Every finding on record at Kirkhaven

Based on observations, interviews, and record review, the facility did not ensure allegations of abuse were responded to timely, thoroughly investigated, and residents were protected from potential abuse for two (2) of three (3) residents reviewed (Resident #1 and Resident #2). Specifically, staff failed to initiate a timely response following allegations or observations of potential abuse, failed to immediately remove involved staff from resident care, and failed to conduct a thorough investigation, as available video surveillance was not reviewed as part of the initial investigation and was only reviewed after surveyor inquiry.The findings include:The facility policy, Abuse Policy, last reviewed 09/05/2024, defined an alleged abuse violation as a situation or occurrence observed or reported by staff, resident, or other individual which has not yet been investigated and, if verified, could demonstrate noncompliance related to mistreatment, neglect, or abuse. The facility will immediately address all incidents of staff-to-resident altercation or assault and provide a safe environment for residents, staff, and visitors. If an employee is suspected of abuse, he or she must be sent off duty until an investigation is complete.1. Resident #2 had diagnoses including anxiety, hypertension, and chronic pain. The Brief Interview for Mental Status (cognitive assessment tool) dated 02/20/2026 documented Resident #2 was cognitively intact.Review of the facility investigation dated 02/20/2026 documented an allegation Resident #2 reported Licensed Practical Nurse #2 placed hands in their face, pushed their head into a pillow, and cut their hair.Review of additional investigation records included: A statement from Resident #2 dated 02/20/2026 documented a staff member placed hands in front of their face and pushed their face and head into a pillow. Resident #2 reported the incident to Licensed Practical Nurse #3, who stated the staff member would not return to the room; however, the staff member re-entered the room and continued to provide care. Resident #2 identified the staff member as Licensed Practical Nurse #2 using photographs and was observed to be upset and anxious during the identification. A statement from Licensed Practical Nurse #3 documented Resident #2 reported concerns during the night shift at 2:30 AM on 02/20/2026. The allegation was not reported to leadership at that time.Review of facility timecards dated 02/19/2026 to 02/20/2026 revealed Licensed Practical Nurse #2 started their shift on 02/19/2026 at 06:56 PM and ended their shift on 02/20/2026 at 07:35 AM.During an interview on 02/25/2026 at 9:58 AM, Resident #2 stated approximately one (1) week prior, a nurse had put their hands in their face, cut their hair in the shower, and they reported the incident.During a telephone interview on 03/02/2026 at 3:49 PM, Licensed Practical Nurse #3 stated Resident #2 reported Licensed Practical Nurse #2 had placed hands in their face and spoke in a derogatory manner. Licensed Practical Nurse #3 stated Resident #2 did not say they were hit, the allegation was not reported to a supervisor and acknowledged it should have been reported. Licensed Practical Nurse #3 stated Licensed Practical Nurse #2 gave Resident #2 a shower after the allegation was voiced and observed Resident #2's hair appeared shorter after the shower.During an interview on 03/18/2026 at 12:02 PM, the Director of Nursing stated when a staff member is made aware of potential abuse, the allegation should be reported immediately and the staff member should be removed from resident care pending investigation.Review of investigative materials revealed video surveillance was available for review at the time of the incident; however, the video was not reviewed as part of the initial investigation and was only reviewed on 02/25/2026 after surveyor inquiry, approximately five (5) days after the incident.During an interview on 02/25/2026 at 1:25 PM, the Administrator stated video footage was reviewed at an accelerated speed and acknowledged not all footage was reviewed.During an interview on 02/26/2026 at 9:29 AM, the Director of Nursing stated video surveillance is not always reviewed if there is a witness account.2. Resident #1 had diagnoses including dementia, cerebral infarct (stroke), and chronic obstructive pulmonary disease (COPD). The Minimum Data Set (a resident assessment tool) dated 01/02/2026 documented Resident #1 had severe cognitive impairment.Review of an Incident Report dated 02/23/2026 at 2:15 AM documented Certified Nursing Assistant #1 grabbed Resident #1 and pushed the resident backward into a chair, resulting in an approximately three (3) centimeter laceration to the left forearm.Additional review of investigative records and interviews revealed the incident occurred between approximately 1:30 AM and 1:45 AM on 02/23/2026; however, Certified Nursing Assistant #1 was not immediately removed from resident care following the witnessed allegation of abuse.Review of facility timecards dated 02/22/2026 to 02/23/2026 revealed Certified Nursing Assistant #1 started their shift on 02/22/2026 at 11:19 PM and punched out on 02/23/2026 at 3:22 AM.During an observation and interview on 02/25/2026 at 9:23 AM, Resident #1 was in bed and stated staff took good care of them and no one had ever physically hurt or pushed them.During a telephone interview on 02/25/2026 at 4:23 PM, Registered Nurse Manager #1 stated they observed Certified Nursing Assistant #1 grab Resident #1 by the arms and push the resident into a chair, resulting in injury. Registered Nurse Manager #1 stated the staff member remained on the unit and continued to provide care after the incident until the Director of Nursing arrived at approximately 3:00 AM, found Certified Nursing Assistant #1 providing care in another resident's room, and sent them home. Registered Nurse Manager #1 acknowledged Certified Nursing Assistant #1 should have been removed immediately.During a telephone interview on 02/26/2026 at 10:29 AM, Certified Nursing Assistant #1 stated after the incident they remained in the same area and provided care to another resident.During an interview on 02/26/2026 at 9:29 AM, the Director of Nursing stated staff involved in potential abuse should be removed from resident care immediately and acknowledged Certified Nursing Assistant #1 should have been sent home at the time of the incident.Review of investigative materials revealed video surveillance was not reviewed as part of the initial investigation. Documentation indicated video playback was not completed until 02/27/2026 due to reported technical issues, which was after surveyor inquiry. Video review findings indicated Certified Nursing Assistant #1 assisted Resident #1 to a chair; however, the initial investigation did not include review of available video evidence.During an interview on 02/26/2026 at 10:22 AM, the Administrator stated staff involved in potential abuse should be removed immediately and acknowledged the expectation Certified Nursing Assistant #1 would have been removed at the time of the incident.10 New York State Code Rules and Regulations 415.4(b)(1)(i), (3)

Based on observations, interviews, and record review, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for one (1) of eight (8) residents reviewed (Resident #112). Specifically, Resident #112 did not receive scheduled hygiene care, including shaving and showering, on multiple occasions, and the facility did not ensure care was completed, documented, or reattempted when missed.The findings include: The facility policy Standards of Care at Kirkhaven, updated 08/20/2020, included baths or showers are given per resident preference and the Certified Nursing Assistant is responsible for informing the nurse the resident is receiving a bath or shower per the schedule. Documentation included the use of POC (Point of Care, the software used by Certified Nursing Assistants to show what work the Certified Nursing Assistants have completed). Refusals of care which included removal of facial hair are to be reported to the primary Licensed Practical Nurse so it can be documented in the resident's medical record. Resident #112 had diagnoses including vascular dementia (dementia caused by reduced blood flow to the brain), heart disease, and diabetes. The Minimum Data Set (a resident assessment tool) dated 12/15/2025 documented the resident had moderately impaired cognition, required staff assistance with showering and personal hygiene, and had no rejection of care. During an observation and interview on 03/10/2026 at 10:07 AM, Resident #112 had several days of beard growth and stated they were due for a shave and shower on Mondays. Review of Resident #112's Comprehensive Care Plan, revised 01/06/2026, revealed the resident had refusal of treatment related to cognitive impairment and lack of knowledge, was at risk for decline in activities of daily living due to muscle weakness, and preferred weekly showers on the evening shift with removal of facial hair weekly with an electric razor. Interventions included, but were not limited to, documenting discussions regarding refusals and providing showers and personal hygiene with the assistance of one (1) staff member. Review of Resident #112's Kardex (care plan used by certified nursing assistants to guide daily care) effective as of 03/12/2026 included preference for weekly showers on Monday evenings and removal of facial hair weekly with an electric razor requiring the assistance of one (1) staff member. Review of a Personal Hygiene Support Provided report (a Point of Care documentation report used to record hygiene care including combing hair, brushing teeth, shaving, applying makeup, washing and drying face and hands, excluding baths and showers) for the period 02/07/2026 through 03/17/2026 revealed no documentation of hygiene care on 03/02/2026, 03/09/2026, or 03/16/2026. Review of the Treatment Administration Record on 03/17/2026 revealed no documentation of showers provided for Resident #112 from 03/01/2026 through 03/17/2026. Additional record review included no documented evidence nursing staff identified missed hygiene care or implemented follow-up to ensure completion. There was no documentation in the electronic health record, including Point of Care documentation or nursing progress notes, indicating hygiene care was provided, refused, or reattempted on the identified dates. No documentation was provided upon request indicating Resident #112 refused showers, shaving, or other hygiene care from 02/07/2026 through 03/17/2026. During an observation and interview on 03/11/2026 at 10:07 AM, Resident #112 had one-quarter inch to one-third inch length facial hair across the entire face and stated they had not received a shower. During an interview on 03/18/2026 at 11:53 AM, Certified Nursing Assistant #7 stated a resident's care needs were determined by checking the Kardex and if they were busy and unable to offer a shower, they would offer a bed bath and shave and stay past their shift to provide care if the resident did not receive care. Certified Nursing Assistant #7 stated they did not know where in the health record shaving care was documented. During an interview on 03/18/2026 at 11:38 AM, Licensed Practical Nurse #8 stated a resident's care needs were determined by checking the care plan, Kardex, Medication Administration Record, and discharge summaries from the hospital. Licensed Practical Nurse #8 stated the expectation from Certified Nursing Assistants was to reattempt care if unable to provide it and to notify the nurse if a resident refused care. Licensed Practical Nurse #8 stated if they had time, they would attempt to shave the resident. During an interview on 03/18/2026 at 12:06 PM, Registered Nurse Manager #2 stated a resident's care needs were determined by checking Plan of Care (software used by Certified Nursing Assistants to document care provided to residents) and Plan of Care allowed nursing staff to view care needs. Registered Nurse Manager #2 stated the expectation for nursing staff was to notify the Nurse Manager if care could not be provided and to document in a progress note. Registered Nurse Manager #2 stated they would provide care if time allowed or ask the next shift to provide care. During an interview on 03/18/2026 at 12:57 PM, the Director of Nursing stated the expectation for a resident who did not receive a shave was for nursing staff to reattempt on the next shift or offer and reattempt the next day. 10 New York Codes Rules and Regulations 415.12(a)(3)

Based on observations, interviews, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible and did not ensure adequate supervision and implementation of individualized interventions to prevent accidents for one (1) of eight (8) residents reviewed for accidents (Resident #149) and across three (3) of five (5) resident use floors (third (3rd), fourth (4th), and fifth (5th) floors). Specifically, (1) hot liquids at temperatures capable of causing burns were accessible to residents, including residents with cognitive impairment requiring supervision, and (2) Resident #149, who had severely impaired cognition and was identified as high risk for falls, was not provided supervision and sustained a fall with a head injury requiring hospital evaluation.The findings include:Issue One (1):Resident #149 had diagnoses including Alzheimer's disease, epilepsy, and hypertension. The Minimum Data Set (a resident assessment tool) dated 12/24/2025 revealed Resident #149 had severely impaired cognition and required supervision or touching assistance for walking.The Comprehensive Care Plan last revised 02/17/2026 included Resident #149 was at high risk for falls related to dementia and impaired mobility with interventions including follow facility fall protocol, staff awareness of resident location in common areas, assist to the floor if out of bed to prevent injury, supervision with a four (4) wheeled walker, anticipate and meet needs, and ensure call bell was within reach when in room.The Kardex (care instructions used by certified nursing assistants) effective as of 03/18/2026 included follow facility fall protocol.Review of an Incident and Accident Report and Incident Report Note dated 01/02/2026, Registered Nurse #1 documented Resident #149 was found sitting on the floor in the doorway between the front and back lounge at approximately 11:00 PM. The resident was sitting upright leaning against the edge of the open lounge door. Assessment included a large purple hematoma (pooling of blood due to larger blood vessel leakage) on the left forehead measuring approximately four (4) centimeters by two (2) centimeters by two (2) centimeters raised area with a small one (1) centimeter abrasion in the center. The left kneecap was reddened with complaints of soreness. The on-call provider was notified and ordered transfer to the emergency department for further evaluation and possible imaging.In a Witness Account of Accident/Incident dated 01/02/2026, Licensed Practical Nurse #14 documented they came out of the nurse office and found Resident #149 sitting on their bottom with their back against the door frame and had a large hematoma on the left side of their forehead. Licensed Practical Nurse #14 documented the only care they provided to Resident #149 prior to the incident was medication assistance and they did not provide toileting or ambulation assistance prior to the fall.The Incident and Accident Report identified predisposing factors including ambulating without assistance and non-compliance with safety recommendations. There was no documentation identifying staff supervision, monitoring, or resident location prior to the fall.The Incident Report Note included an intervention to complete routine safety checks. This intervention was not incorporated into the Comprehensive Care Plan and there was no documented evidence routine safety checks were implemented following the incident or upon return from the hospital.There were no additional staff/witness statements documented, including Certified Nursing Assistant staff, and no documented timeline of events identifying when Resident #149 was last observed prior to the fall.During an interview on 03/18/2026 at 12:02 PM, the Director of Nursing stated the facility completed their investigation, had not suspected abuse, and determined the care plan was followed. Issue Two (2):Observations on 03/09/2026 at 9:30 AM included the surveyor checking the [NAME] thermocouple for proper calibration in the main kitchen using the ice-point method (placing a thermometer into a container filled with a mix of crushed ice and clean water, waiting for stabilization, and adjusting the reading to 32 degrees Fahrenheit). After allowing the ice and water mixture to settle, the [NAME] thermocouple displayed 32.3 degrees Fahrenheit.Observations on 03/09/2026 at 10:35 AM included a coffee and hot water dispensing machine on the counter near the kitchenette in the third (3rd) floor dining room. When the buttons for hot water and coffee were pressed, hot liquids were dispensed measuring 143.6 degrees Fahrenheit and 142.3 degrees Fahrenheit, respectively. The dispensing machine was located at a level and in an area accessible to any ambulatory resident.Observations on 03/09/2026 at 12:10 PM included a coffee and hot water dispensing machine on the counter near the kitchenette in the fifth (5th) floor dining room. When the buttons for hot water and coffee were pressed, hot liquids were dispensed measuring 167.4 degrees Fahrenheit and 161.7 degrees Fahrenheit, respectively. The dispensing machine was located at a level and in an area accessible to any ambulatory resident. There were ten (10) residents seated at tables in the dining room, one (1) resident approximately four (4) feet from the dispensing machine, and another resident walking nearby. The fifth (5th) floor is a secured unit where residents have cognitive impairment and wandering behaviors requiring supervision.Observations on 03/09/2026 at 12:15 PM included a coffee and hot water dispensing machine on the counter near the kitchenette in the fourth (4th) floor dining room. When the buttons for hot water and coffee were pressed, hot liquids were dispensed measuring 166 degrees Fahrenheit and 162 degrees Fahrenheit, respectively. The dispensing machine was located at a level and in an area accessible to any ambulatory resident.Observations on 03/09/2026 at 3:25 PM included a resident on the fifth (5th) floor was seated at a table directly adjacent to the coffee and hot water dispenser and there were no staff in the immediate area.During an interview on 03/09/2026 at 12:15 PM, a food service worker stated residents who are able can get their own coffee.During an interview on 03/09/2026 at 3:09 PM, the Administrator stated there were no incident and action reports within the last 6 months related to burns.During an interview on 03/09/2026 at 3:28 PM, Registered Nurse Manager #1 stated the fifth (5th) floor is a locked behavioral unit with most residents having dementia and at least half of the residents have wandering behaviors. Registered Nurse Manager #1 stated there may be a lockout feature on the coffee and hot water dispenser.During an interview on 03/12/2026 at 5:06 PM, Licensed Practical Nurse Manager #1 stated there are five (5) residents on the fourth (4th) floor with wandering behaviors.10 New York Codes Rules and Regulations 415.12(h) 10 New York Codes Rules and Regulations 415.29(a)(1)

