Every finding on record at Lutheran Center At Poughkeepsie Inc

Based on observation, record review and interview conducted during survey, the facility failed to ensure each resident received adequate supervision and consistent with resident needs to prevent accidents for two (2) of four (4) residents (Resident #9, Resident #8) reviewed for accidents. Specifically, on 03/25/2026, Resident #9 left the facility though an alarmed fire door, staff did not respond for over three (3) minutes to the alarm, and the resident fell in the parking lot and was found bleeding with abrasions to their forehead, nose and knees. 2) Resident #8 was at high risk for falls and care planned to be in the dining room in view of staff. On 04/07/2026, the resident fell in the dining room and sustained a large bump on the forehead while the certified nurse aide providing supervision was looking at their phone and out the window. This resulted in actual harm to Resident #8 and #9 that was not Immediate Jeopardy. Findings include: The facility policy Elopement / Wandering, last reviewed 12/2025, documented the purpose of the policy was to promote the safety of all residents, notification of appropriate parties, and to train and maintain staff awareness of the importance of resident safety and security. Elopement is defined as the ability of a dependent resident to successfully leave the facility unsupervised and unnoticed. 1) Resident #9 had medical diagnoses including encephalopathy (brain dysfunction) dementia, and gait/walking difficulties. A quarterly Minimum Data Set (a resident assessment tool) dated 01/26/2026 documented Resident #9 had severely impaired cognition. The Wander Risk Scale dated 05/09/2025 documented Resident #9 was at risk to wander and was confused, wandered on the unit and in and out of other residents' rooms. The physician order dated 05/16/2025 documented Resident #9 had an electronic monitoring device, and it was to be checked every shift. Physician orders dated 05/27/2025 documented Resident #9 was to receive one-to-one (1:1) staff supervision as needed for increased agitation, wandering and/or exit seeking. Resident #9's care plan The resident has impaired cognitive function/dementia or impaired thought processes related dementia dated 05/09/2025 documented the resident would develop skills to cope with cognitive decline and maintain safety. Resident #9's care plan Risk for wandering related to dementia dated 05/12/2025 documented the resident was often looking for car and car keys. Interventions included an electronic monitoring device to their left ankle, disguised exit doors, to monitor Resident #9's location every hour and to redirect calmly if they enter another resident's room. Resident #9's care plan The resident is an elopement risk/wanderer dated 08/28/2025 documented the resident would not leave facility unattended, and the resident's safety would be maintained. Interventions included disguising exits and providing structured activities. The elopement evaluation dated 01/26/2026, documented Resident #9 was identified as an elopement risk. A score of one (1) or higher indicates Risk of Elopement, Resident #9 scored seven (7) out of nine (9). The Incident & Accident form, dated 03/25/2026, and Registered Nurse Supervisor #8's nursing progress note dated 03/25/2026 at 8:30 PM, documented at 7:00 PM Resident #9 had an unwitnessed fall and elopement and was observed lying on their left side in the south side parking lot. Licensed Practical Nurse #24 reported to Registered Nurse Supervisor #8. The report documented that Resident #9 had a laceration on their forehead and an abrasion to the nose. Resident #9 stated they were looking for their truck. The resident's electronic monitoring device was in place. The resident was transferred to the hospital for further evaluation. Licensed Practical Nurse #24's progress note dated 03/25/0226 at 9:52 PM documented they were returning to the unit, entered the floor to an alarm blaring and Licensed Practical Nurse #25 was at the entrance checking the alarm. Licensed Practical Nurse #24 told Certified Nurse Aide #26 to check Hallway #2. At the nurses' station, the alarm panel showed the alert coming from Hallway #3. They went in that direction and opened the door, checked surroundings and found Resident #9 lying on their left side and bleeding from the face. Registered Nurse Supervisor #8 and Licensed Practical Nurse #25 were alerted. Registered Nurse Supervisor #8 assessed the resident and emergency medical service was called. Resident #9 was transported to the hospital. Certified Nurse Aide #27's statement dated 03/25/2026 documented they were with another resident at the time of the incident and the last time they saw the resident