should have been reported within 24 hours.During an interview on 09/16/2025 at 9:52 AM, The Administrator stated they were notified of the incident on 5/20/2025 around 3:35 PM. They stated they ruled out abuse because nursing staff assessed the resident and determined no physical or psychological harm occurred. They stated if there was no injury or harm, the incident did not need to be reported.3. Resident #8 had diagnoses including Parkinson's Disease (tremors and rigidity of movement), dementia, and schizophrenia. The Minimum Data Set, dated [DATE] documented Resident #8 had moderate cognitive impairment.Resident #131 had diagnoses including dementia, cerebral infarction (stroke), and anxiety. The Minimum Data Set, dated [DATE] documented Resident #131 had severe cognitive impairment.The nursing home facility investigation report submitted successfully to the State Agency completed by Director of Nursing #2 documented an allegation of sexual abuse had occurred on 12/15/2024 at 6:51 PM. The Administrator was first made aware on 12/15/2024 at 6:53 PM. The incident was submitted to the State Agency on 12/16/2024 at 3:01 PM. The undated facility Investigation Summary documented the date and time of the event was 12/15/2024 at 6:51 PM, and Director of Nursing #2 notified was 12/15/2024 at 6:53 PM. The Investigation Summary documented Certified Nurse Aide #10 discovered Resident #8 in their wheelchair next to Resident #131's bed. Registered Nurse Supervisor #2 was immediately notified. The Investigation Summary documented the incident was reported to the New York State Department of Health on 12/16/2024 at 3:01 PM.During an interview on 9/12/2025 at 8:33 AM, Licensed Practical Nurse #3 stated abuse was to be reported to the unit manager or nursing supervisor right away. The abuse then needed to be reported to the New York State Department of Health within two (2) hours. During a telephone interview on 9/12/2025 at 8:55 AM, Registered Nurse Supervisor #2 stated they did not recall the whole situation that had occurred, but remembered it seemed suspicious for abuse and was something that needed to be investigated. They could not recall if they notified Director of Nursing #2 or the Administrator, but they notified them immediately because that was what they were required to do for anything that had the potential to be sexual abuse. They stated they did not know the time frame for the incident to be reported to the New York State Department of Health and that was the Director of Nursing or Administrator's responsibility. A telephone call was made on 9/12/2025 at 9:13 AM and on 9/15/2025 at 10:13 AM to Director of Nursing #2. They did not return the phone call. During an interview on 9/12/2025 at 11:18 AM, Registered Nurse #1 Resident Care Coordinator stated abuse needed to be immediately reported to the nursing supervisor, Director of Nursing and/or the Administrator. They were required to report abuse to the New York State Department of Health within two (2) hours because any allegations needed to be addressed quickly. They stated abuse needed to be addressed quickly because if it was not, then statements might not be as accurate as time went on. Registered Nurse #1 Resident Care Coordinator stated they remembered parts of the investigation for the incident between Resident #8 and Resident #131. They recalled therapy completing a reenactment with Resident #8 and that was how abuse was ruled out, but they were not sure when the incident was reported to the New York State Department of Health. During an interview on 9/15/2025 at 12:52 PM, Director of Nursing #1 stated Director of Nursing #2 was responsible for reporting the incident between Resident #8 and Resident #131 to the New York State Department of Health. They stated, according to the Investigation Summary, Registered Nurse Supervisor #2 had notified Director of Nursing #2 on 12/15/2024 at 6:53 PM and Director of Nursing #2 reported the incident to the New York State Department of Health on 12/16/2024 at 3:01 PM. Director of Nursing #1 stated the investigation was to rule out sexual abuse and that should have been reported to the New York State Department of Health within two (2) hours. They stated they did not know the reason why Director of Nursing #2 did not report the incident in a timely matter. During an interview on 9/15/2025 at 1:10 PM the Administrator stated they could not remember the details of the incident between Resident #8 and Resident #131 but based on the initial report that was submitted to the New York State Department of Health, there was potential for sexual abuse, and it was reported to administration within two (2) hours. They stated the report was submitted by Director of Nursing #2 on 12/16/2024 at 3:01 PM. The Administrator stated the incident was not reported correctly. Both the Director of Nursing and Administrator of the facility were responsible for reporting incidents to the New York State Department of Health. The Administrator stated ultimately, they were responsible for overseeing that the Director of Nursing had reported the incident timely. They stated it should have been reported timely because there could have been sexual abuse or an injury that had occurred however, their investigation showed that abuse did not occur. 10 NYCRR 415.4(b)(2)

Based on interview and record review conducted during a Complaint investigation (NY00372414 - 574672) during the Standard survey completed on 09/19/2025, the facility did not ensure that there was sufficient nursing staff with the appropriate competencies on a 24-hour basis to attain or maintain the highest practicable physical, mental and psychosocial well-being for residents in the facility (floors two (2), three (3), four (4)). Specifically, there was insufficient staff to meet all the residents needs including long wait times to get mediations and call bells answered, toileting/hygiene, and showers. Additionally, the facility did not meet their assessed minimum staffing levels for Licensed Nurses based on the facilities assessment to meet the needs of each resident. The findings are:The undated Facility Assessment documented registered nurse numbers were based on census and licensed practical nurse numbers would be based on census/acuity and level of care. The assessment documented that the staffing and competencies section provided an evaluation of the overall number and types of staff needed to provide the level and types of care appropriate for the resident population. It was a competency-based approach to determine the knowledge and skill required to ensure residents were able to monitor or attain the highest practicable physical, functional, mental and psychosocial well-being and meet current professional standards of practice. An addendum to the Facility Assessment documented the facility staffing was census and acuity based would fluctuate based on admissions/discharge. The addendum documented for a census of 149 the minimums would be one licensed practical nurse per unit per shift with a registered nurse on call. a. Review of the Resident Council Minutes Summary dated 07/25/2025 documented the residents state certified nurse assistants (especially on the night shift) were slow to answer call bells and all nursing staff needed to pitch in to attend to call bells in as timely a fashion as possible. Review of the Resident Council Minutes Summary dated 08/29/2025 documented call bells need to be responded to in a timelier manner and all nursing staff should attend to call bells as quickly as possible. During an interview on 09/09/2025 at 12:41 PM, Resident #114 stated they cannot move by themselves in bed and there have been times when they have waited over two (2) hours to have incontinent care completed, leaving them in a soaking wet brief. Resident #114 stated they push the call light, but no one pays attention, every shift is the same. Staff will come into the room, turn the light off then never return. Nurses were overwhelmed with work. During an interview on 09/09/2025 at 1:03 PM, Resident #75 stated there have been multiple times on the overnight shift (11:00 PM to 7:00 AM) that they would ring their bell because they were in pain and needed their pain medication. No one answered for hours. Resident #57 stated one time they got up after ringing for over an hour to look for staff on the second floor around 3:00 AM. They stated they could not locate any staff on the floor and they had waited over three hours for their pain medication that night. During an interview on 09/10/2025 at 9:32 AM, Resident #5 stated they have not had a shower in three weeks. They stated the certified nurse aides tell them they do not have enough staff to give them. During an interview on 09/10/2025 at 10:33 AM, Resident #114 stated the staff just walk by the room and turn the call lights off, sometimes they must wait over an hour for anyone to return because the nurses and aides are both shorthanded. During an interview on 09/10/2025 at 12:06 PM, Resident #6 stated the third shift had the worst staffing and there were not enough aides. They stated it takes a long time for the call lights to be answered. b. Resident #155 had diagnoses that included dementia, hypothyroid, and hypertension. The Minimum Data Set (a resident assessment tool) dated 08/15/2025 documented the resident have severe cognitive impairment, was usually understood and usually understands. Review of medication administration record dated 09/16/2025 documented Resident #155 was to receive levothyroxine (medication used to treat hypothyroid disease) 50 micrograms daily at 4:00 AM. The medication was not signed off as administered on 09/02/2025. During a telephone interview on 9/15/2025 at 10:42 AM, Registered Nurse #3 stated they did the best they could and prioritized the nursing duties on all three floors. They stated the residents got everything they needed except they could not get to Resident #155's 4:00 AM medications on 09/02/2025. During a telephone interview on 09/15/2025 at 12:03 PM, Nurse Practitioner #2 stated they stated they were not notified that Resident #155's levothyroxine dose was not given and would expect a medical provider to notified. During an interview on 09/15/2025 at 2:24 PM, the Director of Nursing #1 reviewed Resident #155's medication administration record and stated Resident #155's 4:00 AM levothyroxine was not signed as given on 09/02/2025. They stated they do not know why however cannot say it was due to staffing. Director of Nursing #1 stated the staffing numbers were not unsafe but not optimal. c. Review of the nursing staff schedule dated 09/01/2025 documented the 11:00 PM - 7:00 AM had Registered Nurse #3 listed. There was no further nursing staff listed for that shift. It was documented the census number in the facility was documented as 149. Review of nursing staff schedule dated 09/07/2025 documented the 11:00 PM - 7:00 AM had Registered Nurse #3 and Licensed Practical Nurse #2. No further nurse staff were listed for that shift. It was documented the census number in the facility was 147. During an interview on 09/15/2025 at 8:22 AM, the Staffing Coordinator stated the biggest challenge with staffing was call-offs. The Staffing Coordinator stated the minimum nurse staffing was one nurse for each floor (three floors) for all shifts and at least two certified nurse aides per floor. After reviewing the 11:00 PM-7:00 AM nursing schedules for 09/01/2025 into 09/02/2025, the Staffing Coordinator stated there was only nurse that worked in the building that shift, and it was the nursing supervisor (Registered Nurse #3). After reviewing the 11:00 PM-7:00 AM nursing schedules on 09/07/2025 into 09/08/2025, the Staffing Coordinator stated there were only two nurses in the facility working, Registered Nurse #1 and Licensed Practical Nurse #2. They stated Director of Nursing #1 was the registered nurse on-call for both days. The Staffing Coordinator stated they were not aware the facility worked with only one nurse on 09/01/2025 and two nurses on 09/07/2025 until the following mornings when they came into work. During an interview on 09/15/2025 at 8:32 AM, Director of Nursing #1 stated they were not aware of the nurse staffing numbers until 09/08/2025. Registered Nurse #3 had never called them either night (9/1-9/2 and 9/7-9/8). Director of Nursing #1 stated the facilities minimum number of nurses that should be working the 11:00 PM-7:00 AM shift would be three (3) including the nursing supervisor taking a medication cart if needed. They stated one nurse or two nurse working in the facility on the overnight shift with a census of 149 residents was not recommended. During a telephone interview on 9/15/2025 at 8:42 AM, Licensed Practical Nurse #2 stated they worked the 11:00 PM - 7:00 AM shift on 09/07/2025-09/08/2025. They stated they only worked on the second floor and was unsure what nurse staffing was available in the rest of the building. Licensed Practical Nurse #2 stated needed to contact the nursing supervisor that night as a resident was having a seizure and was sent to the hospital. During a telephone interview on 9/15/2025 at 10:42 AM, Registered Nurse #3 stated they were the 11:00 PM - 7:00 AM shift Nursing Supervisor. On 09/01/2025 they were the only nurse in the facility and on 09/07/2025 they worked with only one other Licensed Practical Nurse in the building. Registered Nurse #3 stated they had called the Staffing Coordinator, the Minimum Data Set Coordinator and other staff nurses to notify them about the need for additional nurses without success. They stated the Staffing Coordinator did return their call in the middle of the night but could not get staff to come in. Registered Nurse #3 stated one (1) to two (2) nurses on the 11:00 PM- 7:00 AM shift was not appropriate and probably not a safe situation. During a telephone interview on 09/15/2025 at 12:03 PM, Nurse Practitioner #2 stated they feel nurse staffing for the night shift would be more appropriate at three nurses in the facility to adequately complete the medication pass on each unit. During an interview on 09/15/2025 at 2:32 PM, the Administrator stated that minimum nurse staff number would be to have one nurse each shift per floor. They stated this number would also include the nursing supervisor having to take a floor as a floor nurse if they needed to. The Administrator stated the facility did fall below that number on 09/01/2025 and 09/07/2025 for the 11:00 PM-7:00 AM shift. They stated they were not aware the facility was below their minimum and the nursing supervisor did not contact them on those days. The Administrator stated it was not ideal to work with one or two nurses for the overnight shift but there always was a potential for a negative outcome in the facility whether it was fully staff or understaffed. 10NYCRR 415.13(a)(b) (1) (i)

Based on interview and record review conducted during the Extended Recertification Survey completed on 10/10/2025, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. Specifically, the administration did not ensure that psychiatric services were available, make outside arrangements or assist residents with accessing such services.The findings are:The undated Facility Assessment documented the workforce profile would list all personnel, including manager, staff (both employees and those who provide service under contract), and volunteers. The workforce profile listed that mental/Behavioral health providers would be contracted by the ((name of company) behavioral health services). Section III, Resources Needed, of the facility assessment documented the section provides an evaluation of the overall number and types of staff needed to provide the level and types of care appropriate for the resident population. It was a competency-based approach to determine the knowledge and skill required to ensure residents were able to monitor or attain the highest practicable physical, functional, mental and psychosocial well-being and meet current professional standards of practice.Review of a Job Description: Administrator revised 04/23/2012, documented under the direction of the Regional [NAME] President, the Administrator lead and directed the overall operation of the facility in accordance with resident needs, government regulations and company policies to maintain quality care for the residents while achieving the facilities business objectives. Administrative Responsibilities consisted of but not limited to working with facility management staff and consultants in planning all aspects of facility's operations, including priorities and job assignments; Ensures consultants and other support resources are appropriately utilized and a high level of inter-disciplinary teamwork is maintained.For additional information see Centers for Medicare/Medicaid Services Form 2567, reference F 600 - Free from Abuse, Neglect and Exploitation.For additional information see Centers for Medicare/Medicaid Services Form 2567, reference F742 - Treatment/Services for Mental/Psychosocial ConcernsResident #6 was not receiving psychotherapy services and/or group therapy services as recommended by their psychiatry provider and there was a delay in obtaining a follow up psychiatry consult as recommended for Resident #155.a. During an interview on 09/15/25 at 9:29 AM, Social Worker #1 stated the social workers were responsible for the referral process for when a resident had a recommendation to see the psychiatrist and/or psychologist at the facility. Social Worker #1 stated Resident #6 was under the psychiatric care but was not following with a psychologist. Social Worker #1 stated they did not put in a referral request for Resident #6 to have psychotherapy but should have because it was a recommendation made by the psychiatrist. They stated the previous social worker should have also put in a referral. During a telephone interview on 09/12/2025 at 11:34 AM, Psychiatrist #1stated they made a recommendation for Resident #6 to receive psychotherapy services. They stated they would have expected the social worker to follow up with the recommendations and make an appointment for counseling or even group therapy sessions. During an interview on 09/16/2025 at 9:46 AM, Director of Nursing #1 stated Resident #6 was not participating in psychotherapy with the facility's psychologist. Director of Nursing #1 stated the facility did not and could not provide a phone number for Licensed Psychologist #1 and only communicated with Licensed Psychologist #1 via email. They stated the social workers were responsible for placing any referrals for psychiatry and/or psychotherapy needs. During an interview on 09/16/2025 at 12:16 PM, Director of Nursing #1 stated they could not locate any policies on psychology consultants.b. Review of nursing progress notes dated 02/20/2025 to 09/11/2025 revealed Resident #155 was aggressive and had behaviors at times directed towards staff and other residents, had elopement attempts, wandered the unit and frequently entered other residents' rooms.Review of an untitled facility document dated 07/08/2025, Nurse Practitioner #2 documented Resident #155 was seen for follow up after a resident-to-resident negative altercation where they were the aggressor. Resident #155 was managed on Depakote (mediation used to treat seizures) and Lexapro (antidepressant). Nurse Practitioner #1 documented for Resident #155 to follow up with psych services as indicated.Review of Psychiatry progress note dated 09/18/2025 at 4:26 AM (late entry note), Psychiatric Nurse Practitioner #1 documented Resident #155 was seen for psychiatric follow up to monitor and assess medications. No new medication recommendations were made, and non-pharmacological interventions were encouraged.During an interview on 10/09/2025 at 11:14 AM, the Director of Strategic Planning stated there was a time gap; about a month where the facility was between psychiatric providers. They stated July to September was not an appropriate time frame for Resident #155 to have waited for a psychiatric consult after it was recommended by Nurse Practitioner #2. Director of Strategic Planning stated if there was a psychiatry recommendation made by a provider, then the facility was responsible for ensuring the recommendation was followed through. If there was not a psychiatrist available in the facility when the recommendation was made, the physician should have been notified and asked them what they wanted to do. Director of Strategic Planning stated the facility did not like to send residents out for outside psych services unless it was urgent, or the resident was dangerous. Additionally, the Director of Strategic Planning stated the social workers were previously in charge of setting up all psych consults for residents in the facility.During an interview on 10/09/2025 at 12:27 PM, the Administrator stated there was a lapse at the facility when there was no psychiatric provider. The issue with Resident #155 not seeing a psychiatric provider when it was recommended in July of 2025 fell into that time frame. The Administrator stated they should have looked at other resources for Resident #155 and any other residents who may have needed psychiatric services during that time and made an appointment.10NYCRR 415.26

Based on interviews and record review conducted during the Extended Survey completed on 10/10/2025, the facility did not ensure that the Medical Director was responsible for implementing resident care policies and coordination of medical care in the facility. Specifically, the Medical Director normalized physical altercations between dementia residents. The finding is:Refer to F 600 Free from Abuse and Neglect - Scope and Severity = L The undated facility document titled Medical Director Job Description documented the Medical Director must ensure the implementation of resident care policies and coordination of medical care in the facility to promote quality, safety, and compliance with federal and state regulations. Responsibilities included but were not limited to promoting a culture of accountability, safety, and continuous improvement; provides guidance, consultation, and oversight to clinical staff as needed; promotes ethical medical practice and adherence to residents' rights and choices; ensures resident care decisions respect autonomy, dignity, and rights; and advocates for safe, compassionate, and individualized medical care.The undated policy titled Medical Director documented the Medical Director's responsibilities required that they be knowledgeable about current professional standards of practice in caring for long-term residents and about how to coordinate and oversee other practitioners; administrative decisions including recommending, developing and approving facility policies related to resident care- resident care included resident's physical, mental and psychosocial well-being; ensuring the appropriateness and quality of medical care and medically related care. The facility shall ensure all responsibilities of the medical director are effectively performed, regardless of how the task is accomplished or the technology used, to ensure residents attain or maintain their highest practicable physical, mental, and psychosocial well-being.During a telephone interview on 10/08/2025 at 2:23 PM, the Medical Director stated they were informed of an incident involving two residents on the dementia unit where one resident (Resident #155) punched the other resident (Resident #15) in the face causing an abrasion on residents (Resident #15) left cheek; resident (Resident #15) exhibited pain and crying, and verbalized fear of the aggressor. The Medical Director stated it was not abuse, it was just two demented residents fighting; the residents had dementia, and you cannot control what people with dementia do. The Medical Director stated a reasonable person would not be accepting of being punched in the face, but with a dementia diagnosis could not say if the resident minded or not. That population is going to hit each other sometimes, that is just how it is going to be, they hit each other. During an interview on 10/10/2025 at 10:58 AM, the Administrator stated they expected for the Medical Director to fulfill what was outlined in their duties and responsibilities; being a medical doctor, to understand the diagnosis of dementia and what comes along with residents who have dementia. The Administrator was informed of what the medical director stated regarding dementia residents and stated they would have to talk to the medical director to have a better understanding of the context of why they said what they said to make a better determination as to what they meant by it.During an interview on 10/10/2025 at 11:04 AM, the Director of Strategic Planning stated they expected the medical director to be knowledgeable in dementia and what comes along with it with residents. The Director of Strategic Planning was informed of what the medical director stated regarding dementia residents and stated it was not necessarily okay to say that, but they would have to talk to the medical director and understand exactly what they meant by it; it was a situation that should be taken seriously.10NYCRR 415.15(a)(1)(2)