Based on observations, interviews, and record review, the facility did not ensure sufficient staffing to provide nursing services to attain or maintain the highest practical physical, mental, and psychosocial well-being of residents for four (4) of four (4) resident units reviewed. Specifically, staffing levels were insufficient to meet resident needs, resulting in delayed toileting assistance, missed or delayed bathing and grooming, failure to provide timely incontinence care, delayed response to resident call systems, and inability to complete required nursing tasks.The findings include: For additional information, see the Centers for Medicare/Medicaid Services Form 2567: F550 - Resident Rights/Exercise of Rights, F561 - Self-determination, F677 - Activities of Daily Living Care for Dependent Residents, F689 - Free from Accident Hazards/Supervision/Devices, F761 - Label/Store Drugs & Biologicals, F882 - Infection Preventionist Qualifications/Role.Review of the Facility assessment dated [DATE] documented the facility was licensed for 147 beds with an average daily census of 136 residents. The staffing plan included two (2) licensed practical medication nurses and four (4) certified nursing assistants on each unit during day and evening shifts, and one (1) licensed practical medication nurse and two (2) certified nursing assistants on each unit during the night shift. Additionally, an unspecified number of registered nurses and licensed practical nurse managers were noted, as well as an unspecified number of registered nurse supervisors during evenings and weekends. Two (2) house managers were assigned to the day shift and would adjust to work open shifts as needed.The undated Emergency Staffing List included department heads and staff with phone numbers and instructed all department heads to call their staff in to assist and the Director of Nursing to call in unit managers to assist.During the entrance conference on 03/09/2026 at 9:21 AM, the Administrator stated the facility census was 131 residents. Review of resident information including Minimum Data Set assessments for residents on the Second (2nd), Third (3rd), Fourth (4th), and Fifth (5th) Floor units identified residents who required assistance with activities of daily living, including bathing, grooming, toileting, transfers requiring two (2) staff assist with a mechanical lift (a device used to transfer residents), and residents with cognitive impairment requiring supervision.Review of facility records, including nursing staffing sheets (dailies) and timecards from 02/01/2026 through 03/12/2026, revealed discrepancies between scheduled and actual staffing and staffing levels below the facility's stated plan to include (but not limited to) the following: On 02/02/2026 with a facility census of 136 residents, the day shift (7:00 AM to 3:00 PM) listed seven (7) certified nursing assistants, however two (2) did not have documented punches. On 03/02/2026 with a facility census of 135 residents, the day shift listed six (6) certified nursing assistants and one (1) additional until 1:27 PM, and the House Manager (a certified nursing assistant) assigned to the Fourth (4th) Floor unit did not have a documented punch. On 03/03/2026 with a facility census of 132 residents, the day shift listed six (6) certified nursing assistants and the House Manager assigned to the Fourth (4th) Floor unit did not have a documented punch. On 03/05/2026 with a unit census of 34 residents, day shift staffing on the Fifth (5th) Floor (designated dementia care unit) included two (2) certified nursing assistants and two (2) licensed nurses, including the registered nurse manager that was assigned to pass medications. On 03/08/2026 with a facility census of 131 residents, the night shift (11:00 PM to 7:00 AM) listed two (2) certified nursing assistants and one (1) licensed nurse without documented punches. On 03/09/2026 with a facility census of 131 residents, the day shift had five (5) certified nursing assistants and one (1) additional who arrived at 10:00 AM. On 03/12/2026 with a unit census of 34 residents, day shift staffing on the Fifth (5th) Floor included two (2) certified nursing assistants, two (2) licensed nurses, and one (1) licensed nurse manager.Review of a facility-provided list of nursing staff from 12/01/2025 through 03/13/2026 revealed 42 of 84 (equivalent to 50 percent) certified nursing assistants were no longer employed at the facility.During observations and interviews on 03/09/2026 on the Second (2nd) Floor unit with a census of 24 residents: During an interview at 9:45 AM, Registered Nurse Manager #3 stated day shift staffing included one (1) nurse manager, two (2) licensed practical nurses, and two (2) certified nursing assistants. During an interview on 03/09/2026 at 10:21 AM, Resident #106 stated on 03/08/2026 they waited four (4) hours for a bed pan after pressing the call button at 6:15 AM, defecated (had a bowel movement) on themselves, and were not assisted until 10:20 AM when physical therapy staff arrived. During an interview on 03/09/2026 at 11:26 AM, a visitor stated the unit was often staffed with one (1) certified nursing assistant and one (1) nurse, and Mondays and weekends were short staffed. During an interview on 03/09/2026 at 12:22 PM, Resident #75 stated staff told them they would have to wait to get out of bed due to lack of staff.During observations and interviews on 03/09/2026 and 03/10/2026 on the Third (3rd) Floor unit with a census of 37 residents: On 03/09/2026 at 10:02 AM, there was a strong urine odor in the hallway between rooms [ROOM NUMBERS]. During an interview on 03/09/2026 at 10:15 AM, Certified Nursing Assistant #13 stated there were two (2) nurses and two (2) certified nursing assistants on the day shift. During an observation on 03/09/2026 at 11:03 AM, Resident #76 was in bed in a hospital gown with a breakfast tray in front of them. During an interview on 03/09/2026 at 1:39 PM, Resident #70 stated nothing in the facility was on time, including meals and medications. During an observation and interview on 03/10/2026 at 10:07 AM, Resident #112 had several days of facial hair growth and stated they were due for a shower and shave. During an observation and interview on 03/10/2026 at 10:15 AM, Resident #94 had greasy and stringy hair and stated a certified nursing assistant told them on 03/09/2026 they could not shower due to only two (2) certified nursing assistants on the unit. Resident #94 stated the shower room was across the hall, and they did not hear it in use. During an interview on 03/10/2026 at 12:14 PM, Resident #41 stated they had not received a shower for two (2) months, and the facility was short staffed.During observations and interviews on 03/09/2026 on the Fourth (4th) Floor unit with a census of 36 residents: Day shift staffing included two (2) nurses and two (2) certified nursing assistants. During an interview on 03/09/2026 at 9:26 AM, Resident #161 stated they waited up to one (1) hour for assistance with toileting and staff expressed frustration when the resident was incontinent. During an observation on 03/09/2026 at 3:23 PM, a strong urine odor was present in the hallway. During an interview on 03/09/2026 at 10:17 AM, Resident #10 stated call light response times were hours due to short staffing and at times only one (1) certified nursing assistant was available for the entire floor. Resident #10 stated staff told them to wait until the next shift for care.During observations and interviews on 03/09/2026 and 03/10/2026 on the Fifth (5th) Floor unit with a census of 34 residents: During observations on 03/09/2026 at 9:04 AM, multiple residents were in the dining room wearing pajamas or a hospital gown and a strong urine odor was present throughout the unit. During an observation on 03/09/2026 at 9:46 AM, staffing included two (2) licensed practical nurses, one (1) certified nursing assistant, and one (1) registered nurse manager working as a certified nursing assistant. During an observation on 03/09/2026 at 9:55 AM, Resident #65 had uncombed hair, wore a hospital gown, and one sock, and at 11:37 AM their appearance remained unchanged. During an observation on 03/09/2026 at 12:49 PM, Resident #151 wore pajamas with a visible stain and had an odor of feces. During observations on 03/10/2026 at 10:12 AM and 12:23 PM, Resident #97 had visible fecal matter under their fingernails and was later observed eating without hand hygiene.During an observation on 03/09/2026 at 1:50 PM, signage in the elevator advertised attendance incentives for staff to reduce call offs.During an interview on 03/10/2026 at 11:30 AM during a special Resident Council meeting with four (4) residents, residents stated they waited two (2) to three (3) hours for care, staff had to work in multiple roles due to shortages, residents were not always assisted out of bed which resulted in them not being able to attend activities, and weekend staffing was the worst.During an interview on 03/12/2026 at 10:40 AM, Licensed Practical Nurse #4 stated they were called in and directed to assist in the kitchen, delaying medication administration, and stated there was usually only one (1) certified nursing assistant and medications were often given late due to staffing.During an interview on 03/12/2026 at 11:23 AM, Certified Nursing Assistant #1 stated they were unable to complete rounds and incontinent checks prior to meals due to staffing, resulting in Resident #151 being incontinent prior to lunch.During an interview on 03/12/2026 at 11:39 AM, Certified Nursing Assistant #4 and Licensed Practical Nurse #1 stated staffing shortages prevented completion of assigned tasks, including showers, toileting, transfers requiring two (2) staff assist, and timely medication administration.During an interview on 03/16/2026 at 10:15 AM, Certified Nursing Assistant #12 stated there was never enough staff, at times only one (1) certified nursing assistant was available, residents required full bed changes at the start of shift, showers were missed, and staff had to leave assignments to assist with two (2) person transfers.During an interview on 03/16/2026 at 1:32 PM, Licensed Practical Nurse #6 stated tasks such as checking medication carts for loose or unlabeled pills were not completed due to higher priority care needs related to staffing shortages.During an interview on 03/17/2026 at 12:16 PM, the Staffing Coordinator stated the facility frequently operated below target staffing levels, often with two (2) to three (3) certified nursing assistants per unit on day and evening shifts and one (1) certified nursing assistant on night shift, and acknowledged these levels were not sufficient to meet resident needs. The Staffing Coordinator stated they were unable to consistently meet staffing targets and did not know how to resolve the staffing issues.During an interview on 03/18/2026 at 11:20 AM with the Administrator and [NAME] President of Operations, the Administrator stated the leadership team was not aware of concerns related to insufficient staffing to meet resident needs, but staffing had not been a focus for the Quality Assurance and Performance Improvement committee. The [NAME] President of Operations stated the facility met frequently about staffing and all members of the interdisciplinary team assist with nurse staffing deficits. During an interview on 03/18/2026 at 12:02 PM, the Director of Nursing stated target staffing included four (4) certified nursing assistants and two (2) nurses per unit on day shift, four (4) certified nursing assistants and one (1) to two (2) nurses per unit and one (1) nursing supervisor on evening shift, and two (2) certified nursing assistants and one (1) nurse per unit and one (1) nursing supervisor on night shift. The Director of Nursing stated current staffing was not ideal, was affected by call offs, and required staff to work in multiple roles to meet resident needs.10 NYCRR 415.13 (a)(1)(i-iii)