was during dinner. Resident #9 kept repeating being told to sit down and slow down; he was mad about finding his car. Certified Nurse Aide #21's statement dated 03/25/2026 documented they were coming back from cardiopulmonary resuscitation class at the time of the incident. The last time they saw Resident #9 was during dinner and the resident was asking for their truck. Licensed Practical Nurse #25's statement dated 03/25/2026 documented they were doing a medication pass then were at the nursing station at the time of the incident. The last time they saw Resident #9 was in the dining room and they were asking for their truck. Certified Nurse Aide #22's statement dated 03/25/2026 documented they were Resident #9's assigned certified nurse aide and the last time they saw the resident was during dinner. Certified Nurse Aides #26 and #23's statements dated 03/25/2026 documented they were taking care of other residents at the time of the incident and the last time they saw Resident #9 was at dinner. Both statements documented that they did not notice anything about the resident's behavior. The emergency department physician note dated 03/26/2026 documented the resident stated they fell and their face hurt. Symptoms included pain localized to a facial abrasion, bilateral knee discomfort with motion, and mild pain high on the right posterior neck/occiput region. The resident underwent computed tomography (CT) scans of the head, maxillofacial (jaws and face) and cervical (neck) spine and received a Tdap (tetanus, diphtheria, and whooping cough) vaccine. The wounds were cleansed, and the resident was discharged back to the facility when imaging came back negative. Medical Doctor #2's progress note dated 03/26/2026 at 8:49 PM documented Resident #9 was seen for evaluation of a fall that happened yesterday. Resident #9 received skin abrasions on their forehead and bilateral knees and left shoulder. Resident #9 denied any complaints except some pain in the knees, shoulder and forehead. Medical Doctor #2 ordered to monitor vital signs, added neurological checks every shift for three (3) days and standing order for Tylenol 650 milligrams every eight (8) hours for ten (10) days. The physician order dated 03/26/2026 documented two (2) Tylenol 325 milligram tablets every eight (8) hours for pain for 10 days. Additionally, there were orders for Bacitracin (topical antibiotic) ointment to the face, left shoulder, and bilateral knees topically two (2) times a day for abrasions. The facility investigation submitted to the New York State Department of Health on 03/26/2026, documented an elopement on 03/25/2026 with the last time the resident was seen as 7:00 PM. The investigation documented the system to prevent elopement functioned properly and the resident returned. The resident was observed lying in the parking lot at 7:05 PM, was alert and stated they were looking for their truck. Abrasion noted to the nose, laceration noted to the forehead, pressure dressing applied and transferred to the hospital to rule out injuries, returned to the facility with no major injuries. The camera footage showed Resident #9 open the fire exit door at 7:02 PM and went outside to the parking lot. Licensed Practical Nurse #25 started looking for the resident at approximately 7:03 PM. Licensed Practical Nurse #24 instructed Certified Nurse Aide #26 to go to Hallway #2 to check. Licensed Practical Nurse #24 looked at the nurse's station alarm panel which showed the alert coming from Hallway 3. Licensed Practical Nurse #24 went in that direction and opened the door at 7:05 PM and observed Resident #9 lying on the ground in the parking lot. Immediate response and plan to prevent recurrence included: Resident #9 was assessed by Registered Nurse Supervisor #8 and sent to the hospital. Education was immediately initiated with staff upon notification of the incident. Fire exit doors were supervised by the staff immediately and after the incident and one to one (1:1) supervision with the resident upon return from the hospital. The unit census was counted and made sure all other residents were safe. Doors were continuously monitored. During an observation on 04/06/2026 at 12:30 PM, Resident #9 stood up in the dining room and stated they had to find their car. The resident was redirected by staff. During an interview and observation on 4/09/2026 at 10:24 AM, Licensed Practical Nurse #6 stated Resident #9 left the facility and fell outside on 03/25/2026. Resident #9 had an electronic monitoring device, but the electronic monitoring device did not prevent the fire exit door from opening. Fire exit doors could be pushed open and then the alarm goes off. Residents could exit the fire door, walk six (6) feet to a second unlocked