Based on observation, interview, and record review during the Standard survey completed on 09/16/2025, the facility did not maintain an effective pest control program for four (4) (first, second, third, and fourth floors) of four (4) resident use floors. Issues included observations of evidence of rodents (dead rodents and rodent droppings) and flies.The findings are:The policy and procedure titled Pest Control, revised 7/2023, documented the facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Pest control services are provided by an outside contracted pest control vendor. 1a. Observation on the first floor on 09/09/2025 at 1:40 PM and 09/16/2025 at 1:10 PM revealed rodent droppings were on the floor behind the door of the Dietary Storage Room. During an interview on 09/16/2025 at 1:10 PM, the Dietary Director stated on 09/08/2025, they personally moved chemicals, crates, and carboard in the area behind the door of the Dietary Storage Room. They stated it was possible that they disturbed some older rodent droppings that were behind the large metal cabinets, as there had been no recent rodent sightings in this room. The Dietary Director also stated this room was swept every Thursday, but the area behind the door needed to be swept again. 1b. Observation on the fourth floor on 09/11/2025 at 12:42 PM revealed rodent droppings on the floor in the corner to the right of the window of Resident room [ROOM NUMBER]. Further observation revealed the edge of the black cove base and the floor tile in this corner had small areas of damage, with black shavings on the floor around the droppings. During an interview at the time of the observation, the Regional Maintenance Director stated the black debris on the floor in the corner of Resident room [ROOM NUMBER] could be rodent droppings and shavings from the corner of the cove base, and the floor tile needed to be repaired in this corner. 1c. Observation on the third floor on 09/11/25 at 12:55 PM revealed there were rodent droppings on the floor at the foot of the left side bed inside Resident room [ROOM NUMBER]. Under the bed on the left side of the room were ripped sugar packets and ripped cookie packets. On the right side of the room, there were rodent droppings on the floor under the nightstand, in the bottom drawer of the nightstand, on the closet floor, and on the floor under the right-side bed. Also observed under the bed was a metal rodent trap box. Inside the metal rodent trap box was bits of bread, a crumpled paper towel, and four (4) small dead mice on glue paper. During an interview on 09/11/2025 at 2:00 PM, Resident #140 stated they had personally opened the metal rodent trap box but had had not done so in about a week. They stated they saw three (3) or four (4) mice running around their room, so they put bread into the box to catch the mice. Also at this same time, the Regional Maintenance Director stated they were unaware of the dead rodents inside Resident room [ROOM NUMBER] or the actions of the resident. The Regional Maintenance Director stated a different approach to rodent control would be needed in Resident room [ROOM NUMBER]. 1d. Observation on the third floor on 09/11/2025 at 1:25 PM revealed rodent droppings on the floor to the left of the dresser under the windows and rodent droppings on the floor to the right of the nightstand in the far-right corner of Resident room [ROOM NUMBER]. Continued observation revealed rodent droppings were also observed in the drawers of the nightstand in the far-right corner of Resident room [ROOM NUMBER]. 1e. Observation on the second floor on 09/11/2025 at 3:10 PM revealed there was an empty snack wrapper and rodent droppings on the floor behind the nightstand inside Resident room [ROOM NUMBER]. During an interview on 09/11/2025 at 3:10 PM, Resident #57 stated they saw a mouse two (2) days ago that ran from the closet area of their room to underneath their bed. 1f. Review of the outside contractor licensed exterminator's Service Inspection Report dated 08/05/2025 revealed it included the general comment/ instruction: upon inspection of room [ROOM NUMBER], it was found that mice had chewed through the rubber baseboard on the left side of the radiator. This was reported to maintenance and recommended sealing the hole. Observation on the fourth floor on 09/11/2025 at 12:35 PM revealed a small hole, approximately three-quarters of an inch in diameter, to the left of the radiator inside Resident room [ROOM NUMBER]. During an interview on 09/16/2025 at 8:15 AM, the Regional Maintenance Director stated they were not aware of the hole in Resident room [ROOM NUMBER] or the recommendation on the licensed exterminator's report to seal it. 2a. Observation on the third floor on 09/09/2025 at 9:56 AM revealed a fly in the nourishment area of the Dining Room. There was an insect light trap on the wall in the nourishment area. On the back of the insect light trap was a piece of glue paper that had at least 200 dead insects on it. At the time of the observation, the Maintenance Supervisor stated the facility had a contract with a licensed exterminator and the licensed exterminator maintained the insect light traps. They also stated the glue paper on this insect light trap needed to be changed. 2b. Observation on the third floor on 09/09/2025 at 10:15 AM revealed several live flies were flying around Resident #92 in their room. At the time of the observation, Resident #92 stated the flies bothered them, but they did not complain because they were moving out soon. 2c. During an observation and interview on the second floor on 09/09/2025 at 10:43 AM, Resident #10 was in their room in their wheelchair with their feet exposed on the foot pedals. Both feet had dressings on the heels, and their toes were exposed. Resident #10 stated the flies in their room were horrible. They felt the flies gravitated towards them because of the wounds on their feet. At this time, two (2) flies were observed in their room, hovering near Resident #10's feet. During a second observation and interview on 09/12/2025 at 10:00 AM, Resident #10 was in bed with hovering near them. Resident #10 stated the flies bothered them a lot. 2d. Observation on the second floor on 09/09/2025 at 11:25 AM revealed there was an insect light trap on the wall in the nourishment area of the Dining Room. On the back of the insect light trap was a piece of glue paper that had at least 200 dead insects on it. The insect light trap was plugged in, had a red status light illuminated, but no lights were illuminated inside the device. At the time of the observation, the Regional Maintenance Director stated the glue paper was full and the outside contractor was supposed to maintain the insect light traps. 2e. Observation on the first floor on 09/09/2025 at 1:15 PM revealed an insect light trap was on the wall in the Service Corridor, outside of the Dishwash Room. On the back of the insect light trap was a piece of glue paper that had at least 200 dead insects on it. At the time of the observation, the Regional Maintenance Director stated it was time to replace the glue paper. 2f. Observation on the first floor on 09/09/2025 at 1:20 PM revealed there were flies in the Dishwash Room. At the time of the observation, the automatic dishwasher was not running, and no dietary personnel were in the room. 2g. During an observation and interview on the fourth floor on 09/10/2025 at 9:04 AM, Resident #152 was lying in bed. There were several large black flies moving around on the tray table that was next to the bed. Additionally, there were more large black flies flying around the room, landing on the walls, the door to the bathroom, the windowsill and at times landing on Resident #152. Resident #152 was unable to be interviewed. During a second observation on 09/12/2025 at 8:17 AM, Resident #152 was lying in their bed and there were large black flies, flying around the room and landing on various objects in the room, the wall and the ceiling. During an interview on 09/12/2025 at 8:20 AM, Certified Nurse Aide #5 stated they had worked with Resident #152 and had noticed the flies in their room. They stated they were not sure where all the flies came from but think they were in the room because the resident uses a urinal. Certified Nurse Aide #5 stated that either maintenance or housekeeping were responsible for cleaning and pest control. As a Certified Nurse Aide, they stated their job was to notify the nurse on the cart whenever they see a lot of flies in a room and all the nurses on the unit were aware of the flies in Resident #152's room. During an interview on 09/12/2025 at 8:26 AM, Licensed Practical Nurse #3, stated they were aware of the live flies in Resident #152's room. They stated they believed there were a lot of flies in the room because Resident #152 would refuse care from time to time. Licensed Practical Nurse #3 stated when they saw flies in the room, the Certified Nurse Aide needed to change all the bedding, and a housekeeper was asked to clean the room. Licensed Practical Nurse #3 stated it was housekeeping's responsibility to keep the rooms clean to prevent flies. 2h. Observation on the fourth floor on 09/11/2025 at 11:55 AM revealed live flies in Resident room [ROOM NUMBER] and the bathroom of Resident room [ROOM NUMBER]. 2i. Observation on the second floor on 09/11/2025 at 3:20 PM revealed live flies in Resident room [ROOM NUMBER]. During an interview on 09/11/2025 at 3:20 PM, Resident #118 stated there were flies all over the place. Resident #118 also stated they ate meals in their room, the flies bothered them when they ate, and they had used a rolled-up piece of paper to whack the flies. 2j. Observation on the second floor on 09/11/2025 at 3:40 PM revealed flies flying around Resident #112's walker. At the time of the observation, Resident #112 stated they had flies in their room and sometimes it bothered them. 2k. Observation on the second floor on 09/11/2025 at 3:45 PM revealed a fly was flying between Resident #95's bed and window. At the time of the observation, Resident #95 was sitting on their bed and stated they ate their meals in their room and sometimes flies flew around them when they opened food containers, which bothered them. Review of the outside contractor licensed exterminator's Service Inspection Reports dated 09/05/2025, 08/29/2025, 08/22/2025, and 08/15/2025 revealed they included the general comment/ instruction: replace glue boards in all ILTs (insect light traps) and report any conditions conducive to small fly reproduction. The device inspection summary on all four (4) Service Inspection Reports indicated zero (0) of three (3) insect light traps were inspected. During an interview on 09/15/2025 at 2:24 PM, the Regional Maintenance Director stated the licensed exterminator came to the facility once per week. Their contract did include flies, and the insect light traps were installed by the former exterminating company, but the current exterminating company said they could service those devices. To their knowledge, the facility had four (4) insect light traps, one (1) in the nourishment area of each Dining Room and one (1) in the Service Corridor. The Regional Maintenance Director also stated they expected the current exterminating company to check the insect light traps each week. They stated they did not notice that this was not being done, according to their reports or the accumulation of flies on the insect light trap glue papers. During an interview on 09/15/2025 at 3:00 PM, the Administrator stated the facility's current outside contracted licensed exterminator did treat the facility for flies and did maintain the facility's insect light traps. The Administrator stated it was possible the licensed exterminator just was not recording it on their reports. The Administrator stated they had not personally looked at the glue boards on the insect light traps in a while, but they believed insect light traps were supposed to be checked weekly and the glue boards were supposed to be replaced monthly, or as needed, by the licensed exterminator. The Administrator stated they thought the licensed exterminator dated the glue boards with the date it was installed. The licensed exterminator also treated drains as a separate service, to control drain flies. On 09/15/2025 at 3:10 PM, the Administrator observed the insect light trap in the Service Corridor. They stated the glue board was not labeled with a date and there was still more room on the glue board, therefore it could continue to be used. During an interview on 09/16/2025 at 11:00 AM, the Administrator stated that they have been working on the rodent and fly problem in the facility. They stated they have a weekly exterminator visit. They stated they have provided plastic bags and bins for residents to store any food to prevent rodents from eating their food. They stated that they just hired a new Housekeeping Director who will be working on this issue. They stated that rodents and flies were part of the environment committee discussions that they have weekly. 10 NYCRR 415.29(j)(5)

Based on observation, interview, and record review during a Complaint investigation (NY00370611-574668, NY00372414-574672, and 2563935) completed during the Standard survey on 09/16/2025, the facility did not provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment. Specifically, there were areas of damaged walls and ceilings, dust laden fans inside resident rooms, soiled and sticky floors, and unpleasant odors. This affected three (3) (second, third, and fourth floors) of four (4) resident use floors.The findings are:The policy and procedure titled Homelike Environment, revised February 2021, documented residents are provided with a safe, clean, comfortable and homelike environment. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting, including a clean, sanitary, and orderly environment and pleasant, neutral scents.The policy and procedure titled Cleaning and Disinfecting Residents' Rooms, revised August 2013, documented housekeeping surfaces (e.g. floors and tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. Environmental surfaces will be disinfected or cleaned on a regular basis and when surfaces are visibly soiled.1. Observation on the third floor on 09/09/2025 at 10:15 AM revealed the plaster ceiling in Resident room [ROOM NUMBER] had an area 6 feet in diameter that was discolored brown, cracked, and peeled down. Further observation revealed the area was near the end of Resident #92's bed.During an interview at the time of the observation, the Regional Maintenance Director stated the toilet above Resident room [ROOM NUMBER] overflowed one (1) to two (2) weeks ago and the overflow had been taken care of, but the damage to Resident room [ROOM NUMBER]'s ceiling still needed to be repaired and re-painted.During an interview on 09/16/2025 at 11:28 AM, Certified Nurse Aide #8 stated the ceiling damage in Resident room [ROOM NUMBER] had been like that for about a year, and it leaked on and off, but they were not sure when it last leaked.During an interview on 09/16/25 at 11:28 AM, Certified Nurse Aide #4 stated last week, they saw that the ceiling of Resident room [ROOM NUMBER] leaked and the floor was wet. They stated sometimes buckets were used to catch the water, and it was right next to a resident's bed and they were afraid that the resident might slip on the wet floor.Another observation and interview were conducted on 09/16/2025 at 9:27 AM in Resident room [ROOM NUMBER]. Both residents were in their bed during the observation. There was a large area of peeling and crumbling paint and plaster with brown areas on the ceiling above the residents bed that encroached into the other resident's side of the room. One resident stated the area only caused a hazard when it leaked, and the other resident stated it only leaked when it rained. Both residents stated they would not have a ceiling that look like that in their homes, it needed to be fixed and then painted. During an interview on 09/16/2025 at 9:29 AM, Registered Nurse #2 (Resident Care Coordinator of the third floor) stated the ceiling in Resident room [ROOM NUMBER] was appalling to have such a large area of peeling paint. They stated that having a ceiling that look like that might be okay in some homes, but it should not be like that in the facility. 2. Observation on the third floor on 09/09/2025 at 10:20 AM revealed brown, rust-like streaks appeared down the wall of the west corridor Tub and Shower Room. The streaks were in an area that was two feet wide by three feet long. Further observation revealed the ventilation fan in this room was not functional.At the time of the observation, the Regional Maintenance Director stated the streaks must be recent because this room was painted about three (3) weeks ago. They also stated they were unaware of the streaks on the wall or that the fan was not functional, and the fan would remove excess humidity in this room, which could help the situation.3. Observation on the second floor on 09/09/2025 at 11:38 AM revealed ceiling and wall plaster damage in the west corridor Tub and Shower Room. The area of ceiling damage was 3 feet in diameter and the area of wall damage was 18 inches long by 8 inches wide.At the time of the observation, the Regional Maintenance Director stated there was a leak from the floor of the shower above within the last two (2) months. Additionally, on 09/16/2025 at 1:25 PM, they stated the leak was fixed with silicone and held for one (1) to two (2) weeks but started leaking again. At the time of the second leak, about two (2) to three (3) weeks ago, epoxy grout was applied, which stopped the leaking.4. Observation on the fourth floor on 09/11/2025 at 12:25 PM revealed the drywall in Resident room [ROOM NUMBER] had been cut in rectangular areas that were 1 foot wide by 1 foot high and 2 feet wide by 2 feet high. The cut pieces of drywall were attached to the wall with black tape. Additionally, in this same room, there was an area of wall damage to the right of the window that was 12 inches high by 18 inches wide.At the time of the observation, the Regional Maintenance Director stated they were not aware of the wall cuts in Resident room [ROOM NUMBER] and was not sure why it was done. They stated the facility's maintenance staff did not do it, and if it was done by an outside contractor, they should have notified maintenance staff. The Regional Maintenance Director added that the area of wall damage to the right of the window was likely from the removal of a wall-mounted television.5. Observation on the third floor on 09/11/25 at 1:25 PM revealed the plaster ceiling in Resident room [ROOM NUMBER] had an area 2 feet in diameter that was discolored brown, cracked, and peeled down.6. Observation on the second floor on 09/11/25 at 3:20 PM revealed the plaster ceiling in the bathroom of Resident room [ROOM NUMBER] had an area 2 feet in diameter that was discolored brown and cracked.During an interview on 09/11/25 at 3:20 PM, the resident in room [ROOM NUMBER] stated sometimes there was water on the floor of their bathroom and they were not sure where the water came from. They stated the water takes over the corner, and I have no choice but to work around it if I want to use the bathroom.7. Observation on the third floor on 09/11/2025 at 12:55 PM revealed there were two (2) fans at the window side bed of Resident room [ROOM NUMBER]. The outside of the black fan was completely coated in a sticky-looking and dusty substance, and its louvers were coated in a thick layer of dust. The white fan had front and rear cages and blades that were coated in a thick layer of gray dust.At the time of the observation, the Regional Maintenance Director stated the fans should be cleaned by the facility's housekeeping staff, even if they belonged to the resident, and both fans in Resident room [ROOM NUMBER] needed to be cleaned.8. Observation on the second floor on 09/11/25 at 3:27 PM revealed a floor fan was on in Resident room [ROOM NUMBER] and the blades and front and rear cages were coated in a layer of dust.9. Observation on the second floor on 09/11/2025 at 3:40 PM revealed the wall along the left side of Resident room [ROOM NUMBER] was cracked with a piece missing in an area that was 2 feet high by 18 inches wide. Further observation revealed another area of wall damage below the first area behind a nightstand that was 1 foot high by 2 feet wide. There was also an area of peeled plaster on the ceiling that was 18 inches in diameter. These three areas were above and adjacent to the left side resident's bed.At the time of the interview, the Regional Maintenance Director stated the wall and ceiling damage in this room was related to the leak from the third floor west corridor shower that occurred within the last two (2) months.During an interview on 09/11/2025 at 3:40 PM, the resident in room [ROOM NUMBER] stated they did not like the way the wall and ceiling looked in their room.10. Observation on the fourth floor on 09/09/2025 at 9:08 AM and 11:13 AM revealed the Unit #4 floor felt sticky with multiple areas of brown and black debris. This affected three (3) of three (3) hallways and the area in front of the Nurses' Station. Unit #4 also had a urine odor that permeated the area. Observation on the third floor on 09/09/2025 at 11:23 AM and 4:06 PM revealed the floors on three (3) of three (3) hallways and the area in front of the Nurses' Station were sticking underneath feet and had multiple black and brown spots in various areas. During an interview on 09/09/2025 at 10:21 AM, Resident #74's representative stated that the floors were sticky and dirty. They stated that whenever they visited Resident #74, the unit always smells bad and that the facility could be cleaner. During an interview on 09/12/2025 at 8:55 AM, Resident #143 stated that the facility could be cleaner. They stated that the facility needed to clean the floors and the windows. During an interview on 09/12/2025 at 8:58 AM, Licensed Practical Nurse #3 stated that the floors could be cleaner. They stated that housekeeping was responsible for cleaning the floors. Licensed Practical Nurse #3 stated that they didn't believe the facility was homelike for the residentsDuring intermittent observations on 09/09/2025 to 09/16/2025 from 8:47 AM to 4:06 PM there was a noted pungent smell of urine and unpleasant body odor on the third floor when exiting off of the elevator, in the common area and at the Nurses' Station. During intermittent observations on 09/09/2025 to 09/16/2025 from 8:53 AM to 3:45 PM there was a noted pungent smell of urine and unpleasant body odor on the fourth floor when exiting off of the elevator, in the common area and at the Nurses' Station. During an interview on 09/10/2025 at 8:57 AM, Resident #9 stated they attempted to get out of bed a few times a week and when they were in the hallway of the third floor, it did not smell well. They stated the smell was not good and the unit had a smell of body odor. During an interview on 09/10/2025 at 10:31 AM, Resident #6 stated they did not feel their room or unit was homelike. They stated at times the hallway had a smell of urine and feces, and the unit needed a fresh paint job. During an interview on 09/10/205 at 11:23 AM, Resident #5 stated the unit was not clean. They stated that housekeeping did not mop the floors every day and the unit had a smell of urine and feces. During an interview on 09/12/2025 at 11:45 AM, Certified Nurse Aide #2 stated on 09/11/2025 they washed Resident room [ROOM NUMBER]'s floor. Certified Nurse Aide #2 stated a resident in that room would spill their urinal onto the floor and they washed the floor instead of housekeeping washing it, adding, I wanted it done (washed) the right way. They stated the third floor unit had an unpleasant odor of urine that was not homelike. During an interview on 09/15/2025 at 3:39 PM, Social Worker #1 stated there was a strong odor of urine and unpleasant body odor on the third floor and sometimes on the fourth floor. Social Worker #1 stated they have received complaints from the residents and family members about the unpleasant odors in the facility and that it does not present as a homelike environment. During an interview on 09/16/2025 at 8:18 AM, Certified Nurse Aide #1 stated the third floor had an odor mixed of urine and unpleasant body odor. They stated that the odor could come and go as long as all of the staff were during their jobs. They stated the smell did not provide a homelike environment, adding they would not want their house to have that type of odor.During an interview on 09/16/25 at 9:06 AM, Resident #155's spouse stated the facility occasionally had an odor of urine with sticky floors, especially on the fourth floor. They stated Resident #155 would urinate on their wall and bedroom floor. Resident #155's spouse stated when they came in to visit every night, they had to wash the resident's floor themselves. During an interview on 09/16/2025 at 9:46 AM, Director of Nursing #1 stated they frequently rounded on the units and there were occasional offensive odors in the facility. They stated the third and fourth floor units did not have a constant odor but there could be some odors at change of shift, when a resident had an incontinent episode, or when garbage or linen were being taken off the unit. During an interview on 09/12/2025 at 8:30 AM, the Assistant Administrator stated the facility's Environmental Services Director position was vacated within the last few weeks. They stated under the previous Environmental Services Director, housekeeping staff were assigned to different areas each day and they would work where the need was for that day. The Assistant Administrator stated a new Environmental Services Director was just hired.10 NYCRR 415.29