Based on observations, interviews, and record review, the facility did not ensure residents were treated in a dignified manner for two (2) of seven (7) residents reviewed (Residents #97 and #151). Specifically, Resident #97 was observed with fecal matter on their hands, clothing, and assistive device and was later observed eating without hand hygiene while fecal debris remained present under their fingernails. Resident #151 was observed eating meals while wearing feces-soiled clothing and had a strong odor of feces and was observed in an unclean and improperly prepared bed environment.The finding include:The undated facility policy, Your Rights as a Nursing Home Resident in New York State, provided to residents upon admission, documented in part, as a resident in this facility, you have rights guaranteed to you by state and federal laws. This facility is required to protect and promote your rights. Your rights strongly emphasize individual dignity and self-determination, promoting your independence and enhancing your quality of life. You have the right to be cared for in a manner which enhances your quality of life, free from humiliation and to be offered choices and allowed to make decisions important to you.1. Resident #97 had diagnoses including Alzheimer's dementia with agitation, anxiety disorder, and gastro-esophageal reflux disease (GERD). The Minimum Data Set (a resident assessment tool) dated 01/18/2026 documented the resident had severe cognitive impairment, required assistance with toileting and personal hygiene, and did not exhibit behaviors related to rejection of care.Review of nursing progress notes from 02/13/2026 to 03/12/2026 documented the last nail care provided occurred on 02/13/2026. No additional documentation related to nail care or refusals of care was identified.During an observation on 03/10/2026 at 10:12 AM, Resident #97 was sitting in bed with a meal tray present. A golf-sized amount of feces was on the resident's rolling walker. The resident's left hand had visible fecal matter beneath the fingernails. Fecal matter was smeared on the front of the resident's gown, and the gown was undone and hanging off the right shoulder. Certified Nursing Assistant #1 entered the room, applied a glove, removed the feces from the rolling walker, leaving a visible smear on the surface, and exited the room without providing hygiene care to the resident.During an observation and interview on 03/10/2026 at 10:27 AM, Certified Nursing Assistant #2 entered the room, identified themselves as assigned to the resident, removed the meal tray, exited the room, and did not return to provide care.During an observation on 03/10/2026 at 10:32 AM, Licensed Practical Nurse #3 entered the room, stated they would return with topical cream, exited the room, and did not return.During an observation on 03/10/2026 at 10:35 AM, Registered Nurse Manager #1 entered the room with disinfectant wipes and closed the door.During an observation on 03/10/2026 at 12:23 PM, Resident #97 was seated in the dining room with visible dark brown debris beneath the fingernails on both hands. At 12:27 PM, a meal tray was placed in front of the resident with no hand hygiene performed. The resident began eating and was observed retrieving dropped food from their lap with their hands and consuming it.During an interview on 03/11/2026 at 11:01 AM, Certified Nursing Assistant #1 stated they notified Certified Nursing Assistant #2 and Registered Nurse Manager #1 of the condition of Resident #97 and left to assist other assigned residents. Certified Nursing Assistant #1 stated the resident should not have been allowed to eat with dirty fingernails and hygiene should have been provided prior to the meal.During an interview on 03/17/2026 at 12:00 PM, the Director of Nursing stated staff were expected to complete nail care during showers and were expected to provide or offer hand hygiene to residents prior to meals.2. Resident #151 had diagnoses which included vascular dementia, history of falling, and cerebral infarction (stroke). The Minimum Data Set, dated [DATE] documented the resident had moderately impaired cognition, required assistance with toileting, was frequently incontinent of bowel and bladder, and did not exhibit behaviors related to rejection of care.Review of the comprehensive care plan dated 04/04/2025 documented the resident required extensive assistance with toileting, personal hygiene, and dressing. The care plan included the resident may be non-compliant with care at times and staff were to reapproach as needed.Review of nursing progress notes from 02/09/2026 to 03/12/2026 did not document refusals of care.During an observation on 03/09/2026 at 12:49 PM, Resident #151 was seated in the dining room eating lunch while wearing pajama pants and a white shirt visibly soiled on the front. A strong odor of feces was present.During an interview on 03/12/2026 at 11:23 AM, Certified Nursing Assistant #1 stated Resident #151 was soiled prior to lunch and required care. Certified Nursing Assistant #1 stated care was not provided prior to the meal due to short staffing and the resident was taken to the room after lunch where a significant amount of stool was present extending up the resident's back.During an observation and interview on 03/16/2026 at 9:23 AM, Resident #151 was lying in bed on a pillow without a pillowcase. The fitted sheet was partially removed and hanging off the bed. The room had a urine odor, and the floor was sticky and unclean. The call light was observed on the floor next to the bed. Resident #151 stated they did not have a pillowcase when they laid down.During an observation and interview on 03/16/2026 at 9:29 AM, Certified Nursing Assistant #2 entered the room with the resident's meal tray, assisted the resident to a seated position, and set up the meal. No hand hygiene was performed prior to the meal. Certified Nursing Assistant #2 stated training included anticipating resident needs and performing hand hygiene. They acknowledged hand hygiene was not provided.During an interview on 03/16/2026 at 9:57 AM, Registered Nurse Manager #1 stated beds were expected to be properly made with pillowcases in place.During an interview on 03/17/2026 at 12:17 PM, the Director of Nursing stated staff were expected to provide care prior to meals so residents were not eating while soiled and were expected to ensure residents were clean and in clean clothing. The Director of Nursing stated hand hygiene was expected prior to meals regardless of dining location and residents' beds were expected to be properly made to promote a homelike environment.10 New York Codes Rules and Regulations 415.5

Based on observations, interviews, and record review, the facility did not ensure its system for developing and implementing individualized meal service (use of meal tickets), including honoring resident preferences and available substitutions, was consistently followed for three (3) of thirteen (13) residents reviewed (Resident #10, Resident #77, and Resident #126). Specifically, residents were served food items which did not match their meal tickets and/or included items identified as dislikes, and substitutions available on the meal tickets were not provided.The findings include:1. Resident #10 had diagnoses including severe protein-calorie malnutrition, weight loss, and chronic pain. The Minimum Data Set (a resident assessment tool) dated 01/29/2026 documented Resident #10 was cognitively intact, required a mechanically altered diet, and had an active diagnosis of malnutrition or was at risk for malnutrition.Review of Resident #10's Comprehensive Care Plan last revised 09/05/2025 indicated Resident #10 was at risk for alteration in nutrition with a history of significant malnutrition and abnormal weight loss. Interventions included a regular diet, mechanical soft texture (foods blended, ground, or finely chopped to make chewing and swallowing easier), and thin liquid consistency.Review of Resident #10's medical orders on 03/17/2026 included an order dated 07/25/2025 for a regular diet, mechanical soft texture, and thin liquids.During an observation and interview on 03/12/2026 at 12:52 PM, Resident #10 had green beans on the meal tray. Review of the meal ticket at the time did not include green beans and indicated the resident disliked green beans. Resident #10 stated the meal tray frequently had incorrect items.2. Resident #77 had diagnoses including severe protein-calorie malnutrition, adult failure to thrive, and muscle weakness. The Minimum Data Set, dated [DATE] documented Resident #77 had moderate cognitive impairment and was on a therapeutic diet.Review of Resident #77's Comprehensive Care Plan last revised 02/25/2026 indicated Resident #77 was at risk for alteration in nutrition and hydration status. Interventions included a consistent carbohydrate diet (a diet to help manage blood sugar levels in individuals with diabetes), mechanical soft texture, and thin liquid consistency.Review of Resident #77's medical orders on 03/17/2026 included an order dated 02/24/2026 for a consistent carbohydrate diet, mechanical soft texture, and thin liquids.During an observation and interview on 03/11/2026 at 12:45 PM, Resident #77 was seated at a dining room table with a lunch tray containing pasta, spinach, pie, and applesauce. At 12:47 PM, Resident #77 stated the resident did not eat pasta and requested tuna fish. Review of the meal ticket indicated a mechanical soft chicken salad sandwich on white bread, sauteed spinach, three (3) boiled eggs, a mechanical soft peanut butter and jelly sandwich, unsweetened applesauce (handwritten), and tomato soup. The meal ticket also indicated staff were to offer chicken salad, tuna salad, or a grilled cheese sandwich if the resident did not accept the meal. The meal tray did not include sandwiches, boiled eggs, or tomato soup. Substitutions listed on the meal ticket were not provided at the time of observation. At 12:51 PM, Quality Assurance Nurse #1 spoke with Resident #77 regarding meal preferences.3. Resident #126 had diagnoses including hypertension, heart failure, and disease of the spinal cord. The Minimum Data Set, dated [DATE] indicated Resident #126 was cognitively intact and had an active diagnosis of malnutrition or was at risk for malnutrition.Review of Resident #126's Comprehensive Care Plan last revised 03/06/2026 indicated Resident #126 was at risk for alteration in nutrition with a history of malnutrition. Interventions included a regular diet, regular texture, and thin liquid consistency.Review of Resident #126's medical orders on 03/17/2026 included an order dated 08/05/2025 for a regular diet, regular texture, and thin liquid consistency.During an observation and interview on 03/09/2026 at 11:47 AM, Resident #126 had apple juice on the meal tray. Review of the meal ticket did not include apple juice. Resident #126 stated the meal usually did not match the meal ticket.During an observation on 03/11/2026 at 12:35 PM, Resident #126's meal ticket included salad, salad dressing, and cranberry juice. The meal tray included apple juice and did not include salad, salad dressing, or cranberry juice.During an interview on 03/17/2026 at 10:34 AM, Certified Nursing Assistant #5 stated if a resident's meal ticket indicated an item should not be served or was listed as a dislike, the item should not be on the tray. Certified Nursing Assistant #5 stated dietary staff (kitchen ambassadors) and nursing staff were responsible for checking meal tickets and ensuring meal trays were accurate.During an interview on 03/17/2026 at 11:13 AM, Certified Nursing Assistant #6 stated in the role of passing meal trays, the meal ticket and tray contents were reviewed to ensure the resident received all items. If an item was missing, staff would notify the individual preparing the tray.During an interview on 03/17/2026 at 11:12 AM, Licensed Practical Nurse Manager #1 stated the dietary team created meal tickets based on diet consistency, preferences, and allergies. Licensed Practical Nurse Manager #1 stated nursing staff delivering meal trays should verify accuracy and ensure items identified as dislikes were not served.During an interview on 03/17/2026 at 1:55 PM, Registered Dietitian #1 stated items identified as dislikes should not be served and emphasized honoring preferences to promote adequate intake and prevent weight loss or malnutrition.During an interview on 03/18/2026 at 10:04 AM, the Director of Nursing stated meal tickets should be checked for accuracy and items identified as dislikes should not be served and should be removed if present on the tray.10 New York Codes Rules and Regulations 415.14(c)(1-3)

Based on observations, interviews, and record review conducted during an Abbreviated Survey (NY00370316/443765, NY00372543/443769) completed on 12/08/2025, the facility failed to ensure one (1) of seven (7) residents reviewed (Resident #8) was treated with respect and dignity and cared for in a manner that promoted quality of life. Specifically, the facility failed to honor Resident #8's expressed preferences and repeated requests for assistance with grooming and hygiene and the resident stated it made them feel dirty and grubby. This resulted in actual psychosocial harm that was not Immediate Jeopardy.The findings include:The undated facility document provided to residents upon admission, Your Rights as a Nursing Home Resident in New York State, included but was not limited to: As a resident in this facility, you have rights guaranteed to you by state and federal laws. This facility is required to protect and promote your rights. Your rights strongly emphasize individual dignity and self-determination, promoting your independence and enhancing your quality of life. You have the right to be cared for in a manner that enhances your quality of life and free from humiliation. You have the right to be offered choices, allowed to make decisions important to you, and to receive adequate and appropriate care. Resident #8 had diagnoses including chronic pain syndrome, major depressive disorder, and anxiety disorder. The Minimum Data Set (a resident assessment tool) dated 10/29/2025, documented the resident was cognitively intact, did not reject care during this time, and required staff assistance with personal hygiene.Review of Resident #8's Comprehensive Care Plan, revised 11/12/2025, revealed the resident required assistance with their activities of daily living (ADLs, self-care tasks like bathing and grooming) and had non-compliance/refusal of care related to medications, treatments, the preference not to go out on appointments, and the resident was on comfort care. Interventions included, but were not limited to, limited assistance of one (1) staff for personal hygiene, to document discussions regarding refusals, and to reapproach as needed.Review of the Kardex (care plan used by certified nursing assistants to direct care) current as of 12/08/2025, revealed Resident #8 required the limited assistance of one (1) staff for personal hygiene, staff were to encourage the resident to use their call light for assistance as needed and to respond promptly to all requests for assistance. Review of the Household Bath List, last updated on 11/12/2025, revealed Resident #8 was scheduled to receive a bed bath on Thursday evenings and nursing staff should enter a skin note in the electronic health record on the resident's bath day. The Household Bath List did not include documented evidence Resident #8 received bed baths from 11/08/2025 to 12/07/2025. Review of nursing progress notes from 11/08/2025 to 12/07/2025 did not include documented evidence Resident #8 was offered assistance with shaving or hair washing, or any refusals of personal hygiene services. During an observation and interview on 12/02/2025 at 10:57 AM, Resident #8 was sitting up in bed with oily, uncombed hair, and a significant amount of overgrown facial hair. When interviewed at that time, Resident #8 appeared frustrated and spoke hurriedly stating they did not like their overgrown beard and had asked staff for assistance with shaving and the use of a shampoo cap (an alternative method used to clean a person's hair and scalp without water) to wash their hair but had not received assistance.During an interview on 12/03/2025 at 11:21 AM, Certified Nursing Assistant #1 stated there were days when they were unable to assist residents with scheduled showers and bed baths or assist residents who asked for assistance with shaving because they did not have time due to staffing challenges. During an observation and interview on 12/05/2025 at 10:18 AM, Resident #8 continued with an overgrown beard and oily, uncombed hair. When interviewed at that time, Resident #8 stated they did not like having an overgrown beard and they had asked more than once to be shaved, including asking a supervisor (name unknown). Resident #8 stated they had asked for a shampoo cap to wash their hair, and no one provided it. Resident #8 stated they felt dirty and grubby, and their care was horrible. During an interview on 12/05/2025 at 10:45 AM, Licensed Practical Nurse Manager #1 stated shower/bed bath day consisted of hair washing, shaving, nail care, and bed linen changes. Licensed Practical Nurse Manager #1 stated Resident #8 preferred bed baths and required assistance with their activities of daily living, as the resident could not complete them independently, and there was no documentation of Resident #8 refusing shaving or hair washing. Licensed Practical Nurse Manager #1 stated Resident #8 had not reported to them directly about wanting a bed bath or shave, but staff should still offer. If the resident refused, the staff should reattempt care and document and report further refusals to Licensed Practical Nurse Manager #1 and the Director of Nursing. During an interview on 12/05/2025 at 1:45 PM with the Administrator and Director of Nursing, the Administrator stated they were not aware residents were not receiving assistance with shaving and hair washing. The Administrator stated if a resident reported feeling dirty and grubby, it could be a sign of psychosocial harm as a resident should not be made to feel that way. During an observation and interview on 12/08/2025 at 10:27 AM, Resident #8 was sitting up in bed and their hair remained oily. When interviewed at that time, Resident #8 stated staff assisted them with shaving the other day, but they still had not had their hair washed. Resident #8 stated a professional came to the facility every two (2) weeks to cut other resident's hair who had an account, but the resident did not receive the same services. Resident #8 stated they wished they could have the same service or that facility staff was consistent in helping them. Resident #8 stated they sometimes refused to get out of bed when they were not feeling well, but denied refusing shaving, and/or hair washing. During an interview on 12/08/2025 at 2:05 PM, the Medical Director stated they would expect staff to offer residents the level of support needed and include family in their care since they knew the residents best. The Medical Director stated the facility's approach to resident care should always be person-centered and based on Resident #8's feelings about not receiving assistance with shaving or hair washing, they could see the potential for psychosocial harm.During an interview on 12/08/2025 at 3:14 PM with the Administrator and Director of Nursing, the Administrator stated they expected staff to respect what residents wanted and honor their care preferences. The Administrator stated if a resident wanted a shave and hair wash, they should receive those services, and if a resident refused, staff should reapproach as needed. 10 NYCRR 415.5