door and exit the building into the parking lot. The facility front doors and other doors would lock when a resident with an electronic monitoring device was near the door. Licensed Practical Nurse #6 demonstrated opening the fire door and the alarm went off; it was loud, and another staff responded instantly. They stated the alarm would continue to sound until it was turned off by staff. During observation of camera footage on 04/13/2026 at 12:01 PM, the Director of Nursing was present and provided names of staff and residents during the observation; the video was stamped with date and time. On 03/25/2026 at 7:01 PM, Hallway #3 had a vacant med cart against the wall at the end of the hallway closest to the nurses' station. Resident #9 walked down the hallway, past the fire door to the sitting area, and then turned back around and went to the fire exit door. The resident exited at 7:02 PM. At 7:02:36 PM, a visitor walked down the hall and entered the resident room across from the fire door that Resident #9 exited. At 7:03:38 PM, another resident was seen wheeling in their wheelchair and stopped in the hallway next to the med cart. At 7:04:10 PM, Certified Nurse Aide #27 pushed Resident #97's wheelchair, going around the other resident, and into a resident room. Certified Nurse Aide #27 came out of the room, walked across the hall, in and out of another resident room, then grabbed towels off the linen cart and went back in Resident #97's room. At 7:05:04, Licensed Practical Nurse #24 walked down the hall and exited though the fire door at 7:05:17 PM. At 7:06 PM, Licensed Practical Nurse #25 ran down the hall, exited, and came back in at 7:07:57 PM. The Director of Nursing stated there were no camaras outside to review. During an interview on 04/13/2026 from 12:09 PM to 12:56 PM, the Director of Nursing stated staff should have responded when the fire alarm sounded. They stated Certified Nurse Aide #27 said they did not hear the alarm. Certified Nurse Aide #22 said they were in a room giving resident care and the radio was loud. Certified Nurse Aide #26 said they were in a room giving care and the TV was loud, so they did not hear the alarm. Licensed Practical Nurse #25 said they were giving medications. Licensed Practical Nurse #24 and Certified Nurse Aide # 21 were at the cardiopulmonary resuscitation class and when they returned to the unit the alarm was going off. Licensed Practical Nurse #24 went to the panel and saw it was Hallway #3 and went out the fire door and found the resident in the parking lot. Licensed Practical Nurse #24 called the Supervisor, and they went to the parking lot to assess the resident and sent the resident to the hospital. The Director of Nursing stated the resident always wanted to get their car or truck and had not pushed the fire door before. They stated the electronic monitoring device did not work on fire doors; it was for the front door and patio doors. At those doors, there are alarms and locks. Usually, staff were able to redirect residents. Resident #9 was now on one-to-one (1:1) supervision. They stated after the incident; all staff were educated by the Director of Nursing and Director of Maintenance. Certified Nurse Aide #27 was new, and their probation was extended and Licensed Practical Nurse #25 was terminated. They stated they were looking at fire doors that had a delayed opening when pushed. During an interview on 04/13/2026 at 2:25 PM, Certified Nurse Aide #27 stated when the fire door opened it made a loud noise that was different from the noise made when residents with electronic monitoring device triggered the front door. They stated they were familiar with the noise made when the electronic monitoring device triggered the front door, but they were not familiar with the sound of the fire doors. They stated the alarm went off when they had just finished a resident's care and were getting ready to do Resident #97's care. They saw Licensed Practical Nurse #25 sitting at the nurses' station and since Licensed Practical Nurse #25 was eating, and not reacting to the alarm, they did not know what was going on and took care of Resident #97. During interview and observation on 04/13/2026 at 3:00 PM, Licensed Practical Nurse #6 walked out the door Resident #9 exited on 03/25/2026 and pointed to where on the parking lot the resident was found. Using a measuring tape, Licensed Practical Nurse #6 assisted in measuring the area from the door to the parking lot where the resident was found. The shortest distance using a straight line was 114 feet and would include walking across the grass, a landscaped area with mulch, and across the sidewalk in front of the parking lot. During an interview on 04/13/2026 at 3:10 PM, Certified Nurse Aide #22 