Based on interview and record review during the Standard survey completed on 09/16/2025, the facility did not implement written policies and procedures for screening employees that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not provide documentation that verified three (3) (Registered Nurse Supervisor #1, Unit Clerk #1, and Dietary Supervisor #1) of eight (8) employees reviewed that worked in the facility and were subject to the New York State Nurse Aide Registry had been screened through the New York State Nurse Aide Registry prior to their first date worked at the facility.The findings are:The policy and procedure titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, documented the resident abuse, neglect and exploitation prevention program consisted of a facility-wide commitment and resource allocation to support its objectives. The objectives included developing and implementing policies and protocols to prevent and identify abuse, neglect, or mistreatment of residents or theft, exploitation or misappropriation of resident property. The facility will conduct employee background checks and not knowingly employ or otherwise engage any individual who has had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. 1a. Review of Dietary Supervisor #1's personnel file revealed it contained no documentation that a New York State Nurse Aide Registry check was performed for Dietary Supervisor #1, who was a full-time employee at this facility between 04/08/2025 and 04/25/2025. During an interview on 09/11/2025 at 11:12 AM, the Administrator stated the Nurse Aide Registry should be checked for all employees before they start working at this facility. The Administrator also stated they believed they personally checked the New York State Nurse Aide Registry for Dietary Supervisor #1 upon hire but could not locate the paperwork or digital record at this time. 1b. Review of Unit Clerk #1's personnel file revealed it contained no documentation that a New York State Nurse Aide Registry check was performed for Unit Clerk #1, who was a full-time employee at this facility between 04/08/2025 and 06/05/2025.1c. Review of Registered Nurse Supervisor #1's personnel file revealed it contained no documentation that a New York State Nurse Aide Registry check was performed for Registered Nurse Supervisor #1. Registered Nurse Supervisor #1 was a per-diem employee who started working at the facility on 04/08/2025 and was still actively employed, but their last date worked was 05/05/2025. During an interview on 09/11/2025 at 11:15 AM, the Human Resources Director stated they did not work at this facility at the time Dietary Supervisor #1, Unit Clerk #1, or Registered Nurse Supervisor #1 were hired, but the current procedure in place was that they looked up each new hire's name on the New York State Nurse Aide Registry and printed the verification sheet before their start date. Additionally, on 09/15/2025 at 10:10 AM, the Human Resources Director stated they could not locate a documented Nurse Aide Registry check for Dietary Supervisor #1, Unit Clerk #1, or Registered Nurse Supervisor #1.415.4(b)(1)(ii)(a)(b)

Based on observation, interview and record review conducted during a Complaint investigation (Complaint #NY00381662-574015) during the Standard survey on 09/16/2025, the facility did not ensure the resident's environment remained free from accident hazards over which the facility had control and provide adequate supervision to prevent accidents for one (1) (Resident #29) of one (1) resident reviewed for elopement. Specifically, on 05/26/2025 Resident #29 had exited the facility through a service door, out of a fenced gate and was found at the local corner store. Additionally, Resident #29 was observed not wearing their wander guard as care planned, wander guard checks were not implemented for placement every shift, and the 11:00 PM-7:00 AM wander guard checks for functionality were not implemented. The finding is:The policy and procedure titled Wandering and Elopements, last revised March 2019, documented the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The policy and procedure titled Elopement Security System alarms/devices, last revised 7/2024, documented security alert devices are used to alert staff to resident movement outside a designated area. The alarm devices will be assessed at regular intervals to insure proper functions. The policy documented all code alert bracelet alarms that are in use will be checked daily by nursing staff by using the hand-held transmitter tester or as otherwise stated in the manufacturer's direction and the findings would be recorded on the code alert log. The policy documented the wander guard devices will be monitored by the med/treatment nurse every shift by placing it on the TAR (electronic treatment administration record). Location/placement of the devices will also be identified and checked. Resident #29 had diagnoses that included Wernicke's encephalopathy (serious neurologic disorder caused by thiamine deficiency often linked to chronic alcohol abuse), alcohol dependence and type II diabetes. The Minimum Data Set (a resident assessment tool) dated 04/25/2025 documented the resident had severe cognitive impairment, was understood, understands and did not display any wandering behaviors.Review of the Comprehensive Care Plan with initiated date 5/26/2025, documented Resident #29 was at risk for elopement related to elopement assessment and/or attempt. Interventions included to apply a wander detection system bracelet and check it every shift; evaluate activity preferences; post resident picture on the facility risk book at reception; place resident on one-to-one observation; and the resident would be considered for a secured unit. The care plan documented Resident #29 had impaired cognitive function or impaired thought process related to altered mental status and was alert and oriented x 1 (to self). There was nothing documented regarding the resident removing their wander guard bracelet.Review of the kardex (residents) care guide dated 05/25/2025 documented Resident #29 was a limited assist of one (1) person with a two (2) wheeled walker for transfers and a limited assist of one (1) person with a manual wheelchair for locomotion.Review of the Elopement Evaluation dated 04/22/2025 revealed the resident scored a 0 (no risk), on 05/26/2025 they scored a 6 and on 06/30/2025 they scored a 3. All three assessments documented that a score of 1 or higher indicated a resident was at risk for elopement and all three assessments had no interventions marked under the clinical suggestion section. The nursing Progress Note dated 05/26/2025 at 12:26 PM, written by the Assistant Director of Nursing, documented a certified nurse aide, that was on their break, found Resident #29 in their wheelchair outside of a store about two blocks from the facility. Certified Nurse Aide stayed with Resident #29 until the Assistant Director of Nursing arrived at the store. Resident #29 was returned to the facility with no injuries or distress. The note documented Resident #29 stated they exited through a side door, pointed they went down the main elevator, through double door while someone held the door open and down the kitchen hallway. Resident #29 pointed to the service/delivery entrance door which was slightly open and not alarming. The note documented maintenance locked and secured the door with the alarm. Review of the facility's investigation summary dated 05/29/2025, revealed Director of Nursing #1 documented Resident #29 had an elopement from the facility on 05/26/2025 at 9:35 AM and was last seen in the facility around 8:00 AM. The investigation summary follow-up actions documented Resident #29 was placed on a one-to-one until a room change to the fourth floor occurred. One-to-one was discontinued after the wander guard placement.Review of the medical providers orders dated 09/11/2025 at 11:28 AM documented Resident #29 had an order for wander guard placement checks every shift for an elopement risk. The order documented it was an active order with start date of 09/10/2025.Review of the Wanderguard check list (night nursing supervisor log for checking functionality of wander guard) from 06/01/2025-09/10/2025 documented Resident #29 was not being monitored until 09/10/2025. Per an internet-based map application the distance from the facility to where the resident was located at the corner store was 0.1 miles away or a three-minute walk.During observations and interviews at 09/09/2025 at 9:50 AM and 09/10/2025 at 11:00 AM Resident #29 was in their room either sitting on their bed or in a straight back chair. The resident was pleasantly confused and stated they had never left the facility and went to the corner store. During an observation on 09/10/2025 at 3:39 PM, Resident #29 did not have a wander guard bracelet on their wrists and/or ankles nor was a wander guard bracelet observed on the resident's wheelchair or walker. Resident #29 stated that they do not wear any bracelets showing their bilateral wrists and ankles. During an interview on 09/10/2025 at 4:18 PM, Certified Nurse Aide #11 stated they were familiar with Resident #29 and Resident #29 did not wear a wander guard bracelet and the resident never leaves their room. Certified Nurse Aide #11 stated they would know if a resident was supposed to be wearing a wander guard just by observing them for exit seeking behavior. Certified Nurse Aide #11 stated they would know if a resident was to have safety interventions in place by reading the residents plan of care in their electronic medical record. After they reviewed Resident #29's plan of care in the electronic medical record, Certified Nurse Aide #11 stated Resident #29 was care planned to wear a wander guard and the location of the bracelet was not documented.During an interview and observation on 09/10/2025 at 4:25 PM, Licensed Practical Nurse #6 stated they were familiar with Resident #29 and Resident #29 usually did not wear a wander guard and they have never seen the resident attempt to leave the unit. They stated the order to check Resident #29's wander guard was just implemented into the electronic medication administration record a few moments ago. Licensed Practical Nurse #6 entered Resident #29 room, and it was observed that the resident was now wearing a wander guard bracelet to their left ankle. Licensed Practical Nurse #6 stated the wander guard was just place on Resident #29, but they were unsure by who and was unsure who just implemented the checks into the electronic medical record.During an interview on 09/11/2025 10:53 AM, Registered Nurse #1 (Resident Care Coordinator of the fourth floor) stated they placed a wander guard bracelet on Resident #29 on 09/10/2025 and put an order into the electronic medication record for the wander guard to be monitored for placement every shift. They stated they were not sure what time they applied the wander guard bracelet but did so because Resident #29 was not wearing one. They stated they had applied a wander guard to Resident #29 when the resident was moved to the 4th floor the end of May 2025. Registered Nurse #1 stated Resident#29 had a tendency to remove their wander guard bracelet, and they have even attempted to place it on the resident's wheelchair. Registered Nurse #1 stated they also put an order in the electronic medication record to monitor the wander guard placement every shift on 09/10/2025 because it was the facility procedure to do so, and the resident did not have an order. During a further interview on 09/15/2025 at 3:45 PM, Registered Nurse #1 stated they did not recall if they told a nursing supervisor that they placed a wander guard on Resident #29 as they should have. They stated they should have informed the nursing supervisor so the night nursing supervisor could check the wander guard and ensure it was working.During an interview on 09/16/2025 at 8:38 AM, the Minimum Data Set Coordinator stated they would supervise the facility often on the 11:00 PM- 7:00 AM shift. They stated one of the overnight supervisor duties was to check the wander guards that were placed on residents for functionality. The Minimum Data Set Coordinator stated you would slide a box over the wander guard and a light would indicate if it was working. They stated they had never checked Resident #29 for wander guard function and did not believe the resident had a wander guard. During an observation and interview on 09/12/2025 at 11:09 AM, the Regional Maintenance Director along with the Maintenance Supervisor #1 observed the service receiving door Resident #29 was believed to exit from. The door contained a numeric code magnetic lock that required a digit code to exit. Outside the door was a small dumpster to the left and after about 12 steps was a fence with a gate. The Regional Maintenance Director stated after the incident they installed the code magnetic lock to the door and installed a camera facing the door. They stated they also installed a lock on the gate. The Regional Maintenance Director stated if the door was not shut properly, and the fence was open a resident could have gotten out of the door and away from the facility. During a further interview on 09/16/2025 at 1:25 PM, the Regional Maintenance Director along with the Maintenance Supervisor #1 stated when Resident #29 exited the building the service receiving door had a regular door lock and when the door was opened a ringing sound would occur. They stated to disable the ringing noise a key would need to be inserted into the box and turned to off. The Maintenance Supervisor #1 stated they believe someone had turned the box to the off position and the door did not ring when Resident #29 had exited the building in May 2025. During an interview at 09/16/2025 at 1:47 PM, Maintenance Staff #1 stated they assessed the service door on 05/26/2025 after the request by the Assistant Director of Nursing because a resident had exited the facility through that door. Maintenance Staff #1 stated the door was cracked open and the alarm was not ringing. They stated the alarm was turned to the off position and they were unsure who had turned the alarm to off. Maintenance Staff #1 stated they shut the door fully and reset the alarm position to on. During an interview on 09/15/2025 at 3:54 PM, Director of Nursing #1 stated on 05/26/2025 Resident #29 was located at the corner store around 9:30 AM. They stated Resident #29 left the facility via the service door and out a gate by the facility's dumpster that was in front of the building. They stated the door was not secure and the gate was unlocked and if the door and gate were secure, it could have prevented Resident #29 from exiting the building. Director of Nursing #1 stated the resident was placed on a one-to-one until they were moved to the fourth floor and a wander guard was placed. They stated Resident #29 should have been wearing the wander guard during the observation on 09/10/2025 at 3:39 PM because it was the intervention that was put into place after the incident. They stated Resident #29 should have also had wander guard checks for placement every shift put into the electronic medication record. Director of Nursing #1 stated Resident #29 should have also been placed on the 11:00 PM - 7:00 AM wander guard log checks for the nursing supervisor to ensure the wander guard was functioning properly. They stated this would have been the responsibility of Registered Nurse #1 to complete. Director of Nursing #1 stated they were unsure why Registered Nurse #1 did not implement those items but should have. During an interview on 09/15/2025 at 4:13 PM, the Administrator stated Resident #29 exited the facility in May 2025. After review of the facility investigation folder and nursing progress note, the Administrator stated Resident #29 came down the main elevator where an unknown staff member held the double door open for the resident to enter the service hallway. Resident #29 then went out of the service door. They stated at that time the service door had an alarm that would alarm when the door opened. The Administrator stated they were unsure why the alarm did not ring, but Resident #29 should have not gotten out of the service door. They stated they would expect all care planned interventions be in place unless they were discontinued, including Resident #29's wander guard. They stated they would expect Resident #29's wander guard checks to be on the medication administration record and on the 11:00 PM -7:00 PM nurse supervisor checks log if it was the facility's policy to do so.During a telephone interview on 09/15/2025 at 6:17 PM, the Assistant Director of Nursing stated on 05/26/2025 Certified Nurse Aide #12 called them to tell them Resident #29 was in front of a store in their wheelchair. The Assistant Director of Nursing stated they met Resident #29 and Certified Nurse Aide #12 at the store which took about 10 minutes to walk there and returned the resident to the facility. They stated Resident #29 showed them they went down the main elevator, through the double doors to the service hallway and out the side service door. The Assistant Director of Nursing stated upon inspection of the service door it was shut but not locked and the alarm was not sounding. During a further interview on 09/16/2025 at 1:32 PM, the Assistant Director of Nursing stated they had maintenance look at the service door after their initial inspection and they also interviewed the dietary staff. They stated the staff denied turning the service door alarm off and/or holding the double doors opened for Resident #29 to enter the service hallway.During a telephone interview on 09/15/2025 at 5:00 PM, Medical Doctor #1 stated they were familiar with Resident #29 and could not recall the details around the incident when the resident exited the building and was found at the corner store. They stated that Resident #29 did not have the capacity to leave the building unsupervised in May 2025 and they would expect that all care planned intervention would remain in place for the resident's safety. 10 NYCRR 415.12(h)(2)

Based on interview, and record review conducted during the Standard survey, completed on 09/16/2025, it was determined that the facility did not ensure that residents received proper treatment and assistive devices to maintain vision abilities; and if necessary, must assist the resident in making appointments for one (1) (Resident #57) of one (1) resident reviewed for treatment/services to maintain vision. Specifically, the facility did not act on the optometry recommendations for cataract surgery for Resident #57 from 10/29/2024 and again on 06/10/2025. The finding is:The policy titled Resident Rights, last revised December 2016, documented federal and state laws guaranteed certain basic rights to all residents of the facility. Those rights included the residents right to a dignified existence and communication with and access to people and services, both inside and outside the facility.The facility did not have any policies regarding hearing or vision, consultants or outside consults, or provider recommendations.Resident #57 had diagnoses including schizoaffective disorder (a mental health condition), diabetes mellitus type two (2), and anxiety disorder. The Minimum Data Set (a resident assessment tool) dated 06/13/2025 documented Resident #57 was cognitively intact, was understood, understands and had adequate vision.The comprehensive care plan dated 12/18/2024 documented Resident #57 was independent for ambulation for unlimited distances with their personal four (4) wheeled walker. There was nothing related to vision on the comprehensive care plan.Review of the outside consult form dated 10/29/2024 revealed Resident #57 was recommended by Ophthalmologist #2 for cataract surgery in both eyes. This form had an undated signature by Nurse Practitioner #1.Review of the facility eye consult form dated 04/24/2025 revealed Resident #57 told Ophthalmologist #1 they were waiting to have their cataract surgery but was unsure when it was scheduled for. Ophthalmologist #1 documented please keep cataract surgery plans for patient. Keep was underlined three (3) times. This form had an undated signature by Nurse Practitioner #1.Review of the Ophthalmology consult form dated 06/10/2025, revealed Ophthalmologist #2 documented Resident #57 stated when they read something close there was not enough contrast on the page/paper and they could not read it unless they used more light to see the contrast on the things they are reading. Occasionally they would see a line floating in their vision. Resident #57 had cataracts/anatomic narrow angles in both eyes. The cataracts were causing blockade of drainage channels, Resident #57 was at risk for angle closure, also causing vision to blur. Resident #57 would benefit from cataract surgery. Discussed cataract surgery versus Laser Peripheral Iridotomy (laser eye surgery that treats closed angles). Last time, Resident #57 was planned for cataract surgery in 10/2024, but could not reach out to Rehab facility, fell through cracks, so it was better to do Laser Peripheral Iridotomy in the interim while waiting cataract surgery. Follow up in one (1) to two (2) weeks. This form had an undated signature by Nurse Practitioner #1.Review of facility eye consult form dated 07/25/2025 revealed Ophthalmologist #1 documented Resident #57 needs to continue care with Ophthalmologist #2, needs Laser Peripheral Iridotomy to both eyes and cataract surgery ASAP (as soon as possible).During an interview on 09/09/2025 at 8:59 AM, Resident #57 stated I am going blind, and no one is doing anything. Resident #57 stated they saw the eye doctor, but the facility was dragging their feet and my eyes are getting worse by the day. Resident #57 stated they were supposed to have cataract surgery a while back but now the ophthalmologist recommended laser eye surgery, but nothing had been done yet regarding either. They gave their paperwork to the person at the desk when they got back from the appointment and has heard nothing since. During an interview on 09/15/2025 at 10:01 AM, Registered Nurse #4 (Resident Care Coordinator) stated they were unaware that Resident #57 was supposed to be scheduled for Cataract surgery; they had not seen the consult form sent from Ophthalmologist #2 on 06/10/2025 and was not working in the facility when the initial recommendation was made in October of 2024. Registered Nurse #4 stated the process for all consults was the unit managers went through the consults and reviewed them, updated the providers on any new recommendations, then the consults went into the providers folder to be reviewed. After the provider reviewed them, the consults would go to the Director of Medical Records who then scanned them into the computer and made any follow up appointments necessary. Registered Nurse #4 stated it was very important for Resident #57 to have the cataract surgery because their vision is impaired, and they should not have to deal with that.During an interview on 09/15/2025 at 10:15 AM, the Director of Medical Records stated they did not know how Resident #57s appointment for their cataract surgery was never scheduled, I did not have anything written down after Resident #57 returned from their appointment, it must have fell through the cracks. The Director of Medical Records stated typically the unit manager would tell the unit clerk who needed what appointment scheduled and the unit clerk would be responsible for scheduling all appointments, but the second and third floors did not have a unit clerk until very recently, so the Director of Medical Records was scheduling all appointments for residents in the interim. Director of Medical Records stated they did not know why the appointment from October 2024 was never scheduled, there During a telephone interview on 09/15/2025 at 11:34 AM, Nurse Practitioner #1 stated they reviewed all consults and signed them, then they expected them to be reviewed by the unit managers and then the Director of Medical Records made any appointments necessary. Nurse Practitioner #1 stated they agreed with Ophthalmologist #1 and Ophthalmologist #2 recommendations; Resident #57 should not have had to wait since October of 2024 for their cataract surgery and it was important for Resident #57 to have their cataract surgery so that their quality of life could be sustained.During an interview on 09/16/2025 at 9:28 AM, Director of Nursing #1 stated the unit managers were responsible for following through with all recommendations made from providers and outside consultants, like the Ophthalmologist. Director of Nursing #1 stated Resident #57 should have been scheduled for their cataract surgery in October of 2024, but there were changes with staff, including unit managers and unit clerks, so it was possible that played a role in the appointment not being scheduled. Director of Nursing #1 stated they did not know why Resident #57s appointment was not scheduled after their appointment in June of 2025, but it was important for Resident #57s cataract surgery to be scheduled as soon as possible to improve their vision and quality of life.During a follow up interview on 09/16/2025 at 12:16 PM, Director of Nursing #1 stated the facility did not have any policies regarding consults, vision, or following provider recommendations.10 NYCRR 415.12(b)(1-2)