Based on observations, interviews and record review conducted during an Abbreviated Survey (Incident ID: NY00368335/443768, NY00370316/443765, and NY00372367/443775) completed on 12/08/2025, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs, self-care tasks like bathing and grooming) received the necessary services to maintain good grooming and personal hygiene for eight (8) of eight (8) residents reviewed (Residents #8, #13, #14, #15, #17, #18, #19 and #20). Specifically, Resident #8 was observed on multiple occasions with overgrown facial hair and oily, uncombed hair and stated they had asked staff for assistance but did not receive it. Residents #13, #14 and #20 were observed on multiple occasions with overgrown facial hair and there was no documented evidence staff offered, provided, or the residents refused assistance. Residents #15, #17, #18, and #19 were observed in common areas with oily uncombed hair, overgrown facial hair and the residents were unable to request assistance. The findings include:The facility policy Standards of Care updated on 08/20/2020 included, but was not limited to, as a person-centered community for elders, facility staff will honor and respect individual choice. Elders residing at the facility are encouraged to express personal choice regarding daily living. Choices or preferences that are not consistent with the care card or care sheet will be communicated to the House Manager, primary nurse and/or Neighborhood Nurse for awareness and/or appropriate follow up. Bath/showers are given per resident preference. The certified nurse assistant is responsible for informing the nurse when the resident is receiving a bath/shower per the schedule. Refusals of care, which include showers, baths, and removal of facial hair are to be reported to the primary licensed practical nurse so it can be documented in the resident's medical record. 1. Resident #8 had diagnoses including chronic pain syndrome, major depressive disorder, and anxiety disorder. The Minimum Data Set (a resident assessment tool) dated 10/29/2025, documented the resident was cognitively intact, did not reject care during this time, and required staff assistance with personal hygiene.Review of Resident #8's Comprehensive Care Plan revised 11/12/2025, revealed the resident required assistance with their activities of daily living and had non-compliance/refusal of care related to medications, treatments, the preference not to go out on appointments, and the resident was on comfort care. Interventions included, but were not limited to, limited assistance of one (1) staff for personal hygiene, to document discussions regarding refusals, and to reapproach as needed.Review of the Kardex (care plan used by certified nursing assistants to direct care) current as of 12/08/2025 revealed Resident #8 required the limited assistance of one (1) staff for personal hygiene, staff were to encourage the resident to use their call light for assistance as needed and to respond promptly to all requests for assistance. Review of the Household Bath List last updated on 11/12/2025 revealed Resident #8 was scheduled to receive a bed bath on Thursday evenings and nursing staff should enter a skin note in the electronic health record on the resident's bath day. The Household Bath List did not include documented evidence Resident #8 received bed baths from 11/08/2025 to 12/07/2025. Review of nursing progress notes from 11/08/2025 to 12/07/2025 did not include documented evidence Resident #8 was offered assistance with shaving or hair washing, or any refusals of personal hygiene services. During an observation and interview on 12/02/2025 at 10:57 AM, Resident #8 was sitting up in bed with oily, uncombed hair, and a significant amount of overgrown facial hair. When interviewed at that time, Resident #8 appeared frustrated and spoke hurriedly stating they did not like their overgrown beard and had asked staff for assistance with shaving and the use of a shampoo cap (an alternative method used to clean a person's hair and scalp without water) to wash their hair but had not received assistance.During an interview on 12/03/2025 at 11:21 AM, Certified Nursing Assistant #1 stated there were days when they were unable to assist residents with scheduled showers and bed baths or assist residents who asked for assistance with shaving because they did not have time due to staffing challenges. During an observation and interview on 12/05/2025 at 10:18 AM, Resident #8 continued with an overgrown beard and oily, uncombed hair. When interviewed at that time, Resident #8 stated they did not like having an overgrown beard and they had asked more than once to be shaved, including asking a supervisor (name unknown). Resident #8 stated they had asked for a shampoo cap to wash their hair, and no one provided it. Resident #8 stated they felt dirty and grubby, and their care was horrible.During an interview on 12/05/2025 at 10:45 AM, Licensed Practical Nurse Manager #1 stated shower/bed bath day consisted of hair washing, shaving, nail care, and bed linen changes. Licensed Practical Nurse Manager #1 stated Resident #8 preferred bed baths and required assistance with their activities of daily living as the resident could not complete them independently and there was no documentation of Resident #8 refusing shaving or hair washing. Licensed Practical Nurse Manager #1 stated Resident #8 had not reported to them directly about wanting a bed bath or shave, but staff should still offer. If the resident refused, the staff should reattempt care, document and report further refusals to Licensed Practical Nurse Manager #1 and the Director of Nursing.During an observation and interview on 12/08/2025 at 10:27 AM, Resident #8 was sitting up in bed and their hair remained oily. When interviewed at that time, Resident #8 stated staff assisted them with shaving the other day, but they still had not had their hair washed. Resident #8 stated a professional came to the facility every two (2) weeks to cut other resident's hair who had an account, but the resident did not receive the same services. Resident #8 stated they wished they could have the same service or that facility staff was consistent in helping them. Resident #8 stated they sometimes refused to get out of bed when they were not feeling well, but denied refusing shaving, and/or hair washing.2. Resident #14 had diagnoses including vascular dementia, anxiety disorder, and a history of falling. The Minimum Data Set, dated [DATE], documented the resident had moderately impaired cognition, did not reject care during this time, and required staff assistance with personal hygiene.Review of Resident #14's Comprehensive Care Plan revised on 11/18/2025, documented the resident was at risk for decline in their activities of daily living due to muscle weakness, had non-compliance/refusal of medication and treatment related to cognitive impairment and lack of knowledge, and had impaired cognitive function related to vascular dementia. Interventions included, but were not limited to, limited assistance of one (1) staff for personal hygiene, to document discussions regarding refusals, and communicate with the resident and family regarding residents capabilities and needs.Review of the Kardex current as of 12/08/2025 revealed Resident #14 required the limited assistance of one (1) staff for personal hygiene and to observe and report resistance to care. Review of the Household Bath List last updated on 12/01/2025 revealed Resident #14 was scheduled to receive a shower on Mondays and Certified Nursing Assistant #2 was assigned to their care. The Household Bath List did not include documented evidence of recent showers for Resident #14. During an observation and interview on 12/03/2025 at 12:11 PM, Resident #14 had a significant amount of thick, overgrown facial hair, and hair on the front of their neck was approximately 2.5 inches long. The resident's hair was uncombed, with white flakes visible on the front of their shirt. When interviewed at that time, Resident #14 stated they hated having a beard and had asked staff several times to be shaved. They could not remember the last time they asked staff for assistance but had asked often before finally giving up.During an interview on 12/03/2025 at 12:15 PM, Certified Nursing Assistant #2 stated Resident #14 needed a shave because their facial hair was thick, but they could not assist with shaving when there was not enough help on the unit. Certified Nursing Assistant #2 stated the facility used an outside barber, and did not know why Resident #14 was not on the list to be seen. During an observation on 12/05/2025 at 2:47 PM, Resident #14 continued with a significant amount of thick, overgrown facial hair. During an interview on 12/05/2025 at 2:55 PM, Certified Nursing Assistant #2 stated Resident #14 was on their assignment and their shower day was Wednesdays. They stated shower day also consisted of shaving, but Resident #14 did not like to be shaved. Certified Nursing Assistant #2 stated they had offered to shave the resident, but they refused. They had not documented or reported the refusal to anyone because they did not know they had to. Certified Nursing Assistant #2 stated they believed they only needed to report shower refusals.During an interview on 12/05/2025 at 3:02 PM, Registered Nurse Manager #2 stated Resident #14 was an easy-going person who required help, could not shave independently, and did not have a history of refusing care or being combative. Registered Nurse Manager #2 stated they would expect refusals of care to be brought to their attention, and residents who refused shaving should be care planned for refusals and have appropriate interventions in place. Registered Nurse Manager #2 stated they recalled Resident #14 had asked them for an electric razor and Registered Nurse Manager #2 was supposed to follow up with the resident but forgot. Registered Nurse Manager #2 stated they would expect staff to offer care without residents having to ask, round on all residents to ensure their needs were met, and to document all refusals.3. Resident #13 had diagnoses including vascular dementia, heart failure, and a history of falling. The Minimum Data Set, dated [DATE], documented the resident had severely impaired cognition, did not reject care during this time, and required staff assistance with personal hygiene.Review of Resident #13's Comprehensive Care Plan dated 09/16/2025, revealed the resident required assistance with activities of daily living related to vascular dementia and impaired balance, had impaired cognitive function, and was at risk for behaviors related to resisting care. Interventions included, but were not limited to, staff to provide set-up assistance with personal hygiene, staff to anticipate and meet the resident's needs, communicate with the resident and family regarding their capabilities and needs, and to provide the resident with necessary cues, and to stop and return if agitated. Review of the Household Bath List last updated on 08/11/2025 revealed Resident #13 was scheduled to receive a shower on Monday day shift and nursing staff should enter a skin note in the electronic health record on the resident's shower day. The Household Bath List did not include documented evidence of recent showers for Resident #13.During an observation and interview on 12/05/2025 at 9:22 AM, Resident #13 was seated at the dining room table and had a significant amount of overgrown facial hair. When interviewed at that time, Resident #13 stated they did not know what day their shower was scheduled for, but they wanted to be shaved and had asked staff for assistance.During an interview on 12/05/2025 at 9:34 AM, Registered Nurse Manager #1 stated shower day consisted of hair washing, nail care, and shaving. They stated Certified Nursing Assistant #4 assisted Resident #13 with a shower on an unassigned day, but did not know why the resident had not been shaved.During an interview on 12/05/2025 at 9:43 AM, Certified Nursing Assistant #4 stated they had assisted Resident #13 with a shower, the resident was easy to care for and never refused care. Certified Nursing Assistant #4 stated they did not shave Resident #13 because there was not enough help on the unit. During an interview on 12/08/2025 at 3:14 PM with the Administrator and Director of Nursing, the Administrator stated they expected staff to respect what residents wanted and honor their care preferences. The Administrator stated if a resident wanted a shave and hair wash, they should receive those services, and if a resident refused, staff should reapproach as needed. 10 NYCRR 415.12(a)(3)

Based on observations, interviews and record review conducted during an Abbreviated Survey (NY00368335/443768 and NY00372367/443775) completed on 12/08/2025, the facility failed to ensure all drugs and biologicals used in the facility were stored in locked compartments and permit only authorized personnel to have access for one (1) of four (4) residential units reviewed (Unit Three). Specifically, four (4) bins filled with medication blister packs (a type of packaging that organizes medications into individual, sealed compartments) and medications stored in three (3) plastic bags were observed on an office desk, unsupervised with the door open, and accessible to unlicensed personnel. The findings include:The facility policy, Storage of Medications and Chemical Products last revised on 08/30/2016 included, but was not limited to, all medications and other substances will be stored according to New York State and the Occupational Safety and Health Administration (OSHA) regulations. All medications, including treatment items, will be stored in a locked room inaccessible to residents and visitors. All medications, excluding controlled drugs and cool temperature drugs, shall be stored in a locked medication cart. When the medication cart is not in use, it is to be locked at all times and returned to the medication room for prolonged periods of time when not in use.During an observation and interview on 12/05/2025 at 3:02 PM, three (3) bags containing various medications and four (4) bins of medication blister packs were setting on Registered Nurse Manager's #2's office desk. The office door was open and Certified Nursing Assistant #2, Certified Nursing Assistant #5, and Licensed Practical Nurse #2 were seated less than five (5) feet from the office door. Registered Nurse Manager #2 was standing in the hallway near the nurse's office. The medications inside the bins included, but were not limited to, blood pressure medications, pain medications, thyroid medications, psychotropic medications, diuretic medications, and bowel medications prescribed for several different residents. There were brown plastic bags on the desk and in the bins that contained injectable and glass vials of medications. When interviewed at that time, Registered Nurse Manager #2 stated the medications had been removed from the medication carts on the unit, were going to be returned to the pharmacy, and had been stored in their office for the last week. Registered Nurse Manager #2 stated they usually locked their office door when they were not in the building but there were times they left the door open with staff in the office while Registered Nurse Manager #2 was out on the unit. Registered Nurse Manager #2 stated they had never discarded medications before, but knew they were not supposed to have medications stored in their office. Registered Nurse Manager #2 stated the Director of Nursing was aware medications were being stored in the office as they had previously met there with the medications present. During an interview on 12/05/2025 at 4:00 PM with the Administrator and Director of Nursing, the Director of Nursing stated while they had gone to Registered Nurse Manager #2's office, they had not noticed any medications stored there. The Director of Nursing stated staff would sometimes remove medications prescribed for discharged residents from medication carts, but they should be sent back to pharmacy. They stated while waiting for pharmacy, the medications should be secured in a locked medication room. The Director of Nursing stated certified nursing assistants should not have access to medications and storing medications in places other than locked medication carts or rooms was improper. 10 NYCRR 415.18(e)(1-4)