stated they were assigned to Resident #9. After dinner they were putting residents to bed when Resident #9 went to the front door first and was brought back and put in the dining room across from the nurses' station where Licensed Practical Nurse #25 was eating at the desk. They went into a room to give another resident care and did not hear the alarm. They stated they saw Resident #9 after the incident when staff brought them to the unit in a wheelchair. They stated the resident's face was bloody and the ambulance was called. During an interview on 04/13/2026 at 3:35 PM, Licensed Practical Nurse #24 stated they were at a cardiopulmonary resuscitation class and when they got to the unit, the alarm was blaring. They checked the panel at the nurses' station and saw it blinking for Hallway 3. They went out the fire door and found the resident lying on their side on the ground. They called Registered Nurse Supervisor #8 who assessed, and Certified Nurse Aide #26 came with a wheelchair. The resident was taken back inside, Registered Nurse Supervisor #8 took care of the wounds, emergency medical service was called, and the resident went to the hospital. During an interview on 04/14/2026 at 1:16 PM, Medical Doctor #2 stated they were informed on the next day of Resident #9's elopement and fall with injuries. On 03/26/2026, Medical Doctor #2 examined the resident and saw the bruises on the forehead, elbow and knees. The resident was in some pain and Tylenol was prescribed. The resident had a history of falls, had a shuffling gait and the shuffling gait on a grass area was a problem for them, making it easier to trip. During an interview on 04/14/2026 at 3:25 PM, Registered Nurse Supervisor #8 stated they were told that Resident #9 had fallen outside. They went to the south side parking lot and found Resident #9 lying on their stomach. Resident #9 was assessed and found to have a laceration to the forehead, abrasions to the nose and cheeks. Resident #9 hit their head on the concrete and had blood coming from the forehead laceration. Resident #9 was assisted into a wheelchair and brought back into the facility. A pressure dressing was applied to the resident's forehead and Resident #9 was given Tylenol for comfort. Emergency medical service arrived and transported Resident #9 to the hospital for evaluation and treatment. 2) Resident #8 had diagnoses including renal failure (kidney failure), dialysis (process of removing toxins from the blood), and rib fractures (broken bones). The Five-Day Minimum Data Set, dated [DATE] documented intact cognition, supervision/touch assistance for transfers, fall in last month and last two (2) to six (6) months prior to entry, and fracture related to fall prior to entry. The resident's at risk for falls care plan (initiated 03/01/2026) documented Resident #8 was at high risk for falls. The resident had falls on 03/11/2026, 03/16/2026, 03/18/2026, 03/19/2026, 04/01/2026, 04/05/2026, and 04/07/2026. Interventions were updated after each fall and included remaining in the dining room and in view of staff, continue therapy for strengthening, Dycem (surface pad to prevent sliding) for wheelchair, encourage compliance with call bell, keep call bell in reach, and low bed. The fall risk assessment dated [DATE] documented resident high risk for falls. During an observation and interview on 04/06/2026 at 10:59 AM, there was bruising under both of Resident #8's eyes and left forehead. Resident #8 stated that the bruising was from a fall sustained when they were getting out of bed. The Accident and Incident Report dated 04/07/2026 documented that Resident #8 sustained an unwitnessed fall in the dining room on 04/07/2026 at 6:55 AM that resulted in a large bump to the forehead. Statements from staff, a rehabilitation referral, nursing notes, and care plan updates were attached to the report. The statement from Certified Nurse Aide #10 documented that they last saw Resident #8 at 6:30 AM in the dining room. Licensed Practical Nurse #18's progress note dated 04/07/2026 at 8:45 AM, documented that on 04/07/2026 that at approximately 6:55 AM, Resident #8 was on the floor in front of their wheelchair in the dining room lying on their right side. Resident #8 was alert and verbal with no complaints of pain. Registered Nurse Supervisor #19 was notified and came to the unit to assess. Vital signs were obtained. A raised area to their right forehead was noted. Ice pack applied to forehead by staff. Three (3) staff assisted the resident back to the wheelchair. Registered Nurse Supervisor #19's progress note dated 04/07/2026 at 7:40 AM documented on 04/07/2026 they were called to assess Resident #8 who was observed on the floor in the dining room at 6:55 AM and had sustained