Based on observation, interview, and record review conducted during the Standard survey completed on 9/16/25, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice for one (1) (Resident #88) of one (1) resident reviewed for positioning. Specifically, while sitting in their wheelchair, Resident #88's feet were hanging down and were approximately four (4) to six (6) inches from touching the floor for extended periods of time.Based on observation, interview, and record review conducted during the Standard survey completed on 9/16/25, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice for one (1) (Resident #88) of one (1) resident reviewed for positioning. Specifically, while sitting in their wheelchair, Resident #88's feet were hanging down and were approximately four (4) to six (6) inches from touching the floor for extended periods of time. The finding is: The policy and procedure titled Repositioning revised May 2013 documented repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. Evaluate resident who can reposition independently to determine the following: is a positioning device needed to maintain independent positioning. Resident #88 was admitted with diagnoses hemiplegia (paralysis on one side of the body) and hemiparesis (weakness of one side of the body) affecting the right dominant side, cerebral infarction (stroke), and aphasia (absence or difficulty with speech). The Minimum Data Set (a resident assessment tool) dated 8/5/25 documented Resident #88 was usually understood, usually understands and was severely cognitively impaired. Resident #88 required partial/moderate assistance for transfers and was dependent on staff for lower body dressing and putting on/taking off footwear. The comprehensive care plan dated 3/23/23 documented Resident #88 had limited physical mobility. Interventions were revised on 9/11/25 to include locomotion on unit: extensive assist of one (1) staff member with a manual wheelchair with a calf board. Additionally, Resident #88 had a communication problem related to aphasia. Interventions included anticipate and meet needs. Review of the Kardex (guide used by staff to provide care) dated 9/10/25 documented the resident required extensive assist of one (1) staff member with a manual wheelchair for locomotion. During a continuous observation and interview on 9/9/25 from 12:46 PM until 1:19 PM, Resident #88 was in the dining room sitting in their wheelchair. Resident #88 smiled but was unable to answer any questions. The leg rests attached to the wheelchair were extended straight out from the wheelchair. Resident #88's legs were straight down, and their feet were not touching the floor. Their feet were pointed downwards with their toes approximately four (4) inches from the floor. Occasionally, Resident #88 would move their right leg upwards, reaching towards the leg rest but was unable to raise the leg onto it. During a continuous observation on 9/11/25 from 11:00 AM until 2:01 PM, Certified Nurse Aide #13 wheeled Resident #88 from their room to a table in the dining room. Both wheelchair leg rests were attached and extended straight out from the wheelchair. Resident #88's left leg was on the leg rest and the right leg was hanging down, not touching the floor while the wheelchair was moving. When they stopped at the table, Certified Nurse Aide #13 walked away and Resident #88's left leg fell off the leg rest. They attempted to lift their leg back up but were unable to. Both of Resident #88's feet were pointed downwards at an angle with their heels approximately six (6) inches from the floor and their toes approximately four (4) inches from the floor for the remainder of the observation. At times, Resident #88 alternated placing the bottom of one foot on top of their other foot. During an interview on 9/11/25 at 2:06 PM Certified Nurse Aide #13 stated they were responsible for Resident #88's care and their legs should have been on the leg rests so their feet could rest. Certified Nurse Aide #13 stated that Resident #88's right leg always slid off the leg rest but sometimes the left leg would stay on it. Certified Nurse Aide #13 stated they thought Resident #88 would have been able to complain if their legs bothered them. They stated that the leg rests were always extended straight out and never down but the leg rests should have been in a downward position so Resident #88 could reach them. Certified Nurse Aide #13 stated they thought everybody already knew that Resident #88's leg rests looked like that, and Resident #88 was unable to hold both of their legs on the leg rests for a long time. During an interview on 9/12/25 at 8:31 AM Licensed Practical Nurse #3 stated both of Resident #88's feet and legs should have been supported. Sometimes one leg was on the leg rest and sometimes it was not. Licensed Practical Nurse #3 stated Resident #88's legs would hang down because Resident #88 was very short, the wheelchair was higher because of the cushion and the wheelchair leg rests were so long for Resident #88.During an interview on 9/12/25 at 11:13 AM Registered Nurse #1 Resident Care Coordinator stated Resident #88's wheelchair leg rests should not have been straight out and should have been angled downwards so that Resident #88 could rest their feet on them. Their legs and feet should have been supported for good circulation and to prevent foot drop or any contractures. During an interview on 9/15/25 at 8:54 AM the Director of Rehabilitation stated they were notified by Registered Nurse #1 Resident Care Coordinator on 9/11/25 to look at Resident #88's positioning in their wheelchair. They stated they assessed Resident #88's positioning and they noticed the wheelchair leg rests were straight out and extended longer than they should have been, they were not angled downwards. Even if the wheelchair leg rests were angled downwards, they would have still been too long and Resident #88's feet would not be able to touch the pedals. During the assessment, they stated Resident #88 had a tendency of pulling their leg in and they felt a calf board would be more comfortable. They stated when it was observed that Resident #88 alternated placing one foot on top of the other, that could have indicated discomfort. The Director of Rehabilitation stated residents were evaluated quarterly by the therapy department but for any new problems, it was the responsibility of the certified nurse aide to notify either a nurse or the therapy department of any concerns with a resident. They stated usually the certified nurse aide would let the nurse know and then it would be discussed in morning report. During an interview on 9/15/25 at 10:52 AM, Director of Nursing #1 stated they expected all residents to be positioned appropriately in an upright position while in their wheelchair and be repositioned as needed. It was the responsibility of any staff member who noticed Resident #88's feet being unsupported to say something to a manager or the therapy department. Resident #88's legs and feet should have been supported for comfort. During a telephone interview on 9/15/25 at 11:55 AM, Nurse Practitioner #2 stated they expected staff to ensure Resident #88's legs and feet were supported for their comfort. They stated Resident #88 was unable to verbalize their needs and should have had some form of support to prevent them from becoming uncomfortable. During an interview on 9/15/25 at 1:20 PM, the Administrator stated they expected all staff on the units to ensure residents were positioned correctly in their wheelchairs. They stated any staff who noticed a resident was not positioned correctly should contact a certified nurse aide or a nurse and they were responsible to reposition the resident. 10NYCRR 415.12

Based on observation, interviews and record review conducted during an Extended survey completed on 10/10/2025, the facility did not ensure that each resident received the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being for two (2) (Residents #6 and #155) of five (5) residents reviewed. Specifically, Resident #6 was not receiving psychotherapy services and/or group therapy services as recommended by their psychiatry provider and there was a delay in obtaining a follow up psychiatry consult as recommended for Resident #155. The findings are:The undated policy titled Resident Rights documented federal and state laws guarantee certain basic rights to all residents of the facility. The policy documented those rights included the resident right to self-determination; be informed of, and participate in, his/her care planning and treatment; and participate in decision-making regarding his/her care. 1.Resident #6 had diagnoses that included bipolar, major depressive disorder and generalized anxiety disorder. The Minimum Data Set, dated [DATE] documented Resident #6 was cognitively intact, was understood, and understands. The Comprehensive Care Plan revised date 02/05/2024, documented Resident #6 was alert and oriented with intact cognition, and was independent in decision making. Interventions included to participate in activities to promote socialization and encourage resident to continue to verbalize their wants and needs. Resident #6 had a diagnosis of depression that could cause variations in their mood. Interventions included to administer medications as ordered and arrange for psych consult and follow up as indicated. Resident #6 used psychotropic medications related to bipolar disorder with an intervention to administer medications as ordered by the physician. Review of the Order Summary Reported dated 09/15/2025, documented Resident #6 had an active order with start date of 07/31/2024 for psychiatry evaluation and consults as needed.Review of psychiatry follow up notes revealed:- on 10/04/2024 (untimed) Nurse Practitioner #3 (of psychiatry) documented they had been seeing Resident #6 and the resident continued with somatic symptoms (extreme focus on physical symptoms) most likely related to anxiety and had a differential diagnosis of hypochondriasis (excessive and unduly worried belief that one has a serious illness). They documented Resident #6 reported signs of depression, anxiety and irritability. Nurse Practitioner #3 documented Resident #6 would benefit from psychotherapy and consider placing a referral. -on 01/17/2025 at 10:30 AM, Nurse Practitioner #3 (of psychiatry) documented Resident #6 stated they had been having a lot of crying jags and the resident had displayed behaviors at times, refusing medications, and calling numerous specialty providers to make appointments. Nurse Practitioner #3 documented they recommended to consider follow-up with psychology.-on 07/21/2025 at 3:00 PM, Psychiatrist #1 documented Resident #6 stated they felt the need for more support but expressed insight into their own behaviors. Psychiatrist #1 documented they encourage supportive counseling and group therapy to build coping skills and social connection. Review of Resident #6's electronic medical record (progress notes, medical provider notes, and consultant notes) from 10/05/2024 through 09/11/2025 revealed there was no documented evidence that Resident #6 had psychotherapy/counseling services completed.During an observation and interview on 09/11/2025 at 11:19 AM Resident#6 was sleeping in bed, fully dressed and appeared well groomed. Resident #6 was easily awakened and stated they were not feeling all that well and their blood pressure was elevated. Resident #6 became anxious and was asking what was too high of a blood pressure and how high should the blood pressure be before they needed to go to the hospital.During an interview on 09/11/2025 3:05 PM, Resident #6 was self-propelling their wheelchair around the nursing station and hallways. Resident #6 stated they were not receiving any counseling service, and they would like to as they would like additional people to talk to. They stated the psychiatrist recommended for them to see a counselor and the facility had not yet set it up.During an interview on 09/15/25 at 9:29 AM, Social Worker #1 stated the social workers were responsible for the referral process when a resident had a recommendation to see the psychiatrist and/or psychologist at the facility. They stated they were also responsible to review the psychiatry notes. Social Worker #1 stated if there was a recommendation of psychotherapy, they would email a referral request to the service the facility used for psych services. Social Worker #1 stated Resident #6 was under psychiatric care but was not seeing the psychologist. After they reviewed their email referrals, Social Worker #1 stated they had never put in a referral request for Resident #6 to have psychotherapy but should have because it was a recommended made by the psychiatrist. They stated that they were the only social worker in the facility from about mid-February 2025 to maybe May 2025. They stated the previous social worker must have also never placed the referral for Resident #6, but the previous social worker should have also.During a telephone interview on 09/12/2025 at 11:34 AM, Psychiatrist #1 stated they knew the facility provided psychotherapy services, so they made a recommendation for Resident #6 to receive those services. They stated they expected that their recommendation would have been approved, the social work would have followed up with the recommendation, and had an appointment made. Psychiatrist #1 stated that medication could only do so much, and Resident #6 would have benefited from additional counseling or group therapy sessions. During a telephone interview on 09/15/2025 at 12:16 PM, Nurse Practitioner #1 stated they were familiar with Resident #6 and the resident was under the care of a psychiatrist. They stated they were unsure if Resident #6 was participating in psychotherapy. They stated that if the psychiatrist had recommended psychotherapy and the facility provided that service then they would expect Resident #6 to be seeing a counselor.During an interview on 09/16/25 at 9:31 AM, Registered Nurse #2 (Resident Care Coordinator of the third floor) stated they had only worked at the facility for about four (4) weeks. They stated when a recommendation for a consult was recommended, they would get an order from a medical provider and put the recommendation in the communication book for the unit sectary to obtain the consult. Registered Nurse #2 stated they believed this process was the same for psych visits. They stated they would also read any consult notes themselves to look for any recommendation. After reading the psychiatrist notes dated 10/04/2025, 01/17/2025 and 07/21/2025 they stated they expected that Resident #6 would have been receiving counseling services as recommend by whoever the facility utilized for those services. Registered Nurse #2 stated Resident #6's main behaviors consisted of fixating on their medical complaints. During an interview on 09/16/25 at 9:46 AM, the Director of Nursing #1 stated they had contacted the psych provider service the facility utilized, and Resident #6 did not participate in psychotherapy with the facility's psychologist. Director of Nursing #1 stated the facility did not and could not provide a phone number for Licensed Psychologist #1. They stated the social workers were responsible for reviewing any psychiatry notes and for placing any referrals for psychiatry and/or psychotherapy a resident might need. After they reviewed Resident #6 psychiatry notes dated 10/04/2025, 01/17/2025 and 07/21/2025, Director of Nursing #1 stated they expected that the social worker would have followed up with the psychiatry recommendations and set up a referral with the psychologist. Director of Nursing #1 stated they were very familiar with Resident #6 and the resident could have many complaints, anxiety, and their parents had a history of psychological issues. During an interview on 09/16/2025 at 12:16 PM, Director of Nursing #1 stated they could not locate any policies on psychology consultants or any policies on any type of consults.2.Resident #155 had diagnoses including frontotemporal neurocognitive disorder (brain disorder that affects personality, behavior, and language), dementia without behavioral disturbances, and adult failure to thrive. The Minimum Data Set, dated [DATE] documented Resident #155 was severely cognitively impaired, was understood, and usually understands.The Comprehensive Care Plan, initiated 11/25/2024, documented Resident #155 had impaired cognitive function or impaired though processes related to dementia. Interventions included to cue, reorient, and supervise as needed, engage in simple, structured activities that avoid overly demanding tasks, keep residents' routine consistent and try to provide consistent caregivers as much as possible. The care plan documented Resident #155 had the potential to be physically aggressive and would get aggressive when redirected at times. Some interventions included to adjust voice tone, administer medications as ordered, assess and anticipate resident's needs, engage in activities, provide resident with calm environment in their room when noted behaviors or aggression/agitation arise. Additionally, the care plan documented Resident #155 used antidepressant medications related to mood with interventions to monitor/document side effects, effectiveness, and adverse reactions.Review of the psychiatric consult dated 07/17/2024, revealed Resident #155 had a history of multiple concussions due to their prior career (semi-pro football player), who presented to the hospital due to increased unprovoked aggression towards neighbors which made living at home unsafe.Review of the Order Recap Report dated 10/01/2024 to 10/31/2025, revealed there was no documented evidence that an order was placed for Resident #155 to receive psychiatry services.Review of a psychiatric progress note dated 06/22/2025 at 3:17 PM, Psychiatrist #1 documented Resident #155 was seen for an initial consult to monitor and assess medication effectiveness due to being on Lexapro (medication used to treat depression and anxiety) and Depakote (mood stabilizer) daily, no new medications recommendations were made. Psychiatrist #1 documented to follow up in four (4) weeks. There were no further psychiatry visits until 09/18/2025.Review of a progress note dated 07/08/2025, Nurse Practitioner #2 documented Resident #155 was seen for follow up after a resident-to-resident negative altercation where they were the aggressor. Resident #155 was managed on Depakote and Lexapro. Nurse Practitioner #1 documented for Resident #155 to follow up with psych services as indicated.Review of nursing progress notes dated 02/20/2025 to 09/11/2025 revealed Resident #155 was aggressive and had behaviors at times directed towards staff and other residents, had elopement attempts, and wandered the unit, frequently going into other residents' rooms.Review of the Psychiatry progress note dated 09/18/2025 at 4:26 AM (late entry note), Psychiatric Nurse Practitioner #1 documented Resident #155 was seen for psychiatric follow up to monitor and assess medications. No new medication recommendations were made; non-pharmacological interventions were encouraged.A call was placed on 10/08/2025 at 1:03 PM to Registered Nurse #1 Resident Care Coordinator with message left requesting return call, with no call back.During a telephone interview on 10/08/2025 at 1:11 PM, Psychiatric Nurse Practitioner #1 stated they were asked by the facility to see Resident #155 due to their diagnoses and medications. Based on their assessment and interviews with staff and family, it was determined that Resident #155 required no new medication changes, but non-pharmacological interventions were encouraged and discussed with the Director of Nursing on 09/18/2025.During a telephone interview on 10/08/2025 at 1:40 PM, Nurse Practitioner #2 stated they saw Resident #155 after a resident-to-resident incident; there were medication adjustments recommended so they referred Resident #155 to see psych. Nurse Practitioner #2 stated they would have expected the recommendation to have been carried out in a timely manner; they would have expected Resident #155 to have seen psych prior to 09/18/2025 since the recommendation was put into their progress note on 07/08/2025.During an interview on 10/09/2025 at 11:14 AM, the Director of Strategic Planning stated there was a lapse in psychiatry providers at the facility; Psychiatrist #1 was seeing residents until they had a family emergency and then never returned to the facility, and it was about a month later that Psychiatric Nurse Practitioner #1 started, in September of 2025. The Director of Strategic Planning stated if there was an order or recommendation made by a provider in the facility, they would have expected the physician note to have been reviewed by the nurse manager, and the recommendation to have been carried out; or at the very least notify the provider that the psych recommendation was made, and a psychiatrist was not available in the facility. The Director of Strategic Planning stated July to September was not an appropriate time frame for Resident #155 to have waited to see a psychiatrist after the recommendation was made; they did not always like to send residents out to see outside psych providers unless it was urgent. The Director of Strategic Planning stated originally the social workers oversaw making all providers referrals for residents to see psych, but the process changed when Psychiatry Nurse Practitioner #1 started and now the Director of Nursing makes all psych referrals.During an interview on 10/09/2025 at 12:27 PM, the Administrator stated there was a lapse in having a psych provider in the facility so that could be the reason that it took from July to September for Resident #155 to see a psych provider. The Administrator stated the facility should have looked at other resources to send them to an external provider for the psych consult, we could have made (Resident #155) an appointment at an outside facility.During an interview on 10/10/2025 at 11:04 AM, the Director of Strategic Planning stated Resident #155 received psych services in the facility on 06/22/2025 and again on 09/18/2025 because of a previous order. The Director of Strategic Planning stated Nurse Practitioner #2 saw Resident #155 on 07/08/2025 and wrote in their note Follow up with psych as indicated. The Director of Strategic Planning stated they were confused as to what as indicated meant and would have to ask for guidance, they stated there was never a physician order placed for Resident #155 to receive psych services, but there should have been since they saw a psych provider.10 NYCRR 415.12(f)(1)

Based on interview, observation, and record review conducted during a Standard survey completed on 9/16/2025, it was determined that the facility did not ensure that the resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident. Specifically, one of three residents (Resident #5) reviewed for choices had issues with not receiving a shower for three weeks per their preference. The finding is:The policy and procedure titled Resident Rights dated 12/2016 documented that the resident has a right to self-determination.The policy and procedure titled Resident Rights Guideline for All Nursing Procedures dated 10/2010 documented that the resident has a freedom of choice.Resident #5 was admitted to the facility with diagnoses of paralysis of the right side of the body and depression. Review of the Minimum Data Set (a resident assessment tool) dated 6/19/2025 documented that the resident understands and is understood by others, cognitively intact, and requires maximal assist of staff for bathing.Review of the comprehensive care plan dated 11/12/2024 documented that Resident #5 was a maximal assist of two staff members for bathing their upper and lower body.Review of the Certified Nurse Aide closet care plan dated 09/16/25 documented that Resident #5 was an extensive assist of two staff members for bathing their upper and lower body. The closet care plan documented that the resident was to receive a shower once a week. Review of the interdisciplinary progress notes dated 08/19/2025 to 09/16/2025 revealed that there was no documentation that the nurse performed a skin check during this time. The progress notes revealed that there was no documentation that the resident refused a shower.Review of the shower sheet schedule dated 09/12/2025 documented that the resident was to receive a weekly shower on the 7:00 AM to 3:00 PM shift every Monday. During an interview on 09/10/2025 at 9:33 AM with Resident #5, they stated that they haven't had a shower in three weeks, and they wanted one. They stated that they are supposed to get a shower on Monday. During an interview on 09/16/2025 at 7:41 AM with Certified Nurse Aide #4, they stated that if a resident doesn't get a shower, then they should get one on the next shift. They stated that Resident #5 just moved rooms and that might have messed up their shower schedule. They stated that they would tell the nurse if the resident refused a shower. During an interview on 09/16/2025 at 7:44 AM with Licensed Practical Nurse #7, they stated that they reviewed the progress notes and weekly skin check wasn't documented that it was completed for Resident #5. They stated that it is important that a resident's skin is checked weekly so they can prevent skin breakdown. During an interview on 09/16/2025 at 7:48 AM with Resident #5, they stated that they didn't receive a shower last night. They stated that they wanted a shower last night and it bothered them they didn't get one. During the interview, it was observed that Resident #5's hair appeared greasy and unkempt. During an interview on 09/16/2025 at 8:05 AM with Director of Nursing #1, they stated that it was important for a resident to get showers, so they got their skin checked to prevent skin breakdown. They stated they would expect nursing staff to document the weekly skin check in progress notes. 10 NYCRR 415.5(b)(1-3)