Based on interviews, and record review conducted during an Abbreviated Survey (Intake ID: NY00368335/443768 and NY00372367/443775) completed on 12/08/2025, the facility failed to provide services that met professional standards of quality for one (1) of three (3) residents reviewed (Resident #4). Specifically, for Resident #4 there was missing administration documentation for several medications, including but not limited to significant medications used to treat hypertension and cardiac related conditions, and no documented evidence the resident received the medications or notifications of missed medications to a medical provider. The findings include:The facility policy, Medication Administration/ Documentation dated 07/15/2025 included, but was not limited to, medications will be dispensed only by registered nurses/licensed nurses and prepared, administered, and charted by the same nurse. Each nurse passing medication on the unit is to document each medication as given in the electronic medication administration record and notify the Registered Nurse or Licensed Practical Nurse Supervisor of a medication omission and the Registered Nurse/ Licensed Practical Nurse Supervisor will determine the next step; for example, to notify the doctor, or obtain a missing medication or its substitute. Each nurse is to check the electronic medication administration record at the end of the shift to ensure all medications and treatments are signed off. Resident #4 had diagnoses including diabetes, congestive heart failure, and atrial fibrillation (heart rhythm disorder leading to a fast, irregular pulse). The Minimum Data Set (a resident assessment tool) dated 11/21/2024, documented the resident was cognitively intact, had no rejection of care, including taking medications, and was taking high-risk medications including an antidepressant (medications used to improve mood), anticoagulant (medications that stop blood from clotting too easily), and hypoglycemic (medications used to lower high blood sugars). Review of Resident #4's Comprehensive Care Plan last revised on 10/22/2025 revealed the resident had diabetes, chronic pain, and used psychotropic medications. Interventions included, but were not limited to, administer medications as ordered by the doctor and to monitor and document side effects and effectiveness. Review of Resident #4's medical orders included, but was not limited to, the following: Acetaminophen 650 milligrams three (3) times daily for pain (ordered 11/20/2024). Check blood sugar every day, notify Medical Doctor if blood sugar is greater than 400 and less than 70 before meals for diabetes (dated 02/12/2025). Eliquis 5 milligrams two (2) times daily for atrial fibrillation (dated 01/15/2025). Gabapentin 200 milligrams three (3) times daily for diabetic neuropathy (dated 11/21/2024). Hydralazine 25 milligrams three (3) times daily for hypertension (dated 01/16/2025). Metformin 500 milligrams two (2) times daily for diabetes (dated 10/31/2024). Trazodone 50 milligrams at bedtime for depression and insomnia (dated 08/16/2024). Vital signs every day shift starting on the first and ending on the sixth of every month (dated 10/31/2024).Review of Resident #4's February 2025 Medication Administration Record revealed missing administration documentation (blank boxes) on the following dates/times for each medical order:- Acetaminophen 650 milligrams three (3) times daily: 02/03/2025 at 9:00 PM.- Check blood sugar every day: 02/04/2025 at 6:00 AM.- Eliquis 5 milligrams two (2) times daily: 02/03/2025 at 8:00 PM- Gabapentin 200 milligrams three (3) times daily: 02/03/2025 at 9:00 PM- Hydralazine 25 milligrams three (3) times daily: 02/03/2025 at 10:00 PM and 02/04/2025 at 6:00 AM.- Metformin 500 milligrams two (2) times daily: 02/03/2025 at 9:00 PM and 02/17/2025 at 5:00 PM.- Trazodone 50 milligrams at bedtime: 02/03/2025 at 9:00 PM- Vital signs every day shift: 02/03/2025, 02/04/2025, and 02/05/2025Review of nursing progress notes from 02/01/2025 to 02/28/2025 did not include documented evidence missed medications, vital signs, or blood sugar checks had been administered or a medical provider had been notified. During an interview on 12/05/2025 at 4:00 PM with the Director of Nursing and Administrator, the Administrator stated Resident #4 was in the building on 02/03/2025, 02/04/2025 and 02/17/2025, they did not know why the boxes were left blank on the Medication Administration Record and was unable to follow up with the nurses assigned on those shift because the nurses had been terminated. The Administrator stated they would expect all medications to be given as ordered. During an interview on 12/08/2025 at 9:51 AM, Registered Nurse Manager #1 stated if there were blank boxes on the Medication Administration Record, the medication was not given and if a resident refused their medications, the nurse should document the refusal, how many times the resident refused, and who the nurse notified about the refusal. Registered Nurse Manager #1 stated a pharmacy representative checked the medication carts and the Medication Administration Records monthly for missing documentation and reported their findings to the Director of Nursing. Registered Nurse Manager #1 stated the Director of Nursing then made the unit managers aware of the missed documentation to ensure resident safety and continuity of care. 10 NYCRR 415.11(c)(3)(i)

Based on observations, interviews, and record review conducted during an Abbreviated Survey (Intake ID: 2561610) from 07/15/2025 to 07/16/2025, for one (1) (Resident #1) of one (1) resident reviewed, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice and the person-centered care plan. Specifically, Resident #1 refused several doses of haloperidol (an antipsychotic medication that is used to control severe agitation and aggression) in June 2025 and July 2025 and a medical provider was not notified. Additionally, on 07/11/2025 the resident had increased agitation, wandering behaviors, attempted to exit a bedroom window, and a medical provider was not notified of the incident. The findings include:The facility policy Medication Administration/Documentation, dated 12/06/2024 included, but was not limited to, if the resident does not take the medication, mark the electronic medication administration record (EMAR) as other and note why the medication was not given. Notify the Registered Nurse/Licensed Practical Nurse Supervisor of the medication omission and the Supervisor will determine the next step (i.e. to notify the doctor).Resident #1 had diagnoses including dementia, cerebral infarction, and diabetes. The Minimum Data Set (a resident assessment tool), dated 06/03/2025, documented the resident had moderately impaired cognition, daily wandering behaviors (a pattern of locomotion that can appear aimless or repetitive, and may involve leaving a safe environment), required supervision or touching assistance for walking, and was taking an antipsychotic medication. Review of the Comprehensive Care Plan, dated 06/16/2025, included Resident #1 had the potential to be physically aggressive and received a psychoactive medication for behavior management. Interventions included, but were not limited to, monitor, document, and report signs and symptoms of the resident posing a risk to themself or others and to administer psychotropic medications as ordered. Review of physician's orders, dated 06/03/2025, included (but were not limited to) haloperidol 0.5 milligrams by mouth two (2) times daily for dementia with agitation, to observe and document any side effects from the antipsychotic medication, and notify the medical provider. Review of Resident #1's Medication Administration Records revealed the following:From 06/03/2025 to 06/30/2025, the resident refused haloperidol on 29 of 55 opportunities.From 07/01/2025 to 07/14/2025, the resident refused haloperidol on 17 of 28 opportunities. Review of progress notes from 06/03/2025 to 07/13/2025 did not include documented evidence that a medical provider was notified regarding the frequency of Resident #1's medication refusals. In a medical progress note dated 07/07/2025, Physician #1 referenced nursing progress notes since Resident #1's last visit including on 06/22/2025 the resident was agitated, angry and refused his medications and on 06/26/2025, the resident refused all care, refused evening medications, and accepted morning medications. Physician #1 documented the care plan was reviewed with nursing staff and all medications and other orders were reviewed and approved. In a nursing progress note, dated 07/11/2025, Registered Nurse #2 documented Resident #1 was wandering into other resident rooms, refusing evening medications, becoming agitated, and wanted to leave the facility. The Director of Nursing was notified of the resident's behavior, and the resident was placed on every 15-minute checks. The staff would continue to monitor the resident's behaviors and elopement attempts. Review of a 24-Hour Nursing Report, dated 07/11/2025, included Resident #1 tried to climb out of a window and was put on 15-minute checks. Additional review of the electronic health record and facility documents did not include documented evidence a medical provider was notified of the incident. During an interview on 07/15/2025 at 1:33 PM, the Director of Nursing stated on 07/11/2025 Resident #1 was found in another resident's room with a foot and leg out of the window. When the electronic health record was reviewed at that time, the Director of Nursing revealed there was no progress note related to the incident and the comprehensive care plan had not been revised. They stated a progress note should have been entered and the care plan updated. The Director of Nursing stated they would expect that a medical provider was eventually notified of medication refusals although there was no set timeframe for notification. During an interview on 07/15/2025 at 2:00 PM, Licensed Practical Nurse Manager #1 stated if a resident refused medications they would attempt again, have another nurse attempt to administer the medications, and notify the medical provider of any refusals. During an interview on 07/15/2025 at 3:30 PM, Registered Nurse #1 stated if a resident refused medications they would notify the medical provider at that time. During an interview on 07/15/2025 at 3:40 PM, Nurse Practitioner #1 stated they would expect to be notified at the time medications are refused or the next day. If there are several refusals, the medical provider should be called. Nurse Practitioner #1 stated there was one entry in the provider communication book (used by the facility to communicate resident concerns to the medical provider) on 07/11/2025 notifying that Resident #1 had refused medications, but they were unaware the resident had several refusals of the haloperidol in June 2025 and July 2025. During an interview on 07/15/2025 at 4:00 PM, Physician #1 stated they were unaware Resident #1 had missed several doses of haloperidol, and a medical provider should have been notified. Additionally, Physician #1 stated they were unaware of the incident 07/11/2025 and a medical provider should have been notified. 10 NYCRR 415.12Based on observations, interviews, and record review conducted during an Abbreviated Survey (Intake ID: 2561610) from 07/15/2025 to 07/16/2025, for one (1) (Resident #1) of one (1) resident reviewed, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice and the person-centered care plan. Specifically, Resident #1 refused several doses of haloperidol (an antipsychotic medication that is used to control severe agitation and aggression) in June 2025 and July 2025 and a medical provider was not notified. Additionally, on 07/11/2025 the resident had increased agitation, wandering behaviors, attempted to exit a bedroom window, and a medical provider was not notified of the incident. The findings include:The facility policy Medication Administration/Documentation, dated 12/06/2024 included, but was not limited to, if the resident does not take the medication, mark the electronic medication administration record (EMAR) as other and note why the medication was not given. Notify the Registered Nurse/Licensed Practical Nurse Supervisor of the medication omission and the Supervisor will determine the next step (i.e. to notify the doctor).Resident #1 had diagnoses including dementia, cerebral infarction, and diabetes. The Minimum Data Set (a resident assessment tool), dated 06/03/2025, documented the resident had moderately impaired cognition, daily wandering behaviors (a pattern of locomotion that can appear aimless or repetitive, and may involve leaving a safe environment), required supervision or touching assistance for walking, and was taking an antipsychotic medication. Review of the Comprehensive Care Plan, dated 06/16/2025, included Resident #1 had the potential to be physically aggressive and received a psychoactive medication for behavior management. Interventions included, but were not limited to, monitor, document, and report signs and symptoms of the resident posing a risk to themself or others and to administer psychotropic medications as ordered. Review of physician's orders, dated 06/03/2025, included (but were not limited to) haloperidol 0.5 milligrams by mouth two times daily for dementia with agitation, to observe and document any side effects from the antipsychotic medication, and notify the medical provider. Review of Resident #1's Medication Administration Records revealed the following:From 06/03/2025 to 06/30/2025, the resident refused haloperidol on 29 of 55 opportunities.From 07/01/2025 to 07/14/2025, the resident refused haloperidol on 17 of 28 opportunities. Review of progress notes from 06/03/2025 to 07/13/2025 did not include documented evidence that a medical provider was notified regarding the frequency of Resident #1's medication refusals. In a medical progress note dated 07/07/2025, Physician #1 referenced nursing progress notes since Resident #1's last visit including on 06/22/2025 the resident was agitated, angry and refused his medications and on 06/26/2025, the resident refused all activities of daily living care, refused evening medications, and accepted morning medications. Physician #1 documented the care plan was reviewed with nursing staff and all medications and other orders were reviewed and approved. In a nursing progress note, dated 07/11/2025, Registered Nurse #2 documented Resident #1 was wandering into other resident rooms, refusing evening medications, becoming agitated, and wanted to leave the facility. The Director of Nursing was notified of the resident's behavior, and the resident was placed on every 15-minute checks. The staff would continue to monitor the resident's behaviors and elopement attempts. Review of a 24-Hour Nursing Report, dated 07/11/2025, included Resident #1 tried to climb out of a window and was put on 15-minute checks. Additional review of the electronic health record and facility documents did not include documented evidence a medical provider was notified of the incident. During an interview on 07/15/2025 at 1:33 PM, the Director of Nursing stated on 07/11/2025 Resident #1 was found in another resident's room with a foot and leg out of the window. When the electronic health record was reviewed at that time, the Director of Nursing revealed there was no progress note related to the incident and the comprehensive care plan had not been revised. They stated a progress note should have been entered and the care plan update. The Director of Nursing stated they would expect that a medical provider was eventually notified of medication refusals although there was no set timeframe for notification. During an interview on 07/15/2025 at 2:00 PM, Licensed Practical Nurse Manager #1 stated if a resident refused medications they would attempt again, have another nurse attempt to administer the medications, and notify the medical provider of any refusals. During an interview on 07/15/2025 at 3:30 PM, Registered Nurse #1 stated if a resident refused medications they would notify the medical provider at that time. During an interview on 07/15/2025 at 3:40 PM, Nurse Practitioner #1 stated they would expect to be notified at the time medications are refused or the next day. If there are several refusals, the medical provider should be called. Nurse Practitioner #1 stated there was one entry in the provider communication book (used by the facility to communicate resident concerns to the medical provider) on 07/11/2025 notifying Resident #1 had refused medications, but they were unaware the resident had several refusals of the haloperidol in June 2025 and July 2025. During an interview on 07/15/2025 at 4:00 PM, Physician #1 stated they were unaware Resident #1 had missed several doses of haloperidol, and a medical provider should have been notified. Additionally, Physician #1 stated they were unaware of the incident 07/11/2025 and should have been notified. 10 NYCRR 415.12