a big bump on their forehead. Resident #8 verbalized I tried to walk and fell. Ice packed applied and Tylenol administered for pain. Resident #8 was alert, verbal, and non-compliant. Assisted back to wheelchair with three (3) person assist, for rehab reevaluation due to multiple falls, resident kept in the dining area visible to staff and for close monitoring. Family and physician notified. During an observation on 04/08/2026 at 12:31 PM, Resident #8 was sitting in the dining room for lunch in a wheelchair, bruising noted to both sides of their forehead. During an interview with the Director of Nursing on 04/09/2026 at 4:18 PM, the Director of Nursing stated Resident #8 was at high risk for falls, had multiple falls, and they had added new interventions for Resident #8 after each fall. They stated their most recent fall was on 04/07/2026 and they have now added one-to-one (1:1) supervision in the morning. During an interview and observation on 04/10/2026 at 10:50 AM, the Director of Nursing provided the requested disciplinary file for Certified Nurse Aide #10 and stated that they had been written up. The disciplinary action documented a written warning on 04/08/2026 for poor work performance and failure to tend to Resident #8 timely during a fall on 04/07/2026. It documented that Certified Nurse Aide #10 was present but not actively supervising Resident #8 as they should have been resulting in a fall and head injury. During an interview and observation on 04/14/2026 at 10:41 AM, video footage from the 2 South dining room on 04/07/2026 starting at 6:42 AM was reviewed with the Director of Nursing. The Director of Nursing stated that they had reviewed the footage because they wanted to determine how the resident fell. The 2 South unit staff were aware of Resident #8's risk of falls and history of multiple falls. In the video footage, Certified Nurse Aide #10 and Resident #8 were observed in the dining room at 6:43 AM, Certified Nurse Aide #10 was sitting at a table by a window and Resident #8 was sitting in a wheelchair close to a table in the center of the room, out of arms reach to Certified Nurse Aide #10 who was looking at their phone and looking out the window. Resident #8 was leaning forward in the wheelchair intermittently. At 6:51 AM, Certified Nurse Aide #10 remained sitting at the table away from Resident #8 when they leaned forward and fell out of the wheelchair to the floor. At 6:52 AM, Licensed Practical Nurse #18, Registered Nurse Supervisor #19, and the Director of Nursing were all observed reporting to the unit and assessed Resident #8. The Director of Nursing stated that Certified Nurse Aide #10 should have been supervising Resident #8 more closely and not looking at their phone and out the window. During a telephone interview on 04/14/2026 at 3:08 PM, Certified Nurse Aide #10 stated that they were not the assigned aide for Resident #8 on the morning of 04/07/2026 but agreed to supervise them in the dining room. They were aware that Resident #8 was at high risk for falls. They did not move Resident #8 closer to them because they were sleeping in the wheelchair near a table and they did not think Resident #8 would fall. 10 New York Codes Rules Regulations 415.12 (h)(2)

Based on observations, interviews, and record reviews during the survey, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (1) of three (3) residents (Resident #147) reviewed for Urinary Tract Infection, one (1) of three (3) residents (Resident #13) reviewed for Position/Mobility, and one (1) of one (1) resident (Resident #12) reviewed for Anticoagulation. Specifically, 1) Resident #147 was exhibiting symptoms of a urinary tract infect, urine samples for testing were not collected as ordered and the antibiotic was started prior to the sample collection; 2) Resident #13 was evaluated and waiting for a fitting for new orthotics which was delayed due to untimely follow up by the facility; 3) Resident #12 refused to continue their anticoagulant. There was no documented evidence that education was provided on the possible effects of discontinuation, or that the care plan was updated to reflect the discontinuation of the medication. The findings included:1) Resident #147 had diagnoses that included cirrhosis (liver disease), right hip fracture, and colostomy. The admission Minimum Data Set, dated [DATE] documented intact cognition, maximal assistance with toileting hygiene, and occasionally incontinent of bladder. The physician note dated 01/30/2026 at 10:35AM documented resident was seen for follow up due to elevated white blood cell count and reported burning and frequency with urination. Do urine dipstick, obtain urinalysis and culture if dipstick positive, start Zosyn 3.375gm every six (6) hours