Based on interview and record review conducted during a Standard survey completed on 9/16/2025, the facility did not ensure that comprehensive care plans included to the extent practicable, the participation of the resident and the resident's representative(s); an explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan; and were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for two (2) (Residents #29 and #74) of two (2) residents reviewed for care plan participation and care plan revision related to accidents. Specifically, Resident #74's representative was not invited to participate in care plan meetings and Resident #29's care plan was not revised when the resident was removed from one to one supervision after they transferred to a secure unit. The findings are:The undated document titled Social Worker documented that a Social Worker under job knowledge and responsibilities demonstrates the ability to adjust to changes to unit/shift assignments to meet resident and resident families' needs. It documented that the Social Worker is to attend and lead patient care conference meetings within 21 days of a resident's admission. It documented that the Social Worker is to work directly with family or responsible party to enhance functioning of a resident in the facility.The policy and procedure titled Resident Rights Guidelines for All Nursing Procedures dated 10/2010 documented that staff must have appropriate in-service training on resident rights including resident and family participation in care planning.The policy and procedure titled Care Plans, Comprehensive Person-Centered dated 3/2022 documented that residents have the right to participate in the planning process and be able to request meetings.1. Resident #74 was admitted to the facility with diagnoses of vascular dementia, anxiety and depression. Review of the Minimum Data Set (a resident assessment tool) dated 07/03/2025 documented that the resident was severely cognitively impaired, usually understands others, and was usually understood by others. Review of the Social Work progress notes from 12/31/2024 to 4/1/2025 revealed no documented evidence of an invitation sent to the resident or the resident's representative for a care plan meeting.During an interview on 9/9/2025 at 10:21 AM with Resident #74's representative, they stated that they have not been invited to a care plan meeting since Resident #74's admission and they would like to attend.During an interview on 9/12/2025 at 9:43 AM with the Social Worker, they stated that they did not invite Resident #74's representative to care plan meetings. They stated that they would document in their progress notes if they invited them. They stated that they were covering the entire building and that the invitation for a care plan meeting would have fallen through the cracks.During an interview on 9/16/2025 at 11:00 AM with the Administrator, they stated that Social Work was responsible for inviting residents and or their representative to care plan meetings. They stated that Social Work has been educated to invite residents or their representatives and to document that invitation in progress notes.2. The facility policy and procedure titled Care Plans, Comprehensive Person-Centered dated March 2022 documented a comprehensive, person-centered care plan that includes measurable objectives and timetable to meet the resident's physical , psychosocial and functional needs was developed and implemented for each resident. The policy documented the assessment of residents was ongoing and care plans were revised as information about the residents and the residents' conditions change.Resident #29 had diagnoses that included Wernicke's encephalopathy (serious neurologic disorder caused by thiamine deficiency often linked to chronic alcohol abuse), alcohol dependence and type II diabetes. The Minimum Data Set (a resident assessment tool) dated 06/30/2025 documented the resident had severe cognitive impaired, was understood and understands. Review of the Comprehensive Care Plan with date initiated 5/26/2025, documented Resident #29 was at risk for elopement related to elopement assessment and/or attempt. Interventions included apply wander detection system bracelet and check every shift; evaluate activity preferences; post resident picture on the facility risk book at reception; place resident on one-to-one observation; and resident would be considered for a secured unit.Review of the facility's investigation summary dated 05/29/2025, Director of Nursing #1 documented Resident #29 had an elopement from the facility on 05/26/2025 at 9:35 AM. Resident #29 was found in front of the corner store by a staff member when they were on a break. The investigation summary follow-up actions documented Resident #29 was placed on one-to-one supervision until a room change to the fourth floor occurred. One to one was discontinued after wander guard placement.Review of the facility's incident report dated 5/26/2025 at 9:35 AM, Director of Nursing #1 documented in the notes section of the report on 5/29/2025 that Resident #29 was placed on the fourth floor, one to one was removed and a wander guard was placed on the resident.During an interview on 09/11/2025 10:53 AM, Registered Nurse #1 (Resident Care Coordinator of the fourth floor) stated when Resident #29 was moved to their floor at the end of May 2025 they placed a wander guard on the resident because the resident had eloped from the facility a few days prior. Registered Nurse #1 stated the Resident Care Coordinators were responsible for care plan development and revision and therefore they were responsible for Resident #29's comprehensive care plan. They stated a resident's care plan would be reviewed according to a resident's minimum data set schedule. During a further interview on 09/15/2025 at 3:45 PM, Registered Nurse #1 reviewed Resident #29 comprehensive care plan in the electronic medical record and stated Resident #29's comprehensive care plan documented Resident #29 had an elopement from the facility and an intervention for the resident was to be place on a one-to-one observation. Registered Nurse #1 stated that was not an accurate intervention because the one to one had been discontinued after Resident #29 was transferred to unit four. They stated Resident #29's care plan was not updated and revised, it should have been, and they needed to correct it.During an interview on 09/15/2025 at 3:54 PM, Director of Nursing #1 stated on 05/26/2025 Resident #29 was placed on a one-to-one observation until the resident was moved to the fourth floor and a wander guard was placed. After review of the paper copy of Resident #29's comprehensive care plan, Director of Nursing #1 stated the intervention of a one-to-one observation for Resident #29 was no longer an active intervention as a result of the resident's elopement. They stated the comprehensive care plan was not revised timely and it would be the responsibility of Registered Nurse #1 to update Resident #29's care plan so proper interventions were in place. 10NYCRR 415.11(c)(2)(ii-iii)

Based on interview and record review conducted during an Extended Recertification and Complaint (reference #NY00339732 and #NY00325989) survey from 5/13/2024 to 5/23/2024 the facility failed to protect resident's rights to be free from abuse and failed to protect residents from further abuse for three (Resident #129, #104 and #122) of seven residents reviewed for resident-to-resident abuse. Specifically, Resident #129 was verbally and physically threatened by Resident #74 on 4/16/2024 with a large pair of scissors. The facility failed to provide protection for Resident #129 by allowing Resident #74 ongoing access to Resident #129. This resulted in mental anguish for Resident #129 as they stated on 4/19/2024 to Social Worker #1 that they were fearful for their life as they recounted the events of 4/16/2024. In addition, facility staff failed to provide protection from sexual abuse for Residents #104 and #122. Both residents were severely cognitively impaired and lacked the ability to consent to a sexual relationship. The residents were observed by staff engaged in non-consensual sexual activity on 10/13/2023 and were not immediately separated, which resulted in continued sexual abuse. Neither resident was care planned to prevent sexual abuse. This resulted in, or had the likelihood for, psychosocial harm that is Immediate Jeopardy and Substandard Quality of Care for Resident #s 104,122 and 129 which had the likelihood to affect all 165 residents in the facility. The findings are: The policy and procedure titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised September 2021, documented residents have the right to be free from abuse by anyone which includes but is not limited to verbal, mental, sexual, and physical abuse. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavior, cognitive and emotional problems. Protect residents from any further harm during investigations. 1. Resident #74 had diagnoses which included displaced intertrochanteric fracture (type of hip fracture) of right femur (thigh bone), epileptic seizures (abnormal electrical brain activity), and alcohol dependence with withdrawal. The Minimum Data Set (a resident assessment tool) dated 2/23/2024 documented Resident #74 was cognitively intact. The comprehensive care plan documented Resident #74 was cognitively intact, independent with decision making (2/22/2024) and independent with wheelchair mobility (3/25/2024) on the unit. Resident #129 had diagnoses which included Wernicke's encephalopathy (type of brain injury), alcohol induced persisting dementia and type 2 diabetes mellitus. The Minimum Data Set, dated dated dated [DATE] documented Resident #129 was severely cognitively impaired, was understood and understands others. Resident #129 was independent with chair/bed transfer and required supervision with wheelchair mobility. The comprehensive care plan initiated 8/31/2023 (current) documented Resident #129 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to mild cognitive impairment. The Investigation Summary/QA (Quality Assurance) Privilege report completed by Director of Nursing #1 documented a resident-to-resident altercation took place on 4/16/2024 and was not reported until 4/19/2024. Allegedly, Resident #74 engaged in a verbal argument with their roommate, Resident #129, that quickly turned violent when Resident #74 threatened Resident #129 with a pair of scissors and stated, I am going to kill you. This resident-to-resident altercation was witnessed by Certified Nurse Aide #1 and was reported to Registered Nurse #1 on 4/16/2024. On 4/19/2024, Resident #129 appeared distraught and tearful when recounting the events that took place on 4/16/2024 to Social Worker #1. Resident #129's verbal statement given to Social Worker #1 on 4/19/2024 documented the resident stated they could not live in violence, and it was not good for their mind and well-being. Review of the case report notes submitted by the facility on 4/22/2024 at 2:20 PM documented Resident #129 was crying and trembling when they gave Social Worker #1 their statement. Resident #129 stated they were fearful for their life and did not want their roommate to come back because they almost got stabbed in the back. Review of facility nurse report sheets, Resident #74 and Resident #129's progress notes dated 4/16/2024 through 4/19/2024 revealed Resident #74 (alleged perpetrator) had ongoing access to Resident #129. The two residents (#74 and #129) remained residing in the same room from 4/16/2024 to 4/19/2024 when Resident #74 was hospitalized for an unrelated illness. Upon Resident #74's return on 4/23/2024 they returned to the same unit as Resident #129. During an interview on 5/20/2024 at 8:41 AM, Certified Nurse Aide #1 stated on 4/16/2024 they heard a loud argument and observed the altercation between Resident #74 and #129. The residents were a little bit farther then an arm's length apart when Resident #74 pulled a pair of scissors out of a black bag and raised them toward Resident #129. Certified Nurse Aide #1 stated had they not intervened Resident #74 would have stabbed Resident #129 in the back. Certified Nurse Aide #1 stated after they intervened Resident #74 placed the scissors back into their bag. Certified Nurse Aide #1 stated they could not locate the nurse on the unit after the altercation and went back to their other work duties. They stated about 30 minutes after the altercation they reported it to Registered Nurse #1. During an interview on 5/20/2024 at 9:16 AM, Registered Nurse #1 stated upon being notified of the altercation they went to Resident #74 and #129's room. Both residents were ok, calm, and sitting in their room in their wheelchairs. Resident #74 was asked to surrender the scissors and they complied. Registered Nurse #1 stated the scissors were huge and that if Resident #74 wanted to use them to cause harm they could. Registered Nurse #1 stated that Resident #74 wanted a room change but didn't want to switch floors. Registered Nurse #1 stated they did not separate the resident's or implement any additional safety measures because they felt the situation was defused. Registered Nurse #1 stated they thought it was more of Certified Nurse Aide #1's viewpoint and didn't consider it to be an allegation of abuse. During a telephone interview on 5/20/2024 at 9:44 AM and 5/22/2024 at 8:20 AM, Social Worker #1 stated on 4/19/2024 Resident #129 told them their roommate (Resident #74) got frustrated, was screaming at them, and tried to stab them with a pair of scissors. Social Worker #1 stated that Resident #129 was crying and shaking when sharing what happened. Resident #129 told them they were afraid for their life. During an interview on 5/20/2024 at 11:38 AM, Resident #74 stated they were angry about Resident #129 mixing stuff up in their water pitcher. Resident #74 stated they tried to talk to Resident #129 about it but they're a little off. Resident #74 stated if they caught Resident #129 doing it, they'd stick them, but wouldn't want to hurt them. Resident #74 stated they thought Resident #129 would take the message if they saw the scissors. During an interview on 5/20/2024 at 2:01 PM, Director of Nursing #1 stated the resident-to-resident altercation between Resident #74 and #129 was abuse. Director of Nursing #1 stated the scissors should have been removed immediately from Resident #74. The residents should have been separated for safety and other interventions put into place as deemed appropriate. During an interview on 5/21/2024 at 11:49 AM, current Administrator #1 stated Director of Nursing #1 completed the abuse investigation, and the conclusion was they could not ascertain physical abuse occurred. Administrator #1 stated staff did not follow policy. During a telephone interview on 5/22/2024 at 3:45 PM, the Medical Director stated with resident-to-resident altercations the nursing staff should assess the situation for safety, separate the residents into different rooms, and ensure no additional weapons were present to mitigate any further risk to the resident's safety. 2. Resident #104 had diagnoses including cerebral infarction (stroke), metabolic encephalopathy (a disorder of the brain that can lead to personality changes), and dementia. The Minimum Data Set, dated dated dated [DATE] documented Resident #104 was moderately cognitively impaired, was understood, and understands others. The policy and procedure titled Identifying Sexual Abuse and Capacity to Consent, dated September 2022, documented a resident's consent to sexual activity is not valid if obtained from a resident who lacks capacity to consent, or if consent was obtained through intimidation, fear, or coercion. Sexual abuse is non-consensual sexual contact of any type with a resident, including unwanted intimate touching of any kind especially of breasts or perineal area. Sexual contact is non-consensual if the resident appears to want the contact to occur but lacks the cognitive ability to consent. Any forced, coerced or extorted sexual activity with a resident, regardless of the existence of a pre-existing or current sexual relationship, is sexual abuse. For any allegations or suspicion of sexual abuse, an investigation, protective measures will be implemented to prevent further potential abuse. The comprehensive care plan dated 7/3/2023 documented Resident #104 had impaired cognitive function and was not an independent decision maker. Resident #104 was independent with ambulation and wandered. Intervention included to redirect them as needed. The care plan did not include any evidence of a pre-existing relationship with Resident #122, nor a plan to prevent sexual abuse. A Brief Interview for Mental Status (BIMS) assessment dated [DATE] conducted by Director of Social Work #2 documented Resident #104 scored a 6, indicating they were severely cognitively impaired. Review of the Physician's Statement dated 10/16/2023 revealed Medical Doctor #2 signed that Resident #104 lacked capacity to handle their own affairs. Resident #122 was admitted with diagnoses including dementia, hypertension (high blood pressure), and benign prostatic hypertrophy (enlarged prostate gland). The Minimum Data Set, dated dated dated [DATE] documented Resident #122 was severely cognitively impaired. The comprehensive care plan dated 12/22/2022 documented Resident #122 had impaired cognitive function; was not an independent decision maker, had impaired thought process and was alert and oriented to self only (initiated on 7/3/2023). Interventions included to communicate with resident/family/caregivers regarding resident's capabilities and needs. The care plan did not include any evidence of a pre-existing relationship with Resident #104, nor a plan to prevent sexual abuse. Review of the Physician's Statement dated 3/23/2023 revealed Medical Doctor #2 signed Resident #122 lacked capacity to handle their own affairs. An Investigation Summary/QA Privilege report signed on 10/20/2023 by Former Director of Nursing #2 documented during the morning shift on 10/13/2023 Certified Nurse Aide #2 observed Resident #104, and Resident #122 engaged in inappropriate sexual touching. Certified Nurse Aide #2's investigation statement dated 10/13/2023, documented Resident #104 and Resident #122 were observed in the dining room hugging. Resident #104 was standing next to Resident #122, who was seated. Resident #122 slid their hand down the front of Resident #104's pants and their other hand up their shirt. According to the witness statement, Certified Nurse Aide #2 asked them to stop. Therapy Aide #1 then walked into dining room and observed the sexual activity. Therapy Aide #1's investigation statement dated 10/13/2023, documented around 11:30 AM on 10/13/23 they were walking a resident into the dining room and observed Resident #104 standing next to Resident #122 who was seated. Resident #122 had their hand down the front of Resident #104's pants. Therapy Aide #1's statement documented they verbally intervened. Resident #122 removed their hand from Resident #104's pants. Resident #104 whispered something to Resident #122, who then proceeded to place their hand back into Resident #104's pants and continued for another minute or so. Therapy Aide #1 documented that there was another aide in the corner that said they had been doing that for about 20 minutes or so and they told them to stop but they did not listen. During a telephone interview on 5/17/2024 at 10:46 AM, Certified Nurse Aide #2 stated on 10/13/2023 they were in the dining room charting on a laptop computer when Resident #104 walked over to Resident #122. The residents conversed a bit and then Resident #122 put their hand down the front of Resident #104's pants. Certified Nurse Aide #2 stated they told them to stop, and they did. Certified Nurse Aide #2 stated they did not separate the residents and went back to their charting. Therapy Aide #1 then walked into the dining room and observed the two residents engaged again in sexual activity and separated them. Certified Nurse Aide #2 stated there had been prior incidents between the two residents of hugging and Resident #122 would slide their hand under Resident #104's shirt. Certified Nurse Aide #2 stated it was kind of like an everyday thing that would happen, if you didn't catch it. They had reported it to other Certified Nurse Aides on the unit and they would just brush it off, just yell and tell them to stop. During an interview on 5/17/2024 at 11:56 AM, Nurse Practitioner #1 stated they felt as though Resident #104 may have known what they were doing but did not think it was a big deal. Nurse Practitioner #1 stated they would consider it to be inappropriate in a public setting. During an interview on 5/20/2024 at 9:26 AM, Certified Nurse Aide #3 stated there had been instances prior to 10/13/2023 where Resident #104 and Resident #122 would be seen rubbing each other's backs and with their arms around each other. Certified Nurse Aide #3 stated they would just keep an eye on them and tell them to get away from each other if things got too weird. During a telephone interview on 5/20/2024 at 9:43 AM, Therapy Aide #1 stated they observed Resident #122's hand inside Resident #104's pants and they attempted to intervene by telling the residents to stop. Resident #122 then said to Resident #104, we better stop and removed their hand from Resident #104's pants. Resident #104 whispered something into Resident #122's ear then Resident #122 proceeded to put their hand back in Resident #104's pants. Therapy Aide #1 stated Certified Nurse Aide #2 told them it had been going on for about the past 20 minutes. During a telephone interview on 5/20/2024 at 10:29 AM, former Director of Nursing #2 stated the inappropriate contact happened in the dining room and neither resident had capacity to consent. They did not recall if any prior incidents had been reported to them involving these two residents. During a telephone interview on 5/20/2024 at 10:46 AM, Director of Social Work #2 stated they did not recall either resident having any sort of psychological evaluation completed after the incident. Director of Social Work #2 stated Resident #104 and Resident #122 lacked capacity to make those types of decisions. During an interview on 5/21/2024 at 10:38 AM, current Director of Nursing #1 stated sexual abuse was any unwanted non-consensual situation, could be touching or other forms. Director of Nursing #1 stated Resident #104 and Resident #122 both lacked the capacity to consent according to the Physician Statement documents. They would have expected the residents to be separated by Certified Nurse Aide #2, who witnessed the incident. During an interview on 5/21/2024 at 10:19 AM, Licensed Practical Nurse #8 stated they recalled being made aware of the incident on 10/13/2023 but did not recall any prior instances between Resident #104 and Resident #122. Additionally, they stated they were unsure if staff could properly supervise residents because the staff were always everywhere and the residents are wandering around, so it can be difficult. During an interview on 5/21/2024 at 12:01 PM, Administrator #1 stated sexual abuse was inappropriate touching from someone that was not wanting of that touching and had the capacity to understand what that meant. During an interview on 5/21/2024 at 3:35 PM, the Regional Director of Nursing stated neither resident had a Health Care Proxy on file. During an interview on 5/21/2024 at 3:37 PM, Director of Nursing #1 stated if residents lacked capacity and did not have an activated health care proxy, the residents' responsible parties or next of kin would make decisions for them. They stated a resident who lacks capacity would not be able to consent. During a telephone interview on 5/21/2024 at 3:39 PM, Medical Director #1 stated capacity was a judgement call when it involved determining if a resident lacked capacity to make decisions regarding sexual activity. Medical Director #1 stated it really was a case-by-case basis and depends on who's involved. Sexual touching was probably not something one would usually consent to if they lacked capacity. If there's no health care proxy on file, an interdisciplinary team meeting would be needed to discuss and come up with a plan. 10 NYCRR 415.3 (d) (1) (vii)