Based on interviews and record review conducted during the Recertification Survey conducted from 12/02/2024 to 12/09/2024, the facility did not refer the resident who had an intellectual disability to the appropriate state-designated authority for a Level II Pre-Admission Screening and Resident Review (PASARR) for recommendations for one (Resident #115) of two residents reviewed. Specifically, the resident had a letter from the admitting hospital documentation that the resident required a full Level II assessment (referral process for individuals who were known or suspected of having serious mental illness for care planning recommendations) prior to admission or when a significant change occurred. Consequently, Resident #115 received no Level II referrals or services if needed. Findings include: The facility's revised SCREEN/ PASRR policy, dated 12/13/2018, documented for prospective residents a Level II assessment, based on screen indicators completed by the referring hospital or agency, admissions would request results of the assessment, and once obtained from the hospital or referring agency, the applicant's eligibility for admission would be determined. Level II reports and recommendations would be kept in the resident's chart and Level II recommendations would be incorporated into the resident's care plan. The policy included that a new SCREEN and Level II was required if a previously identified resident with a diagnosis of a serious mental illness or intellectual/developmental disability experienced a significant change in physical and/or mental condition. Resident #115 was admitted with diagnoses including Down Syndrome and acute respiratory failure with hypoxia (low oxygen level). The 09/13/2024 Minimum Data Set Resident Assessment documented the resident had severely impaired cognition, had no behaviors, required substantial/maximum assistance with most activities of daily living, and was receiving hospice care (effective 06/24/2024). The 07/17/2023 (prior to admission) New York State Department of Health Pre-Admission Screening and Resident Review form documented that Resident #115 had a diagnosis or documented history of developmental disability before the age of 22 and is likely to continue indefinitely, has received or is eligible for services for the developmental disability, and does have evidence of cognitive deficits and/or adaptive skills which indicate the presence of a developmental disability. The Screening form documented that Level II services were not warranted at the time. Review of an undated New York State Department of Health Office of Persons with Developmental Disabilities response letter from the admitting hospital on admission to the facility documented that Resident #115 required a full Level II Assessment, parts 1-4 and eligibility needs were to be determined. The form documented the Level II process would stop and proceed once eligibility was established. There was no documented evidence a Level II Assessment had ever been completed. The Comprehensive Care Plan, dated revised 11/18/2024, documented the resident had impaired cognitive function or impaired thought process related to developmentally delayed Down Syndrome. Interventions included to ask yes/no questions to determine their needs, communicate with the resident/family/caregivers regarding resident's capabilities, and cue, reorient, and supervise as needed. The plan included the resident had a terminal prognosis (initiated 06/24/2024) related to end stage dementia and received hospice care. Interventions included to encourage support system of family and friends and observe closely for signs/symptoms of pain. During an interview on 12/09/2024 at 8:52 AM, the Administrator stated they were a Qualified SCREENER for New York State and Resident #115 had been admitted prior to them starting at the facility. The Administrator stated due to the resident's diagnosis, they should have had a Level II Pre-Admission Screening and Resident Review Assessment completed to ensure the resident was appropriate to be placed at the facility and that they received the necessary services needed related to their diagnosis. During an interview on 12/9/2024 at 11:16 AM, the Director of Social Work stated the admission office reviews all documentation prior to admission. The Pre-Admission Screening and Resident Review information would then be passed along to the Director of Social Work for review. The Director of Social Work also stated the previous Director of Social Work should have reviewed Resident #115's paperwork and it was important to ensure residents who were determined to require Level II services had a Level II Assessment completed to ensure they were appropriate to be admitted to the facility and ensure they received the services they needed. The Director of Social Work stated the social work department is responsible for updating the resident's care plan of any Level II services required. 10 NYCRR 415.11(e)

Based on observations, interviews, and record review conducted during the Recertification Survey from 12/02/2024 to 12/09/2024, for one (Resident #4) of two residents reviewed, the facility did not provide specialized care needs for the provision of respiratory care in accordance with professional standard of practice, and the resident's care plan, goals, and preferences. Specifically, Resident #4 was observed intermittently wearing oxygen via a tracheostomy (a surgically created opening in the neck and into the windpipe to breathe through) collar (a soft plastic mask used to deliver oxygen to a person with a tracheostomy tube). There was no physician's order in place for supplemental oxygen use or documentation in the resident's medical record that reflected the use and care of the oxygen. Additionally, the facility was unable to provide evidence that nursing staff had been educated or trained to care for Resident #4's Airvo machine (machine that provides humidified high flow oxygen). This is evidenced by the following: The facility Airvo 2 policy, dated June 2024, included (but not limited to) instructions for use, the step-by-step process for cleaning, and noted that the circuit and water chamber should be changed every 60 days by respiratory therapy. Resident #4 had diagnoses that included chronic respiratory failure, a tracheostomy, and anxiety. The Minimum Data Set Resident Assessment, dated 09/23/2024, documented Resident #4 was cognitively intact, required suctioning and tracheostomy care, and was not receiving continuous or intermittent oxygen therapy. During an observation on 12/02/2024 at 10:34 AM, Resident #4 was observed coming out of their room via motorized wheelchair with an oxygen tank on the back of their wheelchair. An Oxygen in Use sign was on Resident #4's door frame. Review of Resident #4's current physician's orders revealed the resident should use the Airvo machine at all times when in their room with the designated settings (initiated 09/30/2024) and to fill the Airvo water bag with distilled water every four hours (initiated 06/17/2024). The orders did not include the additional use of oxygen via the tracheostomy. Resident #4's current Comprehensive Care Plan reviewed on 12/04/2024, included that Resident #4 had impaired breathing and removed their oxygen at times. The care plan did not include instructions for use of Resident #4's Airvo machine, that the resident was independent with use of the machine, or wore supplemental oxygen via a tracheostomy collar when out of their room. Review of the Medication Administration and Treatment Administration Records from 11/01/2024 to 12/06/2024 did not include any documentation of Resident #4's continuous use of oxygen. Review of a Speech Therapy Evaluation and Plan of Treatment note, dated 06/19/2024, revealed Resident #4 was on three liters of oxygen via their tracheostomy. In an Interdisciplinary Progress Note, dated 11/07/2024, Respiratory Therapist #1 documented they checked Resident #4's Airvo machine and the resident was on three liters per minute of oxygen via a tracheostomy collar. In an Acute Visit Progress Note, dated 11/21/2024, Physician Assistant #1 documented Resident #4 used a tracheostomy collar with oxygen and the treatment plan noted to continue with oxygen via tracheostomy collar. Review of completed Tracheostomy Set-up and Skills Competency Checklists (to be checked as skills were either met or unmet) for Licensed Practical Nurses #11 and #12 (night shift nurses assigned to Resident #4 during the survey), revealed skills related to the Airvo machine were documented as N/A (not applicable). During interviews on 12/02/2024 at 1:12 PM and on 12/03/2024 at 11:40 AM, Resident #4 stated they do not spend a lot of time in their room. The resident stated they wear three liters of oxygen via their tracheostomy collar at all the times (except when smoking). Resident #4 stated the facility's Respiratory Therapist quit three weeks prior and they were nervous that no one else could help them because no one else was trained to care for their tracheostomy. During an observation on 12/04/2024 at 9:58 AM, Resident #4 was wearing three liters of oxygen via their tracheostomy collar. During an interview on 12/04/2024 at 1:05 PM, Licensed Practical Nurse #5 stated Resident #4 wore three liters of oxygen via their tracheostomy collar and Resident #4 was responsible for changing their own inner cannula (tube inserted through main tracheostomy tube, which can be removed for cleaning or replacement) and self-suctioning with staff present. During an interview on 12/05/2024 at 11:19 AM, the Director of Nursing stated Respiratory Therapist #1 last worked on 11/09/2024, and while they were looking to replace the respiratory therapist, no one was currently covering (the position). During an observation in Resident #4's room on 12/05/2024 at 12:40 PM, the Airvo machine's water bag was empty. During an observation on 12/05/2024 at 1:11 PM, Resident #4's oxygen mask was hanging from their wheelchair armrest and the oxygen tank gauge was at empty. During an interview on 12/06/2024 at 4:04 PM, Licensed Practical Nurse #5 stated if a resident required oxygen, it should be on the Medication/Treatment Administration Records so nurses know how much the resident should be on and to monitor it. Licensed Practical Nurse #5 stated Resident #4 did not have a current order for oxygen and should have. Licensed Practical Nurse #5 stated Resident #4 used their Airvo machine overnight when they were in bed and connected it themselves. Licensed Practical Nurse #5 stated they could not explain exactly what the Airvo machine did. During an interview on 12/06/2024 at 4:30 PM, Registered Nurse Manager #1 stated oxygen use should be listed on a resident's care plan and there should be an order. Registered Nurse Manager #1 stated Resident #4 wore oxygen continuously, and believed it was three liters, but would have to check the order. During an observation and interview on 12/06/2024 at 4:45 PM, Resident #4 stated they (staff) would not change their oxygen tank (which was empty at the time) because the resident did not have a current order for the oxygen (via their tracheostomy collar). During an interview on 12/09/2024 at 10:50 AM, the Director of Nursing stated supplemental oxygen required an order. The Director of Nursing stated Respiratory Therapy was responsible for the resident's Airvo machine, and if the resident was independent with use of the machine, they should be care planned for this. 10 NYCRR 415.12(k)(6)

Based on observations, record review, and interviews during the Recertification Survey from 12/02/2024 to 12/09/2024, for one of one main kitchen, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, there were multiple undated food items not in their original containers and a food item was stored uncovered. The findings are: The undated facility policy titled Prepared Foods and Leftovers documented the maximum storage time for refrigerated prepared food items and leftovers was 72 hours and any foods stored beyond that date were to be discarded. Observations in the main kitchen on 12/02/2024 at 8:50 AM, and in the presence of the Food Service Director/Registered Dietitian #2, included the following: - The breakfast preparation cooler contained one undated two-quart container of cooked pureed eggs, one undated pan of cooked bacon, and one undated pan of cooked pancakes. - The cold production cooler contained 8 undated dishes of pumpkin souffle and one uncovered metal bowl of undated vanilla pudding. During an interview on 12/2/2024 at 9:03 AM, the Food Service Director/Registered Dietitian #2 stated it was important for food to be dated to know when it should be discarded to prevent potential food borne illness, and if food items are taken out of the original container or were leftover from a previous meal, those food items should be discarded after three days. The Food Service Director/Registered Dietitian #2 also stated the coolers and freezers were checked daily by all staff for undated food items, and it was important for food items to be covered to prevent contamination. During the follow up visit to the main kitchen on 12/03/2024 at 4:38 PM, and in the presence of Food Service Director/Registered Dietitian #2, there was an undated two-quart plastic container of chicken salad in the cold production cooler. During an interview on 12/03/2024 at 4:57 PM, the Food Service Director/Registered Dietitian #2, stated food service staff should be labeling and dating all food items once they are opened or taken out of their original container to ensure food safety. 10 NYCRR 415.14(h), 10 NYCRR: Subpart 14-1, 14-1.42, 14-1.43(e)