for five (5) days.The nursing note dated 1/30/2026 at 11:02AM documented that Resident #12 was seen by the physician. Per physician, do urine dipstick, if positive obtain urinalysis and culture, do chest x-ray, start Zosyn 3.375gm every six (6) hours for five (5) days. The medication administration record for January 2026 documented the physician order for piperacillin sodium tazobactam (Zosyn) solution 3.375 gram every six (6) hours for urinary tract infection for five (5) days. The first dose was signed for on 01/30/2026 at 6:00PM.The lab result dated 02/05/2026 documented that a urine sample was collected and submitted for the urinalysis and urine culture on 02/03/2026. The culture documented an insignificant count of bacteria.During an interview on 04/10/2026 at 1:48 PM, Physician #1 stated that it was best to collect the urine sample before starting antibiotic treatment but may start the antibiotic before the results are back. They often perform a urine dipstick at the facility to get a preliminary reading and did request that one be performed for Resident #147 on 01/30/2026.During an interview on 04/14/2026 at 11:46 AM, Licensed Practical Nurse Unit Manager #1 stated that the physician ordered a urine dipstick before the urinalysis and culture for Resident #147 on 01/30/2026, but they were unable to find any documented evidence of the dipstick being completed. They stated they did collect the urine for the urinalysis and culture on 01/30/2026 but that sample could not be processed because it was not picked up by the lab in time. There was no documented evidence of the collection on 01/30/2026. A urine sample was obtained again on 02/03/2026 after the antibiotic had already started.2) Resident # 13 had diagnoses that included spinal stenosis, paraplegia, and scoliosis. The Quarterly Minimum Data Set, dated [DATE] documented intact cognition and supervision or touch assistance required for chair-to-chair transfers. The physician note dated 03/24/2026 documented the resident had poor tolerance of Ankle Foot Orthoses, replacement Ankle Foot Orthoses were necessary. The physician order dated 03/26/2026 documented bilateral Ankle Foot Orthosis.During an interview on 04/06/2026 at 12:00 PM, Resident #13 stated that they used bilateral lower extremity orthotics. They discussed getting a new set that provided more comfort and enclosed shoes. The ones that they had could not be repaired. Therapy was handling the replacement, but they had not received any recent updates and would like to.During an interview on 04/09/2026 at 9:59 AM, the Director of Rehabilitation stated that they had been working on getting a new set of orthotics for Resident #13 because modification of the pair they had was not possible. They received an email from the orthotics company on 03/04/2026 which read that the next orthotics appointment was scheduled for 03/12/2026 and the prescription and physician note were needed before the appointment. On 03/11/2026 they received another email from the orthotics company that read that the appointment on 03/12/2026 had to be postponed because the necessary paperwork had not been received. The Director of Rehabilitation for Long Term Care should have the correspondence with the company after that. During an interview on 04/09/2026 at 10:07 AM, the Director Rehabilitation for Long Term Care stated that they did request the physician note and order a few weeks ago and they were completed, they just did not forward them to the orthotics company yet. Once the orthotics company received the order and physician note, they could make an appointment for the orthotics company to return for the casting of the orthotics. They stated they will get those out to the orthotics company and update Resident #13 on the status.3) Resident #12 had diagnoses that included atrial fibrillation, heart failure, and generalized weakness. The Five-Day Minimum Data Set, dated [DATE] documented intact cognition and medications included anticoagulant. The Anticoagulation care plan dated 03/18/2026 documented prescribed Eliquis. The goal was that resident will show no signs or symptoms of bleeding. Interventions included, but not limited to, monitoring for signs of bleeding, evaluate for bruising, monitor labs as ordered.The physician order dated 03/26/2026 documented Eliquis five (5) milligrams every 12 hours for atrial fibrillation. The order was discontinued on 04/02/2026. The physician order dated 04/03/2026 documented aspirin 81 milligrams, one (1) tablet by mouth one time per day for anticoagulation. During an observation on 04/06/2026 at 9:39 PM, Resident #12 was observed with bruising to their bilateral upper extremities. During an interview on 04/06/2026 at 2:39PM, Resident #12 stated that