Based on interview and record review conducted during an Extended Recertification and Complaint (reference #NY00339732 and #NY00325989) survey from 5/13/2024 to 5/23/2024 the facility failed to ensure that all alleged violations of abuse are reported immediately, but not later than 2-hours after the allegation is made to the administrator of the facility and to appropriate officials (including the State Survey Agency) for three (Resident #104, #122, and #129) of fourteen residents reviewed for abuse reporting. Specifically, Registered Nurse #1 did not report alleged resident-to-resident abuse that occurred between Resident #74 and #129 to the Administrator. The lack of reporting resulted in continued access to each other and mental anguish for Resident #129. Additionally, Residents #122 and Resident #104 who lacked capacity to consent were observed engaged in non-consensual sexual activity. Facility staff failed to report the sexual abuse immediately to the Administrator which resulted in continued sexual abuse between the residents. This resulted in, or had the likelihood for, psychosocial harm that is Immediate Jeopardy and Substandard Quality of Care for Resident #s 104, 122, and 129 which had the likelihood to affect all 165 residents in the facility. The findings are: The policy and procedure titled Abuse, Neglect, Exploitation and Misappropriation-Reporting and Investigating revised September 2022 documented if resident abuse was suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as: within two hours of an allegation involving abuse. 1. Resident #74 had diagnoses which included displaced intertrochanteric fracture (type of hip fracture) of right femur (thigh bone), epileptic seizures (abnormal electrical brain activity), and alcohol dependence with withdrawal. The Minimum Data Set (a resident assessment tool) dated 2/23/2024 documented Resident #74 was cognitively intact. The comprehensive care plan documented Resident #74 was cognitively intact, independent with decision making (2/22/2024) and independent with wheelchair mobility (3/25/2024) on the unit. Resident #129 had diagnoses which included Wernicke's encephalopathy (type of brain injury), alcohol induced persisting dementia and type 2 diabetes mellitus. The Minimum Data Set, dated dated dated [DATE] documented Resident #129 was severely cognitively impaired, was understood and understands others. Resident #129 was independent with chair/bed transfer and required supervision with wheelchair mobility. The comprehensive care plan dated 8/31/2023 documented Resident #129 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to mild cognitive impairment. The Investigation Summary/QA (Quality Assurance) Privilege report completed by Director of Nursing #1 documented a resident-to-resident altercation took place on 4/16/2024 and wasn't not reported until 4/19/2024. Allegedly, Resident #74 engaged in a verbal argument with their roommate, Resident #129, that quickly turned violent when Resident #74 threatened Resident #129 with a pair of scissors and stated, I am going to kill you. This resident-to-resident altercation was witnessed by Certified Nurse Aide #1 and was reported to Registered Nurse #1 on 4/16/2024. On 4/19/2024, Resident #129 appeared distraught and tearful when recounting the events that took place on 4/16/2024 to Social Worker #1. The report documented the abuse was reported to the New York State Department of Health on 4/19/2024. Review of a witness statement dated 4/20/2024, Certified Nurse Aide #1, documented that on 4/16/2024 they witnessed Resident #74 shouting obscenities, enraged, and raised a large pair of scissors high above their head as they approached Resident #129. Certified Nurse Aide #1 stated at that time there was no nurse available and that after a while they reported what they witnessed to Registered Nurse #1. Review of Registered Nurse #1's employee file revealed a facility Disciplinary Action dated 10/4/2022 revealed a verbal warning for not notifying Administrator/Director of Nursing on 10/2/2022 of a resident-to-resident altercation resulting in a delay in reporting to the Department of Health. During an interview on 5/20/2024 at 8:41 AM, Certified Nurse Aide #1 stated on 4/16/2024 they witnessed a resident-to resident altercation between Resident #74 and #129. Certified Nurse Aide #1 stated about 30 minutes after the altercation they reported the altercation to Registered Nurse #1. During an interview on 5/20/2024 at 9:16 AM, Registered Nurse #1 stated upon being notified of the altercation they went to Resident #74 and #129's room. Both residents were ok, calm, and sitting in their room in their wheelchairs. Resident #74 was asked to surrender the scissors and they complied. Registered Nurse #1 stated the scissors were huge and that if Resident #74 wanted to use them to cause harm they could. Registered Nurse #1 stated Resident #74 wanted a room change but did not want to switch floors. Registered Nurse #1 stated they did not separate the resident's or implement any additional safety measures because they felt the situation was defused. Registered Nurse #1 stated they thought it was more of Certified Nurse Aide #1's viewpoint and didn't consider it to be an allegation of abuse. During a telephone interview on 5/20/2024 at 9:44 AM and 5/22/2024 at 8:20 AM, Social Worker #1 stated on 4/19/2024 Resident #129 told them their roommate (Resident #74) got frustrated, was screaming at them, and tried to stab them with a pair of scissors. Social Worker #1 stated that Resident #129 was crying and shaking when sharing what happened. Resident #129 told them they were afraid for their life. The abusive altercation should have been reported immediately by staff to administration. During an interview on 5/20/2024 at 2:01 PM, Director of Nursing #1 stated the resident-to-resident altercation between Resident #74 and #129 occurred on 4/16/2024 and they weren't notified until 4/19/2024. The Director of Nursing stated all allegations of abuse needed to be immediately brought to their attention so an investigation could be started and reported accordingly. During an interview on 5/21/2024 at 11:49 AM, Administrator stated that staff didn't follow policy. The resident-to-resident altercation should have been reported the moment it occurred so a thorough investigation could be completed and reported accordingly. 2. Resident #104 had diagnoses including cerebral infarction (stroke), metabolic encephalopathy (a disorder of the brain that can lead to personality changes), and dementia. The Minimum Data Set, dated dated dated [DATE] documented Resident #104 was moderately cognitively impaired was understood and understands others. The comprehensive care plan dated 7/3/2023 documented Resident #104 had impaired cognitive function and was not an independent decision maker. Resident #104 was independent with ambulation and wandered. Intervention included to redirect as needed. The care plan did not include any evidence of a pre-existing relationship with Resident #122, nor a plan to prevent sexual abuse. Review of a brief interview for mental status dated 10/13/2023 was conducted by Director of Social Work #2 Resident #104 scored a 6, indicating they were severely cognitively impaired. Review of the Physician's Statement dated 10/16/2023 revealed Medical Doctor #2 signed that Resident #104 lacked capacity to handle their own affairs. Resident #122 was admitted with diagnoses including dementia, hypertension (high blood pressure), and benign prostatic hypertrophy (enlarged prostate gland). The Minimum Data Set, dated dated dated [DATE] documented Resident #122 was severely cognitively impaired. The comprehensive care plan dated 12/22/2022 documented Resident #122 had impaired cognitive function; was not an independent decision maker, had impaired thought process and was alert and oriented to self only (initiated on 7/3/2023). Interventions included to communicate with resident/family/caregivers regarding resident's capabilities and needs. The care plan did not include any evidence of a pre-existing relationship with Resident #104, nor a plan to prevent sexual abuse. Review of the Physician's Statement dated 3/23/2023 revealed Medical Doctor #2 signed Resident #122 lacked capacity to handle their own affairs. Review of Investigation Summary/QA Privilege report signed on 10/20/2023 by Former Director of Nursing #2 documented during the morning shift on 10/13/23 Certified Nurse Aide #2 observed Resident #104, and Resident #122 engaged in inappropriate sexual touching. Certified Nurse Aide #2 told Resident #122 and Resident #104 to stop. Certified Nurse Aide #2 then returned to doing their charting in the corner. Sometime later, Therapy Aide #1 walked into the dining room and observed Resident #104, and Resident #122 again engaged in sexual activity. During a telephone interview on 5/17/24 at 10:46 AM Certified Nurse Aide #2 stated on 10/13/2023 they observed Resident #104 and Resident #122 engaged in inappropriate sexual touching in the dining room. Certified Nurse Aide #2 stated they told them to stop, and they did. Certified Nurse Aide #2 stated they did not immediately report this incident because this was kind of like an everyday thing that would happen if you didn't catch it. Certified Nurse Aide #2 stated they would report it to other Certified Nurse Aides on the unit and they would just brush it off. They acted like it wasn't a big deal, just yell and tell them to stop and then they would stop. They stated they would consider this sexual abuse because neither resident had capacity to consent. During an interview on 5/20/2024 at 9:26 AM, Certified Nurse Aide #3 stated there had been instances prior to 10/13/2023 where Resident #104 and Resident #122 would be seen rubbing each other's backs and with their arms around each other. Certified Nurse Aide #3 stated they would just keep an eye on them and tell them to get away from each other if things got too weird. During a telephone interview on 5/20/2024 at 9:43 AM, Therapy Aide #1 stated they observed Resident #122's hand inside Resident #104's pants and they attempted to intervene by telling the residents to stop. Resident #122 then said to Resident #104, we better stop and removed their hand from Resident #104's pants. Resident #104 whispered something into Resident #122's ear then Resident #122 proceeded to put their hand back in Resident #104's pants. Therapy Aide #1 stated Certified Nurse Aide #2 told them it had been going on for about the past 20 minutes. I told them to stop but they wouldn't. Therapy Aide #2 stated they physically separated them and went to report the incident to the Director of Nursing (Former Director of Nursing #2). During a telephone interview on 5/20/2024 at 10:29 AM, former Director of Nursing #2 stated the inappropriate contact happened in the dining room and neither resident had capacity to consent. They did not recall if any prior incidents had been reported to them involving these two residents prior to 10/13/2023. During an interview on 5/21/2024 at 10:38 AM, Director of Nursing #1 stated they would have expected Certified Nurse Aide #2, who witnessed the incident, to immediately report the sexual activity to the correct entity. During an interview on 5/21/2024 at 12:01 PM, the Administrator stated the basis of any initial report was that it must be reported to administration so that they can go through the process. 10 NYCRR 415.4(b)(2)

Based on observation, interview and record review conducted during the COVID-19 Infection Control Focus Survey (Complaint #NY 448) completed on 4/26/20, it was determined that the facility did not establish and maintain an Infection Control Program to ensure the health and safety of residents to help prevent the transmission of COVID-19. Specifically, facility staff entered and exited the rooms of residents diagnosed with [REDACTED]. The CNAs (certified nursing assistant) did not remove their gowns or gloves after exiting the rooms of residents on Contact and Droplet Precautions and did not complete appropriate hand hygiene. CNA's were unable to identify residents that were on Contact and Droplet Precautions for COVID-19. This was a pattern of no actual harm that is immediate jeopardy to resident health and safety. Additionally, Resident #1 a person under investigation (PUI) for COVID-19 was not placed on Contact and Droplet precautions per the facility's process and staff were observed not wearing facemasks appropriately in resident care areas. Review of a facility policy and procedure (P&P) titled Preventing the spread of COVID-19 dated 3/10/20 documented infection prevention and control measure must be enhanced at this time and that hand hygiene is of the utmost importance. Employees must clean their hands according to CDC guidelines, including before and after contact with residents, after contact with contaminated surfaces and after removal of PPE. Identify dedicated employees to care for COVID-19 patients. If suspect or confirmed with COVID-19 keep the resident isolated following proper isolation precautions. Review of P&P titled Confirmed of Suspected COVID-19 dated 3/20/20 documented if there is a suspected or positive case of COVID-19 initiate droplet precautions and place signage on the door. Place resident in their room with the door closed. Implement a PPE tote on the resident's door. Assure that all residents in affected units remain in their rooms, cancel communal dining. Review of an undated P&P titled Handwashing /Hand hygeine documented to wash hands before and after entering isolation precaution settings. The finding is: a) During an interview on 4/23/20 at 12:00 PM, the Director of Nursing (DON) and the Administrator stated there were five COVID-19 positive residents on the third floor and six COVID-19 positive residents on the fourth floor. The third and fourth floors have positive residents and exposed residents The 4th floor was the dementia unit and all the residents on that unit were on droplet precautions. Additionally, they had no residents currently under investigation for COVID-19. The facilities bed capacity was 173 and the current resident census was 127. COVID-19 positive residents eat meals in their rooms. During an observation on 4/23/20 at 12:28 PM CNA #3 was on a resident care unit on the fourth floor in the hallway. There were residents, staff and visitors present in the immediate area (with in six feet). CNA #3's mask was below his chin and exposing his nose and mouth. During an observation on 4/23/20 at 12:30 PM there were six residents in a lounge area across from the nurses' station on the fourth floor, they were not maintaining their face masks or social distancing. Staff members (activities/nursing) were present in the area but did not redirect the residents to replace their masks or to social distance, until the surveyors intervened. The Licensed Practical Nurse (LPN) #1 stated there were both COVID-19 positive and negative residents in the lounge area at this time. During continued observations at 12:38 PM the fire doors were closed to the low-end hall (Rooms #401 to #408) designated as the COVID-19 positive zone by the facility. A stocked linen cart was uncovered, and the majority of the resident room doors were open and had Contact and Droplet precautions signs posted on all of them. During interview on 4/23/20 at 12:40, CNA #4 was on the designated COVID-19 zone in the hallway and stated they redirect the residents the best they can, and the residents should have their face masks on, but it's hard for the residents to keep them on. Residents on this floor that are able can move and walk freely around the unit. CNA #4 stated he did not know which residents on the fourth floor were COVID-19 positive and did not know how the facility identified resident's that were positive as they treat all the residents as if they were positive on the fourth floor. CNA#4 was wearing two gowns, his facemask was covering his mouth but not his nose. Throughout the interview CNA #4 would lower his facemask below his mouth to speak. The staff keep their same gowns on all shift until they go on break or home. He was educated on the use of PPE and should not have pulled his facemask down to speak and that it slips down at times. During a lunch meal pass observation on 4/23/20 at 12:45 PM on the fourth floor COVID-19 designated zone, two meal carts were wheeled onto the low-end hall and placed behind the closed fire doors. CNA #1 and CNA #2 were observed to pass the lunch meal trays and provide meal set up assist moving from COVID-19 positive resident rooms to COVID-19 negative resident rooms, wearing the same PPE and without completing hand hygiene. The residents in their rooms were not wearing masks. After the trays were passed CNA #1 and CNA #2 left the COVID-19 designated zone and returned to the resident lounge area wearing the same PPE and without performing hand hygiene. During interview on 4/23/20 at 12:49 PM, CNA #1 stated that he did not know which residents were COVID-19 positive or negative. He did not know how to identify which residents were positive and that he treats every resident as if they were positive, that's just what I do. CNA #1 stated he was educated on PPE use and should have performed hand hygiene between residents. During interview on 4/23/20 at 12:50 PM, CNA #2 stated she was educated on the use of PPE and should have changed her gown and preformed hand hygiene when exiting a COVID-19 positive room and before entering a non COVID-19 resident room, but sometimes there are not enough gowns. CNA #2 did not know which residents were positive, or negative for COVID-19 and that they treat all residents on the fourth floor as if they were positive. During an interview on 4/23/20 at 12:50 PM, the Assistant Director of Nursing (ADON) stated they are treating the entire floor with extreme caution. CNA's should not be moving from COVID-19 positive rooms to COVID-19 negative rooms without removing their gowns and performing hand hygiene. During an interview on 4/23/20 at 2:50 PM, the Director of Nurses stated that they did education on COVID-19, the use of PPE, and handwashing. On the fourth floor there are COVID-19 positive rooms where they were cohorting residents that were both positive and negative. The unit also has dementia residents that independently move and wander throughout the entire fourth floor. If a resident is on precautions for COVID-19 a Contact and Droplet Precautions sign is placed on the door as well as a precaution set up (PPE [MEDICATION NAME]) hung on the room door. With hands on care the expectation would be to change gowns and gloves, but to just do a quick task it was not necessary. During a telephone interview on 4/23/20 at 3:35 PM, a representative from the New York State epidemiology division stated that facility staff should be donning and doffing (putting on and taking off) PPE and performing hand hygiene between COVID-19 positive residents and COVID-19 negative residents. If they cannot maintain the zones or have designated staff for the COVID-19 positive residents, the facility should think about moving the residents to where a red zone could be maintained. During a telephone interview on 4/23/20 at 5:53 PM, the Medical Director stated that staff should be not moving from COVID-19 positive residents to COVID-19 negative residents without removing PPE and performing hand hygiene. The residents are vulnerable population and there is an increased risk of transmission with this disease and he would expect the staff to be removing the PPE and performing hand hygiene. If possible, the facility should dedicate staff, put COVID-19 positive residents in rooms together, and if there was enough room within the facility to put the positive residents all in the same area and remove from them from COVID-19 negative resident areas. During an observation on 4/24/20 at 12:59 PM in the fourth- floor lounge area across from the nurses station revealed three male residents sitting at a table eating lunch within a foot of each other. At the time of the observation the DON was standing by the nurses' station, and was asked does the facility allow communal dining at this time? The DON stated no, and the residents should not have been seated at the same table. After surveyor intervention the DON attempted to redirect the residents. During an observation 4/25/2020 at 12:19 PM LPN #2 was observed at the second- floor nurses' station on with their face mask below their chin exposing nose and mouth within six feet of the DON and surveyor. The LPN stated she should not have the facemask off at the desk, but I knew when I got up and walked away, I would pull it up. Additionally stated, the face mask was to be worn anytime within six feet of anyone else, due to the COVID-19 crisis. During an observation 4/25/2020 at 12:33 PM CNA #4 was observed at the fourth-floor service elevator with facemask below his nose exposing the nose and within six feet of two employees and the surveyor. CNA #4 stated, It gets real hot in here. During an observation on 4/25/2020 at 12:50 PM, the fourth-floor Housekeeper (#1) was observed with a healthcare particulate respirator surgical mask (mask that helps provide respiratory protection against certain airborne particles) below her chin and a disposable facemask that was ripped horizontally exposing the nose. The housekeeper was observed wearing a cover gown, gloves, and ripped facemask entering the room of a COVID-19 positive resident. The housekeeper then exited the room, removed gloves, applied new gloves without performing hand hygiene, and while wearing the same gown and ripped facemask entered the room of a non-COVID-19 positive resident. The housekeeper then exited that room, removed gloves, applied new gloves without performing hand hygiene, and while wearing the same gown and ripped facemask then entered the room of another non-COVID-19 resident. During an interview on 4/25/2020 at 1:20 PM, Housekeeper #1 stated she only changes gloves between resident rooms. I change the gown when I leave the unit. I don't change the gown between precaution (level of infection control) and non-precaution rooms, we only get one gown per shift because there aren't enough gowns to go around. In addition, the housekeeper stated the healthcare particulate respirator surgical mask slips down to her chin which exposes her nose in resident rooms. During further observation on 4/25/2020 at 1:29 PM LPN #2 was again observed at the second- floor nurses' station with her facemask below her chin exposing her nose and mouth and within six feet of two CNA's. b.) Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 2/6/20 documented Resident #1 was moderately cognitively impaired, was understood and understands. Review of Resident #1 care plan revised on 3/5/20 and identified as current revealed there was no care plan developed to address respiratory precautions, measurable goals or interventions. During an interview on 4/24/20 at 11:46 AM with the facility DON, Corporate RN and Administrator present the Administrator stated there was one COVID-19 related death overnight from the fourth floor and there was one resident (Resident #1) under investigation for COVID-19 on the third floor. The results of the swab test were still pending. The DON stated the PUI (Resident #1) was not reported to the surveyors on 4/24/20. During an observation 4/24/20 at 12:49 PM Resident #1 was in lying in bed in their room with the door open. There were no identifiers (precaution signs or precaution totes per facility process) to indicate to staff and visitors that the resident was on Contact and droplet precautions. During an interview on 4/24/20 at 12:50 PM, the ADON stated the resident was moved to their current room on 4/9/20 and was swabbed for COVID-19 on 4/21/20 and the results were still pending. There should have been a Contact and Droplet precaution sign and tote placed on the door to the resident's room to alert staff and visitors the resident was on airborne/droplet precautions. Review of Resident #1's Progress Note dated 4/21/20 at 8:10 AM revealed the resident was lethargic, skin was cool to touch with increased weakness and had a temperature of 99.3 (normal 96.8). At 9:06 AM the ADON assessed the resident and noted the resident to have an occasional loose nonproductive cough, lung sounds were diminished in the bilateral bases and the Swab pending. Continued review of the progress notes revealed on 4/24/20 at 12:40 PM the laboratory (lab) was contacted, and the COVID-19 swab was still pending. Review of Resident #1's Medication Review Reports (physician's orders) dated 4/1/20 through 4/30/20 revealed there was no physician's order to obtain a COVID-19 swab. Review of Resident #1's laboratory Infectious Disease report for with a print date of 4/26/20 at 8:58 AM revealed that [DIAGNOSES REDACTED] CoV 2 RNA was detected (infected with COVID-19 virus). 415.19 (b)(1)