Based on observations, interviews, and record review conducted during a Recertification Survey from 12/02/2024 to 12/09/2024, for three (Residents #36, #41, #42) of eight residents reviewed, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, Resident #41 had their blood sugar checked by a nurse not wearing gloves. Resident #42 was on enhanced barrier precautions (a strategy used by nursing homes to decrease transmission of infectious disease) and received high-contact care from staff not wearing the required personal protective equipment, and infection control practices were not followed during the care of a cholecystostomy (a procedure that creates a surgical opening of the gallbladder to drain it) site. Resident #36 was on enhanced barrier precautions, had an indwelling urinary catheter, and received high-contact care from staff who were not wearing the required personal protective equipment. Additionally, the facility was unable to provide documented evidence that the infection surveillance plan included ongoing analysis of surveillance data and follow-up activity since August 2024. Additionally, the facility did not ensure the Infection Prevention and Control Program policies and procedure were reviewed at least annually as required. This is evidenced by the following: 1. Resident #41 had diagnoses that included diabetes, dementia, and depression. The Minimum Data Set Resident Assessment, dated 11/14/2024, documented Resident #41 was moderately impaired cognitively. Review of the active physician's orders revealed an order for blood sugar checks before meals and at bedtime. During an observation on 12/05/2024 at 12:34 PM, Licensed Practical Nurse #3 performed a blood sugar check with a glucometer (a machine used to check blood sugar levels via a drop of blood) without wearing gloves. During an interview at this time, Licensed Practical Nurse #3 stated it was important to wear gloves during a blood sugar check to prevent cross contamination and any blood contamination, and they should have worn gloves while checking the blood sugar, but forgot. 2. Resident #42 had diagnoses that included cholecystitis (inflammation of the gallbladder), a cholecystostomy tube (tube inserted into the gallbladder to drain fluid), and diabetes. The Minimum Data Set Resident Assessment, dated 10/01/2024, documented Resident #42 was cognitively intact and had a skin ulcer. Review of the active physician's orders revealed a dressing change and tube flush to the cholecystostomy site daily, a dressing change to the right ankle ulcer, and that Resident #42 was on enhanced barrier precautions. During an observation on 12/02/2024 at 11:00 AM, Licensed Practical Nurse #4 provided wound care to the ankle ulcer and the cholecystostomy site wearing gloves but no gown. An enhanced barrier precaution sign was posted in the room and a blue star (per staff interviews indicated enhanced barrier precautions required) was posted next to Resident #42's name outside their room. The enhanced barrier precautions sign included to wear a gown with high-contact resident care. During an observation on 12/03/2024 at 9:50 AM, Certified Nursing Assistant #5 washed and dressed Resident #42 and changed their incontinence brief. Certified Nursing Assistant #5 wore gloves but no gown. During an observation on 12/05/2024 at 11:18 AM, Licensed Practical Nurse #3 flushed Resident #42's cholecystostomy tube. During the flush process, License Practical Nurse #3 removed the port cap from the cholecystostomy tube and attached a syringe to the tubing without cleaning the flush port and did not clean the cap prior to reattaching it to the flush port. During an interview at this time, Licensed Practical Nurse #3 stated they should have cleansed the flush port prior to flushing and the port cap prior to reattaching it to the tube. 3. Resident #36 had diagnoses that included neuromuscular dysfunction of the bladder (improper drainage of the bladder often resulting in incontinence or difficulty urinating completely), schizophrenia, and chronic pain syndrome. The Minimum Data Set Resident Assessment, dated 10/22/2024, documented Resident #36 had moderate impairment of cognitive function and an indwelling urinary catheter. Review of the active physician's orders revealed Resident #36 had an indwelling urinary catheter and was on enhanced barrier precautions. During an observation on 12/04/2024 at 9:59 AM, Certified Nursing Assistant #5 provided direct hands-on care to Resident #36 (changed their brief and assisted with dressing) and emptied their urinary catheter drainage bag. Resident #36 had a blue star next to their name outside their door and no enhanced barrier precaution sign in their room. Certified Nursing Assistant #5 was wearing gloves and no gown. During an interview at this time, Certified Nursing Assistant #5 stated they did not know what a blue star meant and would look for a sign to see if a resident was on precautions. Certified Nursing Assistant #5 stated they did not know they needed to wear a gown when providing hands on care for Resident #36. During an interview on 12/06/2024 at 5:06 PM, the Director of Nursing stated residents with wounds and indwelling urinary catheters should be on enhanced barrier precautions and all staff should wear a gown and gloves when providing high-contact care. The Director of Nursing also stated the Licensed Practical Nurse should have cleansed Resident #42's cholecystostomy tube's flush port before and after flushing and the port cap should have been cleansed prior to being reattached to the flush port. The Director of Nursing stated all nurses should wear gloves when checking blood sugars. 4. Review of multiple Infection Prevention and Control facility policies that included the Antibiotic Stewardship policy, Bloodborne Pathogen policy, Resident Influenza and Pneumococcal Vaccine policy, Personal Protective Equipment policy, and the Employee Influenza and Pneumococcal Vaccine policy revealed none were dated as to when they were last reviewed or revised. Review of facility form titled Infection and Antibiotic Tracking Tool on 12/06/2024 at 10:19 AM with the Director of Nursing and the Infection Preventionist revealed that the previous Infection Preventionist completed the form for July 2024 and August 2024, but the documentation for September 2024, October 2024, and November 2024 did not include ongoing surveillance, analysis, and documentation of facility follow-up activity of infections and antibiotic use. During an interview at this time, the Director of Nursing stated the facility had no designated Infection Preventionist from mid-August 2024 until 10/31/2024, and the Director of Nursing and Administrator had maintained the tracking and surveillance for resident infections. The Director of Nursing stated facility policies were reviewed and updated on an as-needed basis. The facility policy titled Infection Prevention Plan, last reviewed and updated in March 2024, documented that facility policies are reviewed and approved every three years or as needed based on regulatory guidelines, and the bloodborne pathogen policy should be reviewed annually. 10 NYCRR 415.19(a) (1-3)

Based on observation, interview, and record review conducted during a Recertification Survey from [DATE] to [DATE], for one (Resident #127) of 36 residents reviewed, the facility did not ensure that all residents had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive (a resident's wishes to be or not to be resuscitated in the event of an acute cardiac or pulmonary arrest) that would be honored. Specifically, the facility did not ensure Residents #127's advance directive identifiers were consistent with the resident's wishes. This is evidenced by the following: The facility policy Advanced Directives and Code Blue, dated [DATE], included an advanced directive should be maintained in the resident's medical record and should the resident wish to review or revise their advanced directive, the Social Service/Nursing/Designee would be contacted to assist the resident if necessary. All follow-up education and interaction with the resident/significant other should be documented in the medical record by the individual designated to interact with the resident/significant other regarding their concerns surrounding advanced directives. Resident #127 had diagnoses that included a stroke, anxiety, and depression. Review of an Acute Visit Progress Note, dated [DATE] and signed by Nurse Practitioner #1, revealed Resident #127 was alert and oriented to person, place, and time. Review of Resident #127's Medical Orders for Life Sustaining Treatment (MOLST) form, dated [DATE], revealed the resident's advanced directive wishes were for Do Not Resuscitate (allow natural death). The Medical Orders for Life Sustaining Treatment form included Resident #127 was the individual making the decision and verbal consent had been obtained. Review of current Physician orders, dated [DATE], revealed Resident #127's advanced directive wishes were for full cardiopulmonary resuscitation ([CPR] meaning to initiate cardiopulmonary resuscitation in the event of acute cardiac or respiratory arrest). The order was entered into the electronic medical record by the Director of Nursing. Review of Resident #127's current Comprehensive Care Plan on [DATE] revealed the resident's advanced directive wishes were for Do Not Resuscitate. In an admission note (readmission from the hospital), dated [DATE], Nurse Practitioner #2 documented that Resident #127's advanced directive wishes were for Full Code. In a Nursing Progress Note, dated [DATE], Nurse Manager #1 documented that Resident #127 was readmitted from the hospital and a Do Not Resuscitate (Medical Orders for Life Sustaining Treatment) form was completed at the resident's bedside. Review of Interdisciplinary Progress Notes from [DATE] through [DATE] did not reveal any documentation related to a change of advanced directives since Resident #127's [DATE] Medical Orders for Life Sustaining Treatment form was filled out. During an interview on [DATE] at 9:18 AM, Licensed Practical Nurse #13 stated to determine a resident's advanced directive wishes, they would look in the computer (resident's electronic medical record) or the resident's Medical Orders for Life Sustaining Treatment form. During an interview on [DATE] at 1:47 PM, the Director of Nursing stated a resident's advanced directive wishes are determined on admission and the resident's Medical Orders for Life Sustaining Treatment form if they came in with one was reviewed (to ensure current wishes). The Director of Nursing stated nursing staff should refer to the Medical Orders for Life Sustaining Treatment form as primary place or refer to the resident's electronic medical record. The Director of Nursing stated Resident #127 was a Do Not Resuscitate per their Medical Orders for Life Sustaining Treatment form. During a review at this time with the surveyor, Resident #127's physician's orders included the resident was a Full Code. The Director of Nursing stated they entered the Full Code order on [DATE] as they may have received an email from the Social Worker that there was change, but could not recall. In a follow-up interview at 2:56 PM, the Director of Nursing stated they spoke with Resident #127 who verbalized their advanced directive wishes at this time were for Full Code. 10 NYCRR 415.3(f)(1)(ii)

Based on observations, interviews, and record review conducted during the Recertification Survey from 12/02/2024 to 12/09/2024, for two (Residents #4 and #53) of six residents reviewed, the facility did not develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs including resident goals, desired outcomes and preferences related to their ongoing smoking habits. Specifically, the facility was aware that Residents' #4 and #53 continued to smoke against facility policy and there was no care plan in place to ensure the residents remained safe. This is evidenced by the following: 1. Resident #4 had diagnoses that included chronic respiratory failure, anxiety, and a tracheostomy (surgically created hole in the windpipe that provides alternative airway for breathing). The Minimum Data Set Resident Assessment, dated 09/23/2024, revealed Resident #4 was cognitively intact and used a wheelchair. Review of the Smoking Assessment Policy and Assessment form, dated 07/08/2024, and signed by Resident #4 revealed that the resident did smoke cigarettes daily, was on oxygen, was considered safe to smoke by themselves, and was educated that the facility was a non-smoking facility. Review of Resident #4's current Comprehensive Care Plan did not include any information related to the resident's non-compliance with the facility's smoking policy, safety concerns related to continuing to smoke, care of smoking materials, ongoing education, or cessation efforts if desired. During an interview on 12/04/2024 at 1:05 PM, Licensed Practical Nurse #5 stated Resident #4 had a pass to go outside to smoke independently. Licensed Practical Nurse #5 stated the nurses do not assist the resident to smoke and they thought they saw the resident locking their smoking materials in their room. During an interview on 12/06/2024 at 4:30 PM, Registered Nurse Manager #1 stated Resident #4 was noncompliant (with the facility's non-smoking policy), smoked off facility grounds, and this noncompliance with smoking should be on their care plan. 2. Resident #53 had diagnoses that included a below the knee amputation, pulmonary disease, and congestive heart failure. The Minimum Data Set Resident Assessment, dated 10/23/2024, documented the resident was cognitively intact and current tobacco use was indicated at the time. Review of the Smoking Assessment Policy and Assessment form, dated 02/27/2024 and signed by Resident #53, revealed the resident smoked for the past [AGE] years, declined smoking cessation support, and the resident acknowledged the facility's no smoking policy and does not comply with it. Review of Resident #53's current Comprehensive Care Plan did not include any information related to the resident's non-compliance with the facility's smoking policy, safety concerns related to continuing to smoke, care of smoking materials, ongoing education, or cessation efforts if desired. During an interview on 12/05/2024 at 11:39 AM, Resident #53 stated they went outside to smoke a cigar twice weekly despite being told that smoking was not allowed at the facility and had had their smoking supplies taken away by the Social Worker. The resident also stated they were also told by the Administrator where they could go if they insisted on smoking. Resident #53 stated they kept a lighter hidden in their dresser drawer to avoid having it stolen or confiscated. During an interview on 12/06/2024 at 9:55 AM, Certified Nurse Assistant #1 stated they had seen Resident #53 outside smoking while they were taking a break and the resident wore a pass around their neck to indicate they could leave the unit and building unsupervised. During an interview on 12/06/2024 at 11:01 AM, the Administrator stated they discouraged smoking at the facility and if they see on admission that a resident smokes, they encourage their admission planner to enforce that there was no smoking at the facility. The Administrator also stated they had spoken to Resident #53 in the past after the resident went out to smoke and was out of their eyesight and they were worried about the resident's safety. The Administrator stated that smoking assessments were conducted by their therapy department and if residents insisted on smoking, it should be documented on their care plan. During an interview on 12/09/2024 at 10:50 AM, the Director of Nursing stated the purpose of care plans were to inform the staff how to care for the residents. The Director of Nursing also stated as soon as they learn a resident smokes and is noncompliant, it should be put on their care plan. The Director of Nursing stated Resident #4 was not a smoker when they were first admitted , which is perhaps why the resident's care plan did not include any information related to smoking. 10 NYCRR 415.11(c)(1)