they requested that their order for Eliquis be discontinued.During an interview on 04/10/2026 at 11:32 AM, Licensed Practical Nurse #13 stated that Resident #12 was on Eliquis but was refusing the medication and the physician was aware. They stated that the resident was now on aspirin. They were unable to find any nursing or physician progress notes that the resident was refusing or that there was education or discussion about the medication and possible effects of discontinuation. During an interview on 04/10/2026 at 12:00 PM, Licensed Practical Nurse Unit Manager #16 stated that they did speak to Resident #12 about the potential effects of discontinuing the Eliquis when they were refusing and prior to discontinuation, but failed to write a note or update the care plan. They stated they should have entered a note and updated the care plan at that time and would do that now.During an interview on 04/14/2026 at 11:14 AM, the Director of Nursing stated that documentation of the education of stopping Eliquis and an update to the care plan should have been completed for Resident #12 when the Eliquis was discontinued.10NYCRR 415.12

Based on record review and interviews, the facility failed to ensure a resident received care consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for one (1) out of three (3) residents (Resident #1) reviewed for pressure ulcers. Specifically, on 08/20/2025, Resident #1 was assessed as having a blanchable area of moisture associated skin damage to their coccyx/buttocks, was dependent for bed mobility, had no interventions implemented and was later diagnosed with an unstageable pressure ulcer. Additionally, Resident #1 had functional limitations with an order to have their feet offloaded while in bed, which was not consistently done resulting in a deep tissue injury to the resident's right heel. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy. The findings are:The facility Pressure related Injury Prevention and Treatment and Wound Management policy, last revised 11/2018, documented the organization is committed to providing a comprehensive wound management program to promote the resident's highest level of functioning and well-being and to minimize the development of in-house acquired pressure ulcers, unless the individual's clinical condition demonstrates they are avoidable. Any resident with a wound receives treatment and services consistent with the resident's goals of treatment. Risk reduction measures such as turn and position schedule and the use of heel protectors for offloading are initiated if determined appropriate.Resident #1 was admitted with diagnoses including but not limited to dementia, unspecified intracapsular fracture of right femur (hip fracture) and Type 2 diabetes mellitus. Review of skin integrity care plan initiated on 08/20/2025 documented that Resident #1 had potential for impairment to skin integrity. Interventions listed included biweekly skin checks, keeping skin clean and dry, monitoring for signs of infection or drainage and informing the physician of any abnormalities. Review of activities of daily living care plan initiated 08/20/2025 documented Resident #1 had a self-care performance deficit related to activity intolerance, confusion and disease processes. Interventions listed included encourage the resident to fully participate to extent possible with each interaction and praise all efforts of self-care. Review of Resident #1's admission skin assessment, dated 08/20/2025, documented the resident had scattered ecchymosis to their bilateral extremities and a blanchable area of moisture associated skin damage to their coccyx/buttocks area. Review of a Braden Scale for predicting pressure ulcer risk evaluation, dated 08/20/2025 at 1:09 PM, documented the following: Sensory perception-very limited, Moisture-occasionally moist, Activity-chair fast. Resident #1 is very limited-makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. Nutrition-adequate, friction and shear-potential problem. Braden score: 14.0, indicating a moderate risk. Review of a Physician's order dated 08/20/2025 documented monitor skin observations every shift. Review of a wound management care plan initiated 08/21/2025 documented Resident #1 had blanchable moisture associated skin damage to their coccyx area. Interventions listed included providing the resident with an alternating air mattress and per the Nurse Practitioner, cleanse the area with normal saline, apply Santyl (a medication that helps remove dead skin tissue and aids in wound healing) then cover with a foam dressing daily and as needed. An Admission/Medicare Five (5) Day Minimum Data Set, dated [DATE], documented Resident #1 had severe cognitive impairment. The resident had