Based on interview and record review conducted during a Complaint investigation (Complaint #NY 034) completed during the Standard survey on 10/29/18, the facility did not ensure that each resident received treatment and care based on the comprehensive assessment of the resident that is in accordance with professional standards of practice for one (Resident #241) nine residents reviewed for diabetic management. Specifically, the incorrect transcription of medication orders resulted in the administration of insulin (used to decrease glucose (blood sugar) levels in the blood). The administration insulin and the lack of monitoring glucose levels led to critically low blood glucose levels, and subsequently hospitalization . This resulted in actual harm that is not immediate jeopardy. The findings are: The policy entitled Nursing Care of the Resident with Diabetes Mellitus dated (MONTH) (YEAR) documented the purpose of the guideline was to review the most common and serious conditions and complications associated with diabetes, help the resident control his/ her diabetes with diet, exercise, and insulin (as ordered), and to prevent recurrent [MEDICAL CONDITION]/ [DIAGNOSES REDACTED]. The management of individuals with diabetes mellitus should follow relevant protocols and guidelines. The physician will order the frequency of glucose monitoring. Additionally, residents whose blood sugar is poorly controlled or those taking insulin may require more frequent monitoring, depending on the situation. The survey team requested a policy on readmission/ admission procedures on 10/29/18 at 11:00 AM and none was provided by the facility. 1. Resident #241 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-a resident assessment tool) dated 2/19/18 documented the resident was cognitively intact, was understood and understands. The MDS also documented the resident received insulin injections. The current Comprehensive Care Plan with an initiated date of 1/24/18 had no documented plan for the use of insulin and glucose monitoring. A Change of Condition Progress Note dated 2/4/18 at 4:43 PM by Licensed Practical Nurse (LPN #2) documented around 8:00 AM, the resident was found unresponsive, had pursed lip breathing with clear mucous coming from their mouth. Several attempts were made to arouse the resident without success. A blood glucose level was obtained and documented as 33 (normal 70-130). The resident was administered [MEDICATION NAME] (medication used to raise concentration of glucose in bloodstream) IM (intramuscular- injection directly into the muscle) per the physician's orders [REDACTED]. The resident became more alert and responsive after the administration of [MEDICATION NAME]. Repeated blood glucose levels during this time were obtained and documented as 55 and 104. The doctor (MD) was updated on resident's condition and orders were obtained for STAT (now) blood work which included a CBC/ CMB (complete blood count/ comprehensive metabolic panel), reduce [MEDICATION NAME] (insulin) to 10 ml (milliliters) at HS (hour of sleep) and to notify the MD for blood glucose levels below 60 or greater than 300. laboratory results dated [DATE] documented a glucose level of 71 L (low), with a reference range of 74-100 mg/dl (milligram/ deciliter). A nursing Progress Note dated 2/5/18 documented the following: - 4:15 AM, Registered Nurse Supervisor (RN #6) documented the resident was found unresponsive, except to a sternal rub with fixed and dilated pupils. The resident's skin was cold and clammy, the bed linens and the resident's gown were wet. The following vital signs were documented, pulse ox (PO2, amount of oxygen in the blood) 91 % (percent, normal 95-100 %), and pulse rate of 104 (normal 60-100). A new order was obtained to administer 1 mg (milligram) of [MEDICATION NAME], discontinue the HS [MEDICATION NAME] and to increase oxygen (O2) to 4L (liters) for comfort till responsiveness returned. After the administration of [MEDICATION NAME], the resident became responsive to verbal commands, and was able to eat and drink. The BSFS (blood sugar fingerstick) slowly increased to 89 by 4:45 AM. The note did not include a blood glucose level but documented will continue to monitor for [DIAGNOSES REDACTED]. - 7:48 AM, Licensed Practical Nurse (LPN #7) documented she was called to the resident's room by a CNA (certified nurse aide, unidentified), the resident was cold, clammy and unresponsive. The Supervisor was notified. The following glucometer readings (blood glucose levels) were documented: 4:00 AM the FS was 34, 5:00 AM the FS was 89, and at 6:30 AM the FS was 93. The resident was verbally responsive at this time, skin warm and dry to touch. - 9:16 AM, LPN #7 documented that she was called to the resident's room by a CNA (unidentified). The resident was found with cold and clammy skin, and the resident was diaphoretic (sweating heavily). The LPN obtained a fingerstick (blood glucose level) of 38. The Supervisor was called to the unit. The resident's BP (blood pressure) was 170/90 (normal 120/80). A second fingerstick was obtained after orange juice and sugar was given, and the blood glucose was up to 58. A nursing Progress Note dated 2/6/18 at 1:00 AM, RN Supervisor #6 documented the resident was admitted to the hospital with [REDACTED]. A hospital Discharge Summary dated 2/13/18 for a discharge date of [DATE] documented discharge [DIAGNOSES REDACTED]. The discharge summary documented to PLEASE AVOID GIVING THIS PATIENT INSULIN (LONG OR SHORT ACTING). Patient has had multiple admissions for [DIAGNOSES REDACTED], transiently high blood sugars are preferred to low blood glucose. The summary also documented the PATIENT NO LONGER REQUIRES INSULIN and was at high risk for [DIAGNOSES REDACTED]. Additionally, included instructions to STOP TAKING THESE MEDICATIONS - Insulin [MEDICATION NAME] ([MEDICATION NAME], long-acting insulin to help control blood sugar level) 10 units sub-Q (subcutaneous- beneath the skin) injection, daily at bedtime. A Nursing Admit/ Readmit Screen dated and signed by RN Supervisor #6 on 2/16/18 documented admitting [DIAGNOSES REDACTED]. A Medication Review Report signed by physician on 2/17/18 documented orders for Insulin [MEDICATION NAME] Solution Pen-injector 100 unit/ ml (milliliters)- inject 10 unit subcutaneously at bedtime for DM with start date of 2/16/18. There were no orders or instructions to monitor the residents blood glucose levels. A Physician's Comprehensive Nursing Home Visit- Admission History & Physical dated and signed on 2/17/18 documented [DIAGNOSES REDACTED]. The resident was receiving rehabilitation at the facility when she was transferred back to the hospital on [DATE] for [DIAGNOSES REDACTED] and altered mental status. The physician's documented Assessment/ Plan included: Altered Mental Status secondary to [DIAGNOSES REDACTED], resolved, monitor glucose and DM on [MEDICATION NAME]. The Medication Administration Record [REDACTED]. There was no documented evidence of glucose monitoring. Review of the Progress Notes dated 2/16/18 through 2/18/18 revealed there was no documented evidence of glucose monitoring. Review of a document entitled Weights and Vitals Summary for blood sugar results revealed there was no glucose testing documented for the month of (MONTH) (YEAR), except for the result of 222 on 2/19/18. A nursing Progress Note dated 2/19/18 documented: - 1:28 AM, LPN #2 documented the resident was alert with some confusion. PO2 was 95% with O2 on as ordered. The resident was able to participate in ADL's (activities of daily living), and could self-propelled wheel chair. Meds were given as ordered and her appetite was good. - 9:00 AM, the former Assistant Director of Nursing (ADON) documented a change of condition, the resident was lethargic and slumped over in bed. At 9:05 AM, IM [MEDICATION NAME] was given for a fingerstick (blood glucose) of 37. The resident became more alert after the administration of [MEDICATION NAME] and was given juice with sugar. The MD was updated on the hypoglycemic event. - 10:52 AM, an RN #7 RCC (Resident Care Coordinator) documented there was good effect from [MEDICATION NAME] administration, a FS was retaken and the result was 222. Ambulance was called by a 4th party per EMT (emergency medical technician). Resident refused to go out to hospital, and stated she was not having any chest pain. EMT did encourage resident to go for evaluation and she agreed. The resident was transferred to hospital for evaluation. - 8:58 PM, RN Supervisor #6 documented the resident was admitted to the hospital at 2:59 PM with [DIAGNOSES REDACTED]. A hospital Discharge Summary dated 3/1/18 documented an admitting [DIAGNOSES REDACTED]. The patient was given [MEDICATION NAME] and sent to hospital. Upon arrival to the hospital the glucose had normalized and appropriately responded to treatment. Subsequently while in the ED (emergency department) the patient had an alteration in mental status and was found to have a fingerstick glucose of 21. The patient was given 1 amp (25 grams) of D50 ([MEDICATION NAME] in 50 ml (milliliters) - fluids given intravenously to help raise blood sugar level) and was subsequently admitted for refractory [DIAGNOSES REDACTED] (unmanageable). The summary also documented [DIAGNOSES REDACTED]- acute metabolic [MEDICAL CONDITION] mostly likely due to low blood sugars. Additionally, avoid any long acting insulin agents in patient as this is second or third hospitalization for [DIAGNOSES REDACTED]. During an interview on 10/26/18 at 11:22 AM, the Medical Director stated, I would say that 100% of the time I will always go by what the hospital discharge summary would recommend for a resident readmitted into the facility. I have 48 hours to see the resident when they come back from the hospital. The nurses/ supervisors would be the one reading the discharge summary recommended medications to me to order. I go by what the nurses tell me and trust the nurses as to what the discharge summary recommends regarding the medications and other recommendations on it. I do not know why the insulin was ordered if the discharge summary had to stop it, the nurse may have miss-read the orders to me. I usually try to read the discharge summaries from the hospital when I come in and see the resident. I do not know why I did not address the recommendations in my history and physical on 2/17/18 or discontinue the insulin. When a diabetic is admitted or readmitted back to the facility they should have their glucose level be monitored and that is standard for every diabetic. The facility should be monitoring the resident's glucose for the first seven days, four times a day regardless. If the resident becomes stable they should be monitored at least 1 to 2 times a week regardless. As to why the glucose levels would have been discontinued on 1/31/18, I would have to think someone mistakenly clicked something and caused it to be deleted from the system. She should have been having the glucose levels done. The Physician further stated because she has a [DIAGNOSES REDACTED]. I would say this caused harm for such a brittle diabetic. During an interview on 10/26/18 at 12:53 PM, the ADON stated, When a resident is readmitted back into the facility from the hospital, you would use the discharge summary from the hospital and read from that to the physician to confirm the orders. Just the RN's would do this for admits and re-admits. During a telephone interview on 10/26/18 at 1:15 PM, former RN Supervisor #6 Supervisor stated, she would read the discharge summary medications to the physician, get the medications approved by the physician, and place them in name of computer system. The RN stated she did not recall if she read to stop the insulin to the MD but stated, I usually read off the whole discharge summary. If it said to stop the insulin, I am not quite sure why I had the MD order it. Additionally, stated, when a resident comes back on insulin and is a diabetic I would usually ask the Physician if they would like fingerstick levels. During an interview on 10/26/18 at 2:36 PM, the Director of Nursing (DON) stated, the process for taking orders off (transcribing) when a resident is admitted or readmitted to the facility is that the RN would read off the discharge summary to the physician what was recommended, and the nurse would then confirm the orders with the physician and put them in the computer. By reading these orders from Resident #241's discharge summary, I would say the resident should not have been getting the insulin as it says to stop. The error is on the person who took the orders off. In addition, the DON stated, At that time the RN may or may not have asked the MD for glucose levels it would depend on the resident's situation. We would not have necessarily monitored the glucose because she was on [MEDICATION NAME]. During an interview on 10/26/18 at 2:49 PM, the Administrator stated, The DON or myself would do a review of negative outcomes. There is a process for reviewing outcomes. I do not know if we did a review on this issue. The RN Supervisor who took the orders was not released (terminated) because of this situation, she resigned. When asked if this chart was reviewed for the negative outcome of this resident it was stated well we really need to look at the chart to see what is going on. During an interview on 10/26/18 at 3:44 PM, the RN, Regional Director of Quality Assurance stated, When any resident comes back to the facility from the hospital it should be reviewed. It should be reviewed by the nurses and the DON. I would absolutely encourage the physician to do blood glucose monitoring on any diabetic coming back on insulin. The best practice would encourage the MD to monitor the glucose levels, but ultimately the decision is up to physician. During an interview on 10/29/18 at 8:50 AM, the following were present RN/ Administrator, Director of Strategic Planning; RN Regional Director of Quality Assurance; DON; Administrator and Assist Administrator from the facility. The following was stated by the RN/ Administrator, Director of Strategic Planning, The DON had completed an entire chart review with an investigation completed back in (MONTH) (YEAR) when the incident had occurred. A 100% audit of the entire building for all residents with diabetes mellitus was completed in (MONTH) and in-services were done with all the nurses at the time. It was stated that they had signatures from all the nurses from this in-service. The audit was for six weeks, where they found some residents were without fingerstick orders, therefore it was corrected by receiving orders for the fingerstick to be done. The RN Supervisor who transcribed the order incorrectly was disciplined. There was a Quality Improvement Tool completed, so therefore the DON did identify the issue in (MONTH) and corrective actions were taken. The entire building this past weekend was re-educated again regarding glucose monitoring. When asked what they felt went wrong, The DON stated, I think the nurse read the orders on the discharge summary wrong to the doctor. The doctor should have looked at the discharge summary. It is expected the doctors read the discharge summary. The RN/ Administrator, Director of Strategic Planning stated, The nurse must not have seen the discharge summary state do not give the insulin. The doctor should have acknowledged that he reviewed the discharge summary either by signing the copy or writing it in his note on 2/17/18. Review of the facilities investigation revealed on 2/21/18 the DON initiated an investigation secondary to a QI (Quality Improvement) review. The investigation documented that all nurses were educated on the need to monitor blood sugars on any resident admitted to the facility with a [DIAGNOSES REDACTED]. The nurse transcribing the orders was educated and disciplined. A full house review was initiated on all residents with [DIAGNOSES REDACTED]. Review of the In-service Sign in Sheets dated (MONTH) 22, (YEAR) revealed three nurses were educated in February, two nurses in March, five in April, one in (MONTH) and one in September. The in-service addressed the monitoring of residents with a [DIAGNOSES REDACTED]. During an interview on 10/29/18 at 10:01 AM, the RN/ Administrator, Director of Strategic Planning stated, No we did not implement anything for Quality Assurance regarding the doctors reviewing hospital discharge summaries. We do not have any medication errors for the month of (MONTH) (YEAR). We only have two since (MONTH) (YEAR), one in (MONTH) (YEAR) and one in (MONTH) (YEAR). 415.12