Based on observations, interviews, and record review conducted during a Recertification Survey from 12/02/2024 to 12/09/2024, the facility did not ensure that residents received care in accordance with professional standards of practice, their person-centered care plan, and resident's choice for 2 (Residents #53 and #81) of 29 residents reviewed for quality of care. Specifically, Resident #53 was not wearing a physician ordered compression wrap following a recent amputation of their right lower extremity on multiple observations. Resident #81 had multiple falls, one resulting in a major injury, and there was no documented evidence that the resident had been assessed by a Registered Nurse or that neurological checks had been completed following a fall with a potential head injury. This is evidenced by the following: The facility's undated Resident Fall Policy documented that prior to moving a resident after a fall, the Registered Nurse/Licensed Practical Nurse must assess/evaluate the resident for physical injury. Care and transfer will be provided as determined by the Registered Nurse/Licensed Practical Nurse based upon the post fall assessment. Vital signs are obtained as allowed and documented. If a fracture is suspected, the resident should not be moved and made as comfortable as possible at the site of the fall or found on the floor. If a head injury is suspected, the protocol for possible head injury and neurological checks are initiated and a neuro check flow sheet utilized for documentation and the physician notified. 1. Resident #81 had diagnoses that included a cognitive communication deficit and Huntington's disease (disease of the nervous system that affects a person's movements, thinking ability, and mental health). The 09/05/2024 Minimum Data Set Resident Assessment documented the resident had moderately impaired cognition, did not have upper or lower extremity impairments, did not use any mobility devices, and required supervision or touching assistance with most activities of daily living. The resident had two falls with no injury and one fall with major injury since the previous assessment. Resident #81's Comprehensive Care Plan, dated as last revised 09/18/2024, and the current Bedside Kardex (care plan used by the Certified Nursing Assistants for daily care) documented the resident had limited physical mobility, was at risk for falls, had a history of falls, impulsive behaviors, and had at times sat themselves on the floor. Interventions included, but were not limited to, the resident required supervision with transfers, did not use assistive devices, required supervision with ambulation, housekeeping should keep floors clean after meals as possible, and to follow facility fall protocol. In an Unwitnessed Fall Report, dated 08/05/2024 at 9:04 AM, Licensed Practical Nurse Manager #1 documented Resident #81 was found on their knees at 9:04 AM and that seconds prior to the incident, staff observed the resident seated in the dining room. The resident was unable to give a description of the event and the incident was unwitnessed. Immediate action taken included that vital signs were normal and range of motion of extremities was within normal limits. The resident denied hitting their head and it appeared they slid to the floor from how they were positioned. They had blanchable redness (redness that goes away and then comes back) on both knees, but the resident denied discomfort or pain. There were no observed injuries at the time of incident, the resident was alert and oriented, and had nonskid footwear on at the time. Predisposing physiological factors included impaired cognition and impaired judgment. The report notes, completed on 08/07/2024 (two days after the fall), by the facility's Administrator documented the resident had fallen with no injuries sustained and had been placed on 15-minute safety checks until bedtime. The Administrator documented that per the nursing supervisor, there were no care plan violations, mistreatment, neglect, or abuse identified. There was no documented evidence that a Registered Nurse has assessed Resident #81 either on-site or remotely following the fall. In an Unwitnessed Fall Report, dated 08/20/2024 at 12:39 PM, Licensed Practical Nurse Manager #1 documented Resident #81 was found sitting on their buttocks on the floor in the dining room with their legs extended. Staff had informed them that the resident may have bumped their head. Immediate action taken included that vital signs were normal and range of motion was normal. Neuro checks were initiated and predisposing environmental factors included a wet floor. The section titled 'injuries observed at time of incident' included fracture of right elbow and the section titled 'injuries report post incident' included no injuries observed post incident. The fall report did not include any follow-up related to a possible elbow fracture. Review of the Head Injury Flow Sheet, dated 08/20/2024, revealed the resident was to be monitored 12 times post incident for changes in neurological status and 6 of the 12 checks were not signed off as completed. In a nursing progress note, dated 08/21/2024 at 10:39 AM, Licensed Practical Nurse #10 documented Resident #81 complained of arm pain. Physician #1 was in for a follow-up visit and ordered an X-ray. At 2:49 PM, Licensed Practical Nurse Manager #4 documented the X-ray results showed a probable elbow fracture with soft tissue swelling and an orthopedic evaluation was recommended. Review of Resident #81's electronic medical record from 08/05/2024 to present revealed no documented evidence that a Registered Nurse had assessed the resident after either of the two unwitnessed falls. During an interview on 12/06/2024 at 4:18 PM, the Director of Nursing stated when a resident had an unwitnessed fall, staff should notify the nursing supervisor who should ensure the safety of the resident and start the incident report. Licensed Practical Nurses could only gather information and present it to the Registered Nurse as a Registered Nurse should assess the resident either physically or virtually if they were not present in the building. The Director of Nursing stated they do not see documentation that a Registered Nurse saw the resident on 08/05/2024 or 08/20/2024. The Director of Nursing stated residents should be assessed by a Registered Nurse after each incident and the Registered Nurse should document their findings in the resident's medical record. During a follow-up interview on 12/09/2024 at 9:03 AM, the Director of Nursing stated they thought a Registered Nurse did assess the resident after the 08/05/2024 and 08/20/2024 fall, but there was no documentation in the medical record, and it could not be assumed and that it was important for a Registered Nurse to assess the resident to rule out injury. They stated nursing staff should have completed the neurological checks after the unwitnessed fall to rule out any neurological changes. During an interview on 12/09/2024 at 10:57 AM Licensed Practical Nurse Unit Manager #1 stated sometimes they were the building supervisor (was not scheduled as such for the two incidents). If a resident had a fall, they would see the resident, gather information, look for any environmental factors or care plan violations, complete the incident report, and place a note in the medical book. If a resident was unable to describe what happened and it was an unwitnessed incident, they would check the resident's range of motion and skin. If they noticed any pain with range of motion or bruising, they would stop and notify the Registered Nurse, but if they did not observe any issues, they just document the incident and notify medical team via the communication book. They recalled the 08/20/2024 incident and recalled the nurse on the unit told them the resident had no new noted skin issues and was able to move their arms and legs without issues. In this case, they do not always call the Registered Nurse (on call). 2. Resident #53 had diagnoses that included a recent right below the knee amputation, arthritis, and diabetes. The Minimum Data Set Resident Assessment, dated 10/23/2024, documented the resident was cognitively intact and received scheduled and as needed pain medications. Review of a physician's orders, dated 11/19/2024, revealed Resident #53 required an ace wrap compression at all times to the right below the knee amputation to reduce swelling. Resident #53's Comprehensive Care Plan, revised on 10/31/2024, documented the resident had acute and chronic pain related to a surgical amputation of their right lower extremity, but did not include that the resident should wear an ace wrap compression. Review of the nursing progress notes for December 2024 did not reveal any documentation that Resident #53 had refused to wear the ace wrap compression to their right lower extremity. During an observation and interview on 12/04/2024 at 9:27 AM, Resident #53 was seated in their wheelchair in their room, wearing a sweatshirt and brief. There was no compression wrap to the right lower extremity. The resident stated their right leg was recently amputated and their stump should be wrapped, but no one wraps it because they were too busy. Resident #53 stated staff often say they would be right back, but then they do not return. During an observation on 12/04/2024 at 11:21 AM, Resident #53 was in the dining room playing BINGO. There was no ace wrap compression applied to their right lower extremity. During an observation and interview on 12/06/2024 at 9:41 AM, Resident #53 was lying in bed with complaints of pain and stated the severity was eight out of ten. There was no ace wrap compression to their right lower extremity. Resident #53 stated their ace wrap compression had been on, but it had come off during the night. The resident stated around 5:00 AM, the nurse came into their room with their morning medications, they asked if the nurse could reapply the ace wrap compression, they were told by the nurse they would come back to reapply it once they were done passing medications, but never returned. During an interview on 12/06/2024 at 9:55 AM, Certified Nurse Assistant #1 stated that Resident #53 often complained of pain due to their recent amputation and the resident is often without their compression wrap in place, but they could not apply it because it was the nurse's responsibility. During an interview on 12/06/2024 at 1:17 PM, the Director of Nursing stated the nurses should apply Resident #53's ace wrap compression as ordered and if the wrap needed to be reapplied, they would expect the nurse to do so as soon as possible but the resident should never have to wait hours. During an interview on 12/06/2024 at 1:55 PM, Licensed Practical Nurse Manager #1 stated that Resident #53 often complained of pain and they have instructed all nurses to look at the medical orders after their medication pass to see what orders needed to be completed, but due to the unit being acute, the orders did not always get completed promptly. 10 NYCRR 415.12

Based on observations, interviews, and record review conducted during the Recertification Survey from 12/02/2024 to 12/09/2024, for one (Resident #11) of two residents reviewed for communication, the facility did not ensure the resident received treatment and/or assistive devices to maintain their hearing. Specifically, the facility did not ensure the resident's hearing aids were repaired in a timely manner. This is evidenced by the following: Resident #11 had diagnoses that included auditory hallucinations, high blood pressure, and depression. The Minimum Data Set Resident Assessment documented Resident #11 was cognitively intact, was hard of hearing, and wore hearing aids. During an observation and interview on 12/02/2024 at 10:00 AM, Resident #11 was not wearing either hearing aid. Resident #11 stated at this time they could not hear unless voices were raised as they normally wore hearing aids, but had not had them for the last two months because they were broken. The Comprehensive Care Plan, dated 11/01/2024, and the Kardex (a care plan used by the Certified Nursing Assistants to provide daily care), dated 12/09/2024, documented Resident #11 had hearing aids to assist with communication. Review of the current physician's orders included an order, dated 04/03/2024, for hearing aids to be placed in the morning and removed at night. Review of the Treatment Administration Record and notes, dated 10/03/2024 to 12/02/2024, revealed multiple entries that the hearing aid(s) were broken and awaiting repair. In an email, dated 10/09/2024, to Long Term Care Management Provider #1, Quality Assurance and Performance Improvement Coordinator #1 documented Resident #11's hearing aid was broken and needed to be fixed. In an email, dated 10/15/2024, to Quality Assurance and Performance Improvement Coordinator #1, Long Term Care Management Provider #1 documented they were waiting to hear back from them to coordinate picking up Resident #11's hearing aid(s). During an interview on 12/05/2024 at 11:35 AM, Licensed Practical Nurse Manager #4 stated Resident #11 had a broken hearing aid and they had notified Quality Assurance and Performance Improvement Coordinator #1 to coordinate with Long Term Care Management Provider #1 to get the hearing aid(s) fixed. During an interview on 12/05/2024 at 11:45 AM, Quality Assurance and Performance Improvement Coordinator #1 stated they are responsible for coordinating with Long Term Care Management Provider #1 to have the hearing aids picked up to be sent out for repair, but they had not had any communication with them since 10/15/2024, and the broken hearing aid(s) was still in the facility (unrepaired). Quality Assurance and Performance Improvement Coordinator #1 stated Resident #11's hearing aids should have been picked up for repair sooner, but they were the only one handling appointments and transportation for the rest of the facility, and the hearing aids got lost in the shuffle. During an interview on 12/06/2024 at 5:06 PM, the Director of Nursing stated coordination with Long Term Care Management Provider #1 should have been done sooner and two months was too long of a time period for hearing aids to get fixed. 10 NYCRR 415.12(3)(b)(1-3)

Based on observations, interviews, and record review conducted during the Recertification Survey and complaint investigation (NY00361034) from 12/02/2024 to 12/09/2024, the facility did not ensure acceptable parameters of nutritional status for one (Residents #127) of five residents reviewed. Specifically, nutritional assessments by a registered dietician were not performed during Resident #127's initial and readmission to the facility and documented weight losses were not identified timely. This is evidenced by the following: The undated facility policy Nutrition Assessment included that a registered dietician would perform a comprehensive nutrition assessment on residents to determine their risk for malnutrition or nutrition-related problems. A nutrition assessment would be completed on all residents on admission, annually, quarterly, and as needed. The assessment would include (but not limited to) review of documented weights, weight histories as available, clinical factors, and interviews with the resident as appropriate and available. Documentation would be provided in the electronic medical record. Resident #127 had diagnoses that included a stroke, dysphagia (difficulty swallowing), and adult failure to thrive. The Minimum Data Set Resident Assessment, dated 09/11/2024, revealed Resident #127 had a feeding tube, a documented weight of 152 pounds, and any weight loss had not occurred or was unknown. In an Acute Visit Progress Note, dated 11/15/2024, Nurse Practitioner #1 documented Resident #127 was alert and oriented to person, place, and time. Resident #127's current Physician orders, reviewed on 12/05/2024, included a regular diet, one carton of Very High Calorie Boost (nutrition supplemental drink) daily, and monthly weights between the first and third of every month. The current Comprehensive Care Plan, reviewed on 12/05/2024, included Resident #127 was independent with eating, required set-up assist, and was at risk for altered nutrition with interventions that included monthly and as needed weights. Review of a Hospital Nutritionist Note, dated 07/31/2024 (prior to Resident #127's admission to the facility), revealed Resident #127's weight of 113.5 pounds. Review of Resident #127's electronic medical record revealed a 26.6% weight loss over approximately three months (09/05/2024 to 12/02/2024) based on the following documented weights at the facility: - 08/11/2024: 157 pounds - 09/05/2024: 152 pounds - No weight documented after a readmission from the hospital on 09/19/2024. - No weight documented for October 2024. - 11/01/2024: 104.8 pounds - 12/02/2024: 111.6 pounds Review of a Hospital Nutritionist Note, dated 09/17/2024, revealed Resident #127 presented to the hospital on 09/11/2024 and weighed 111.2 pounds on 09/12/2024. In a Readmission Note, dated 09/22/2024, Physician #2 documented that prior to Resident #127's transfer to the hospital, their weight had declined and the resident's readmission weight was pending. Review of Nutrition Assessments revealed a comprehensive Nutrition Assessment had not been completed by a registered dietician on Resident #127's admission to the facility in August 2024 or on their readmission to the facility in September 2024. A Mini Nutrition Assessment (screening tool used to identify residents who are malnourished or at risk for malnutrition) was conducted on 08/12/2024, which identified Resident #127 at risk for malnutrition. A Comprehensive Nutrition Assessment was subsequently completed on 11/14/2024 (by Registered Dietician #1), which included unknown weight loss or gain in the past one, three, and six months. During an interview on 12/05/2024 at 3:01 PM, Registered Dietician #1 stated nutrition assessments were done on admission, quarterly, and if significant changes and were based on the Minimum Data Set Resident Assessments (schedule). Nutrition assessments included review of the resident's electronic health record, visiting the resident, and observing them at meals. Dietician #1 stated a resident's readmission to the facility from the hospital should trigger a Minimum Data Set Resident Assessment, which would show up on their list (to do a nutrition assessment). Registered Dietician #1 stated weights were done monthly or on a weekly basis if needed for tracking, and residents should be re-weighed if something was awry. Registered Dietician #1 stated significant weight loss is the standard for one (5%), three (7.5%), and six (10%) months. Registered Dietician #1 stated the first time they saw Resident #127 was in November 2024 (only works one day a week), and a Comprehensive Nutrition Assessment was done then. Review of the Comprehensive Nutrition Assessment with Registered Dietician #1 at the time revealed that the 11/14/2024 Nutrition Assessment included that Resident #127's (meal) intake was greater than 75%, was receiving Boost supplements to promote weight gain, and they would monitor the resident's weight trends. Registered Dietician #1 stated a Nutrition Assessment should have been done after Resident #127 was readmitted on [DATE], but they were not in the facility that week. Registered Dietician #1 stated Resident #127's weights from September to November met the criteria for significant weight loss, but because the resident had gone to the hospital and had a feeding tube (not in use for nutrition), they chose to use the resident's status in November 2024 as their baseline to work with going forward. During an interview on 12/06/2024 at approximately 3:15 PM, Food Service Director/Registered Dietician #2 stated if a resident was a full readmission (not just a visit to the emergency room ), a Comprehensive Nutrition Assessment was required. Food Service Director/Registered Dietician #2 stated significant weight loss or gain is a five percent difference over 30 days and ten percent difference over 180 days. They did not see a Comprehensive Nutrition Assessment following Resident #127's August 2024 admission, were not sure why one was not done, and that they should also have had one when they were readmitted on [DATE], but did not. Food Service Director/Registered Dietician #2 stated they suspected Resident #127's initial weights (in August obtained by the facility) were inaccurate because the hospital notes listed the resident weighing 113 pounds and the Comprehensive Nutrition Assessment (if completed) would have picked up on the weight discrepancies. Food Service Director/Registered Dietician #2 stated they could not recall notifying the medical provider about Resident #127 potential weight loss. During an interview on 12/09/2024 at 10:57 AM, with the facility Administrator and the [NAME] President of Human Resources, the Administrator stated the facility had a performance improvement project related to timely identification of weight losses. 10 NYCRR 415.12(i)(1)