Based on interview and record review conducted during an abbreviated survey (Complaint #NY 459) completed on 1/27/17, the facility did not ensure that residents were free of significant medication errors. One (Resident #1) of three residents reviewed for significant medication errors was admitted to the facility and due to an error did not receive any of the prescribed medications from the hospital until 3 days later. The medications not administered included but are not limited to [MEDICAL CONDITION] medications [MEDICATION NAME] and [MEDICATION NAME]; anticoagulant medication ([MEDICATION NAME]-used to prevent blood from clotting); antibiotics and blood pressure medications. The lack of administration of the [MEDICATION NAME] led to sub-therapeutic blood levels and the resident had a [MEDICAL CONDITION]. This resulted in actual harm that is not immediate jeopardy. In addition, the resident did not receive the prescribed dose of [MEDICATION NAME] from admission until 3 days later which resulted in a sub-therapeutic INR (international normalizing ratio-standardized normalized blood coagulating values). The findings are: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 12/24/16 revealed that the resident has moderate cognitive impairment. a) Review of an ACTS (Automated Complaint Tracking System) report dated 10/12/16 submitted by the facility Director of Nursing (DON) revealed that the facility reported that none of Resident #1's meds (medications) were administered on 10/7/16 on the 7:00 AM- 3:00 PM shift. It was determined that the resident did not receive her meds from the time of admission on 10/4/16. The meds were ordered but not delivered to the facility. The pharmacy was immediately called for the meds to be sent. A Registered Nurse (RN) assessment was conducted on the resident and the resident's Physician was updated. The Physician assessed the resident the morning of 10/8/16. Laboratory (lab) studies were drawn and meds were administered per physician's orders [REDACTED].>Review of the facility's Incident Investigation (unsigned and undated) of the medication errors from 10/4/16 through 10/7/16 revealed that the cause of the medication error was due to the Licensed Practical Nurse (LPN) #4 Navigator (responsible for the resident's transition from the hospital to the facility) who entered the physician's orders [REDACTED]. Instead of the admission orders [REDACTED]. The medication error was discovered on 10/7/16 after the resident had a [MEDICAL CONDITION] and a discussion took place (in October), between RN #1 Unit 2 Resident Care Coordinator (RCC), RN #6 and the Social Worker (SW) where it was identified that the resident's orders were waiting to be confirmed. RN #1 RCC immediately confirmed the orders on 10/7/16. Upon further investigation the pharmacy reported that they did not receive the orders until 10/7/16 at 12:47 PM. The investigation revealed that the meds were ordered from pharmacy on 10/7/16 and resumed on 10/7/16. In addition, the LPN #4 did not have access to confirm her own orders contributed to the error including the fact that the medication nurses did not check the medications to be confirmed tab on the computer program. It was also identified that the nightly medication check did not occur on 10/4/16. The resident's new medication orders would not show on the EMAR (electronic medication administration record) because they were waiting to be confirmed. The nurses were re-educated on medication checks, the items available in the Cubex (an automated medication dispensing system), orders pending confirmation, orders in the queue, orders pending signature, medication pass on the dashboard, and medications/ treatments not available. In addition, each unit has a list of medications available in the Cubex. A reminder has been placed on each medication cart to remind nurses to check orders pending confirmation, in the queue and pending signature before each medication pass. Review of the hospital History and Physical exam dated 9/30/16 and printed on 10/4/16 revealed under the section Home Medications the resident was ordered [MEDICAL CONDITION] as follows; -[MEDICATION NAME] 100 milligrams (mg) 4 capsules every other day for even days and 100 mg 5 capsules every other day for odd days. -[MEDICATION NAME] 750 mg 1-tab BID (twice a day). -[MEDICATION NAME] ([MEDICAL CONDITION]/ mood stabilizer medication) 125 mg 1-tab BID. Further review of the Home Medications revealed the following; [MEDICATION NAME] ([MEDICATION NAME]) 1 QD. -Aspirin (pain reducer) 81 mg 1 tablet (tab) QD (daily). -Calcium (supplement) 600 mg 2 tabs QD. -[MEDICATION NAME] (promotes excretion of urine) 80 mg 1 tab QD. -[MEDICATION NAME] (used to improve mental status) 10 mg 1 tab QD. -[MEDICATION NAME] (used to treat low [MEDICAL CONDITION] function)150 micrograms (mcg) 1 tab QD. -[MEDICATION NAME] (used to treat moderate to severe dementia of the Alzheimer's type) 10 mg 1-tab BID. -[MEDICATION NAME] (used to treat high blood pressure) 25 mg 1-tab BID. -Potassium Chloride (used to treat low blood potassium) 10 mEq (millequivalents) 1 tab QD. Vitamin B 12 (supplement) 1000 mcg QD. Vitamin D (supplement) 2000 units QD. Review of the hospital Medication Administration Report (MAR) dated 10/4/16 revealed the same medications and doses as the above mentioned Home Medications plus the addition of the following 3 medications: [REDACTED] -[MEDICATION NAME] (antibiotic) 200 mg 1 tab BID give from 10/4/16 through 10/11/16. -[MEDICATION NAME] (used to treat constipation) 20 grams (gm) BID. -Tylenol (pain reliever/fever reducer) 650 mg every 4 hours as needed. Review of a Nursing Progress Note dated 10/7/17 at 3:05 PM written by RN #1 revealed that at approximately 11:45 AM the resident had a [MEDICAL CONDITION]. The resident was lying on her back on the bathroom floor. The CNA (Certified Nurse Aide) had lowered the resident when she began to have [MEDICAL CONDITION] activity. According to the CNA the resident lurched forward and began convulsing. The CNA reported that the [MEDICAL CONDITION] activity lasted approximately 30 seconds. RN #1 documented that when she arrived the resident was in the postictal phase. (An epileptic [MEDICAL CONDITION] also called an ictus so the postictal state refers to any dysfunction that occurs after a [MEDICAL CONDITION] while the brain is recovering from the [MEDICAL CONDITION]). The resident's mouth was clenched, and she was unable to make eye contact but would look around when her name was called. Within 2 minutes the resident started to open her mouth and upon assessment, no injury was noted to her tongue or any other part of oral cavity. After a few more minutes the resident was able to talk in short sentences and the resident returned to baseline. Therapeutic drug levels of [MEDICATION NAME] and [MEDICATION NAME] were drawn on admission and were within normal limits. The resident's health care agent and physician were notified. There were no new orders at the time. Review of the facility EMAR revealed that the following 2 medications were not started until 10/7/16 (3 days after admission) as follows: -[MEDICATION NAME] 4 mg was given on 10/7/16 at 9:00 PM. -[MEDICATION NAME] 25 mg was given on 10/7/16 at 9:00 PM. Review of the facility EMAR for October 2016 revealed that the following medications were not started until 10/8/16 (4 days after admission): -Aspirin 81 mg 1-tab QD given on 10/8/16 at 9:00 AM (per hospital MAR indicated [REDACTED].) -Calcium 600 mg 2-tabs QD given on 10/8/16 at 9:00 AM (per hospital MAR indicated [REDACTED].) -[MEDICATION NAME] 125 mg 1-tab BID, given on 10/8/16 at 9:00 AM (per hospital MAR indicated [REDACTED].) -[MEDICATION NAME] 10 mg 1-tab QD given on 10/8/16 at 9:00 AM (Per hospital MAR indicated [REDACTED]. -[MEDICATION NAME] 80 mg 1-tab QD given on 10/8/16 at 9:00 AM (Per hospital MAR indicated [REDACTED].) -[MEDICATION NAME] 750 mg 1-tab QD, given on 10/8/16 at 9:00 AM. (Per the hospital MAR indicated [REDACTED].) -[MEDICATION NAME] 150 mcg 1-tab QD, given on 10/8/16 at 9:00 AM. (Per the hospital MAR indicated [REDACTED].) -[MEDICATION NAME] 10 mg 1-tab BID, given on 10/8/16 at 9:00 AM (Per the hospital MAR indicated [REDACTED] -[MEDICATION NAME] 100 mg 4 capsules every other day for even days and 100 mg 5 capsules every other day for odd days. ([MEDICATION NAME] 400 mg was given on 10/8/16 at 9:00 AM (Per review of the hospital MAR indicated [REDACTED].) -Potassium Chloride 10 mEq 1-tab QD, given on 10/8/16 at 9:00 AM (Per the hospital MAR Potassium Chloride 10 mEq was last given on 10/4/16 at 10:31 AM.) -Vitamin B 12 1000 mcg QD, given on 10/8/16 at 9 AM (Per hospital MAR indicated [REDACTED].) -Vitamin D 2000 units QD, given on 10/8/16 at 9 AM (Per hospital MAR indicated [REDACTED].) Review of the October 2016 Medication Review Report (MRR-computerized physician's orders [REDACTED]. -[MEDICATION NAME] 200 mg 1 tab BID to be given from 10/4/16 through 10/11/16 (Per hospital MAR indicated [REDACTED].) -[MEDICATION NAME] 20 gm BID (Per hospital MAR indicated [REDACTED].) Review of the resident's 2016 Laboratory Services forms revealed the following: -10/5 WBC (white blood cell) 9.7 (normal range is 4.0 - 11.0- a high count can indicate an infection.) -10/8 WBC 16.9 high. The resident did not receive the antibiotic, [MEDICATION NAME], from the time of admission on 10/4. -10/10 WBC 13.7 high. Review of physician's orders [REDACTED]. -10/5 [MEDICATION NAME] level 15.0 (therapeutic range 10.0 - 20.0); [MEDICATION NAME] level 23.1 (therapeutic range 6.0 - 46.0). -10/8 [MEDICATION NAME] level 5.2 low (resident did not receive the [MEDICATION NAME] from admission through 10/8). Review of the October 2016 MRR revealed an order to administer [MEDICATION NAME] 500 mg one time tonight. -10/13 [MEDICATION NAME] level 5.5 low. Review of the October 2016 MRR revealed an order dated 10/13 to give [MEDICATION NAME] 200 mg one time only for [MEDICATION NAME] level of 5.5 for one day now; and a second order dated 10/13 to administer 3 capsules of [MEDICATION NAME] (300mg) by mouth one time only for [MEDICAL CONDITION] until 10/13. -10/17 [MEDICATION NAME] level 5.4 low. On the lab sheet revealed A physician's orders [REDACTED]. Review of the October 2016 MRR revealed that this order was documented. -10/21 [MEDICATION NAME] level 6.1 low. (Review of the Nursing Progress Notes revealed that on 10/21 the resident was sent to the hospital for an acute [MEDICAL CONDITION]- no further [MEDICATION NAME] levels or medication adjustments were done at the facility.) During an interview on 1/4/17 at approximately 9:30 AM RN #2 Corporate QA (Quality Assurance) nurse stated that LPN #4, offered to enter the resident's Admission physician's orders [REDACTED].#2 stated that this was not normally part of the LPN #4's job. LPN #4 entered the orders and thought everything was OK and did not realize that she did not have the proper computer access to confirm the physician's orders [REDACTED].#2 stated that since the orders were not confirmed they did not get sent to the pharmacy but instead were sent to a pending queue in the computer system. RN #2 stated that the LPNs that were passing medications from 10/4/16 through 10/7/17 were supposed to check the medication pending queue each shift for any un-confirmed orders prior to passing medications, which they did not do. RN #2 stated that during medication passes from 10/4/16 through 10/7/16 the resident's EMAR would not show on the computer screen since the orders were not confirmed, a blank screen would show. RN #2 stated that the nurses on the 11:00 PM to 7:00 AM shift are supposed to do medication checks which they did not do. RN #2 stated that the RN RCC is supposed to ensure that all admission orders [REDACTED]. RN #2 stated that the error was discovered by the SW on 10/7/16 after the resident had a [MEDICAL CONDITION]. The SW was entering admission information into the computer and noticed that the admission orders [REDACTED]. RN #2 stated that since this incident had occurred there has been a 100 percent audit of all nurses in the facility to ensure they have access to confirm their own orders. In addition, the pharmacy will now receive emails notifying them of all new admissions to the facility. If the pharmacy has not received orders on a new admission they are to call the facility to check the status prior to the late delivery leaving the pharmacy. RN #2 stated that all nurses have been re-educated on medication procedures, medication checks and medications available in the Cubex and computer medication procedures. RN #2 stated that in addition, the resident was to be on [MEDICATION NAME] from 10/4/16 through 10/11/16 and that [MEDICATION NAME] was not ordered at the facility. During interview on 1/4/16 RN #1 RCC stated that LPN #4 entered the resident's admission orders [REDACTED] queue. LPN #4 thought the orders were sent to pharmacy on 10/4/16. RN #1 RCC stated that she tries to check the pending orders queue everyday but did not do it that week because it was very busy on the unit. She stated that none of the medication nurses informed her during that time frame that the resident had no EMARs or orders in the pending queue. RN #1 RCC stated that since this medication error, the RNs must complete an admission checklist on all new admissions which includes checking any orders in the pending queue. RN #1 RCC stated that the medication error was discovered on 10/7/16 after the resident had a [MEDICAL CONDITION] and the SW found that the admission orders [REDACTED] During an interview on 1/4/17 at approximately 2:45 PM, the Physician stated he was informed of the medication error that Resident #1 missed approximately 3 days of all her medications upon admission to the facility. He stated that the failure of the resident to receive her [MEDICAL CONDITION] medication including [MEDICATION NAME] resulted in the low [MEDICATION NAME] level which caused the resident to have a [MEDICAL CONDITION] on 10/7/16. The Physician also stated that the lack of the antibiotic [MEDICATION NAME] could have caused the resident's WBC to elevate leading to the order for [MEDICATION NAME] (antibiotic) on 10/10/16. During an interview on 1/5/17 at approximately 10:15 AM, the SW stated that when she does an Admission Assessment on a resident she reviews all discharge paperwork sent from the hospital to ensure that all mediations are carried over to the facility's orders. After reviewing Resident #1's admission paperwork she then checked the facility's computer program for electronic medical records and did not find any of the resident's medications in the computer. The SW stated that upon arriving on Resident #1's unit on 10/7/16 to check into the issue she was informed that the resident had just had a [MEDICAL CONDITION]. The SW stated that she spoke to the Nurse Supervisor about the issue and the investigation started. During an interview on 1/27/17 at approximately 1:30 PM, LPN #3 stated that she now checks the medication pending queue at the beginning or her shift prior to passing medications. LPN #3 stated that all nursing staff have been re-educated to perform this task since the medication error involving Resident #1. LPN #3 stated that currently if a resident has no medications in the cart, she will call the Physician for advice and contact the pharmacy to inquire about the medications. b) Further review of the 2016 Laboratory Services forms revealed the following: -10/5 INR 1.9 (therapeutic 2.0 - 3.0). -10/8 INR 1.2. Review of the October 2016 MRR revealed that on 10/8 [MEDICATION NAME] 6 mg was ordered one time for an INR or 1.2. 10/13 INR level was 2.4. During an interview on 1/4/17 at approximately 2:45 PM, the Physician stated that the lack of [MEDICATION NAME] administration to Resident #1 most likely caused the sub-therapeutic INR levels which necessitated [MEDICATION NAME] adjustments. Review of the facility's corrective actions implemented in October 2016 to address the identified issues were as follows; -Re-education of all nursing staff on procedures for the correct use of the facility's Point & Click computer program for electronic medical records. -Re-education of all nursing staff on managing new admissions, reviewing new admission charts and the completion of an admission checklist, review of medication administration, the need to contact pharmacy and the physician if medications are not available at their scheduled times, review of duties of the 11:00 PM to - 7:00 AM shift nursing duties related to medication responsibilities, the need for all nursing staff to check orders pending confirmation and orders pending signature prior to each medication pass. -All nursing staff has been re-educated on the medications available in the Cubex. -All nursing staff have been audited to ensure they have the proper computer access to confirm physician orders. 415.12 (m)(2)

Based on interview and record review conducted during a Complaint investigation (Complaint #NY 334) during the Standard survey completed on [DATE], the facility did not provide each resident with sufficient fluid intake to maintain proper hydration and health. Two (Resident #219,136) of three residents reviewed for hydration had issues involving a lack of accurate assessment and provision of sufficient fluids. Resident #219 with a Peg tube (percutaneous endoscopic gastrostomy - feeding tube inserted directly into the stomach) and NPO (nothing by mouth) that had loose stools, elevated temperature, and urinary tract infection [MEDICAL CONDITION] was not provided adequate fluids to meet the resident's needs that resulted in hospitalization for dehydration and [MEDICAL CONDITION]. This resulted in actual harm that is not immediate jeopardy. Resident #136 with a tube feed and NPO was not provided adequate fluids to meet the required needs from [DATE] through [DATE] that resulted in hospitalization for dehydration and [MEDICAL CONDITION] (elevated sodium level). This resulted in no actual harm with potential for minimal harm that is not immediate jeopardy. The findings are: 1. Resident #219 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated [DATE] revealed the resident is severely impaired for decision making. Review of a physician's orders [REDACTED]. Review of an Enteral Feed Nutritional assessment dated [DATE] by the Registered Dietitian (RD) revealed the resident received [MEDICATION NAME] 1.5 give 50 milliliters (ml) per hour for 15 hours. Flush the feeding tube with 150 ml of free water every (q) 4 hours, flush 50 ml pre/ post med pass equal to 100 ml. Total volume of feed and flush equals 1780 ml and 1615 ml of free fluid (free water). The resident is NPO. The resident's weight was 183 pounds (#) in kilograms (kg) equals 83 kg, Ideal Body Weight (IBW) was ,[DATE]#, Adjusted body weight (Adj bw) ,[DATE]#. Review of an undated facility policy entitled Estimated Fluid Needs revealed four methods of estimating a resident's fluid needs. Water requirements in adults range from ,[DATE] ml per day with additional needs ranging from 500 ml/ day if the resident has a fever, diarrhea, draining wounds, vomiting, or excessive perspiration. Total daily fluid requirements for residents not needing fluid restriction can be estimated using the following methods: -Method 1 - This method is based on energy intake in calories regardless of age and weight. This method may be used for residents receiving tube feeding 1ml/kcal (calorie). -Method 2 - This method is based on actual body weight in kg and age. This method may be used for residents within their IBW. -Method 3 - This method may be used for residents who are overweight. 1500 ml for the first 20 kg +15 ml for every kg over 20 kg. -Method 4 - This method adjusts for extremes in body weight. 100 ml fluid per kg for the first 10 kg actual body weight. 50 ml fluid per kg for the next 10 kg actual body weight. 15 ml fluid per kg for the remaining kg actual body weight. Further review of the Enteral assessment dated [DATE] revealed the RD assessed the resident's fluid needs based on Adj bw of 58 kg. Further review of the facility Estimated Fluid Needs policy revealed the resident fluid needs should have been assessed on actual body weight of 183.1# (83 kg) which estimates the resident's fluid needs at 2445 ml. Review of a Progress Note dated [DATE] revealed the resident was having excessive loose stools. Review of laboratory (lab) results dated [DATE] revealed BUN (Blood Urea Nitrogen-blood test to determine kidney function and hydration status) 46 high (normal ,[DATE]), sodium 151 high (normal 133- 145). Review of a Progress Note dated [DATE] revealed the resident had a temperature of 102 degrees (rectally). Review of a physician's orders [REDACTED]. Review of the Medication, Treatment and Task Administration Record Report dated ,[DATE] revealed the free water was administered as ordered on [DATE]. Fifty ml per hour times 15 hours to equal 750 ml, 150 ml q 4 hours to equal 900 ml, and 50 ml before and after med pass to equal 100 ml totaling 1750 ml. Review of a Progress Note dated [DATE] revealed Health Care Proxy notified of presumptive urinalysis, culture and sensitivity, dehydration, and treatment. Review of a Progress Note dated [DATE] revealed family requesting transfer to hospital. Review of the History and Physical dated [DATE] revealed the resident presented to the Emergency Department (ED) with presumed altered mental status, elevated temperature of 99.4, and [MEDICAL CONDITION](rapid heart rate) of 179 (average 80), pulse 108 (average 80), blood pressure ,[DATE] (BP-normal ,[DATE]). She has dry mucous membranes and skin is dry with poor skin turgor. Sodium level was high at 151, BUN 40 high. The patient was very dehydrated with free water deficit calculated to be 4.3 liters (L). Patient received 3 L of Normal Saline (NS) in the ED for fluid resuscitation. The resident was later placed on Comfort Care and expired [DATE]. During an interview on [DATE] at 1:30 PM, the RD stated, I wasn't aware of the facility policy to base fluid needs on resident's actual body weight. Additionally, the RD stated, I wasn't aware of the abnormal labs, or that the resident had loose stools, a temperature, and UTI. During an interview on [DATE] at 1:40 PM the Consultant Registered Nurse stated, Understanding the resident's fluid needs should be assessed using the resident's actual body weight and not the adjusted body weight. During an interview on [DATE] at 4:00 PM, the Physician stated, We would be dealing with someone who will end up very dehydrated and very constipated with that kind of discrepancy in fluid requirement and what they're actually receiving. 2. Resident #136 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is severely cognitively impaired, is rarely understood and rarely understands. Review of the Resident Care Plan Report dated [DATE] revealed the resident has an alteration in hydration related to a moderate risk for dehydration. The goal is that the resident will be adequately hydrated without clinical signs of dehydration. The approaches include to provide tube feeding and flushes per the physician's orders [REDACTED].>Review of the Enteral Feed Nutritional assessment dated [DATE] revealed the resident's height is 64 inches, the resident's actual weight is 171.8# or 78 kg, and her ideal body weight (IBW) is 120# to 132#. The current weight goal is for a gradual weight loss of 0.5 to 1 #/month. The resident's estimated nutritional needs based on adjusted weight of 65 kg are as follows; Kcals 1300 to 1625, protein 65 to 78 grams, and requires 1925 ml to 2310 ml of fluid per day. In addition, the Enteral Feed Nutritional assessment dated [DATE] revealed Tube Feed Order: [MEDICATION NAME] AC goal rate 60 ml for 18 hours. Flush Order: Free waster flush 600 ml in 24 hours, flush 50 ml before and after each med pass to equal 400 ml. Feed Provides: 1292 Kcals, Protein: 65 grams, Free Water: 886 ml. Total Free Fluids: 1986 ml and Total volume of feeds and flushes: 2180 ml. Review of Nutritional notes dated [DATE] revealed that the resident is tolerating tube feed and flushes well. The current feeding is adequate to meet the estimated needs of the resident. Estimated need for calories is based on Adjusted weight times ,[DATE] cal/kilograms. The goal is to continue a gradual weight loss. No difficulties noted with bowels. Review of the physician's orders [REDACTED]. Review of Medication Administration Records (MARs) dated [DATE] through [DATE] revealed the resident was administered medications via the Peg tube at 5:30 AM, 9:00 AM, 9:30 AM, 1:30 PM, 9:00 PM and 9:30 PM. Further review of the MAR indicated [REDACTED]. Review of the Treatment Administration Records (TARs) dated [DATE] through [DATE] revealed a free water flush of 175 ml was to be administered through the Peg tube every six hours for hydration. Further review of the MAR indicated [REDACTED]. Review of the Hospital Discharge Summary dated [DATE] revealed the resident was sent to the emergency room (ER) for an evaluation of a choking episode after successfully having a Peg tube replacement. In the ER the resident was found to be hypernatremic (high sodium level) with a sodium level of 159 high likely secondary to volume depletion. Free water flushes were increased to 200 ml every four hours. During an interview on [DATE] at 1:04 PM the Diet Technician (DT) #1 stated that the resident's caloric needs were based on the resident's adjusted weight because of the goal for a gradual weight loss, but her fluid needs are based on her actual weight. DT #1 stated that she only reviews the TAR at the time of an assessment or if the resident was having any kind of issues. DT #1 reviewed the progress notes and stated to the best of her knowledge the resident was not experiencing any fevers, constipation or loose stools and had been tolerating her feeds, and flushes. DT #1 stated that based on the documentation she would have to assume that the resident was not receiving her required flushes as ordered. DT #1 stated she became aware of this when the resident returned from the hospital. During an interview on [DATE] at 1:48 PM the Registered Nurse (RN) #1 Unit Coordinator stated that if the water flushes were not documented that it means they probably were not done. The nurses are expected to flush the PEG tube as ordered and accurately document the water flushes as being completed. During a phone interview on [DATE] at approximately 3:15 PM the Physician's Assistant (PA) stated she had some concerns with the amount of fluid the resident was receiving after the resident was readmitted to the facility and they are monitoring her lab work. The PA stated that she was not aware of the blanks in the TARs and that the resident may not have been receiving the water flushes as ordered. The PA stated that the nurses are expected to accurately document the water flushes and that, This could have played a part in her [MEDICAL CONDITION]. 415.12 (j)