impairment to the lower extremity on one side and required a walker or a wheelchair for locomotion. The resident required set up assistance with meals and was dependent for toileting, bed mobility and transfers. Resident #1 was identified as at risk for developing pressure ulcers/injuries, but had none present on admission. Resident #1 had a pressure relieving device in their wheelchair and bed. There was no documented evidence of orders for turning and repositioning and or risk reduction measures such as turning and positioning. Review of Nurse Practitioner #1's progress note, dated 08/28/2025 at 12:02 PM, documented Resident #1 was seen for an open area on their left buttocks. The note documented the area was not a reopened area but was a Stage 2 pressure injury. The measurements were as follows: Size- 3.1 cm by 1.4 cm, no tunneling or undermining. Appearance-epithelial tissue, moist red and yellow. No odor, no exudate with scant drainage and the progression of healing was stable. Interventions listed included to ensure functioning of the air mattress every shift. Review of Resident #1's certified nurse aide accountability for August 2025 revealed skin observation was not signed by direct care staff as being performed on nine (9) occasions. Further review of the certified nurse aide accountability on 08/28/2025 documented on the evening shift that the resident had skin redness, and no skin findings were documented for the night shift. Review of a nursing progress note dated 09/02/2025 and written by Registered Nurse #3 at 10:53 AM, documented they were informed by the certified nurse aide to check Resident #1's heel. Resident #1 had a deep tissue injury approximately 1.2 cm by 2.4 cm. Apply skin prep every shift to the area. Review of a Physician's order dated 09/02/2025 at 10:55 AM documented offload heels when in bed every shift for pressure relief.Review of Resident #1's certified nurse aide accountability for September 2025 revealed direct care staff did not consistently sign for offloading the resident's heels on 35 out of 90 occasions. Review of Resident #1's wound notes for their left buttocks wound documented the following:-09/04/2025 wound measures 1.0 cm by 1.4 cm-09/09/2025 an unstageable wound measuring 2.3 cm by 1.0 cmReview of Nurse Practitioner #1's skin/wound note dated 09/16/2025 at 10:49 AM documented Resident #1 was seen on wound rounds 09/09/2025. Resident #1 denied any discomfort at the time of the visit. Wound #1- right heel, deep tissue injury from pressure. Wound measurements 1.7 cm by 1.9 cm, description - purple, flat, wound edges are defined, treatment - skin prep daily. Progress showing improvement. Plan-offload heels when in bed. Wound #2-location-unstageable wound left buttocks, due to pressure. Measurements - 0.7 cm by 0.4 cm. Wound description -100% slough (dead tissue or debris of cells, peri-wound pink and blanchable (area of skin that becomes lighter when pressure is applied), no erythema (redness), no odor, edges flat. Treatment-cleanse with normal saline, apply Santyl to the wound bed, cover with a foam dressing daily and as needed. The wound's progress was improved, and the plan was to provide Resident #1 with an air mattress and turning and positioning as per facility protocol.Review of Resident #1's certified nurse aide accountability for September 2025 revealed skin observation was not signed by direct care staff as being performed on 35 out of 90 occasions.During an interview on 10/09/2025 at 9:55 AM, the Director of Nursing stated if a resident is admitted to the facility status post hip fracture, they are not automatically ordered to have heels off loaded and turned and positioned. During a telephone interview on 10/09/2025 at 10:07 AM, Registered Nurse #1 stated they conducted Resident #1's admission assessment on 08/20/2025, and upon admission the resident had an area of moisture-associated skin damage, that was not open but showed some redness. During an interview on 10/09/2025 at 11:37 AM, Licensed Practical Nurse #1 stated upon admission, Resident #1 had an area of moisture associated skin damage, but not a stageable pressure injury. Licensed Practical Nurse #1 stated on 08/28/2025 they were informed by Certified Nurse Aide #1 that Resident #1 had an opened area, which was a Stage 2 pressure ulcer. Licensed Practical Nurse #1 stated Nurse Practitioner #2 documented that the pressure ulcer was acquired in the hospital even though upon admission to the facility, Resident #1 did not have a stageable wound. Licensed Practical Nurse #1 stated that they believe Resident #1's right heel deep tissue injury may have occurred because the resident's heel was not being offloaded each night as ordered. During a telephone interview on 12/26/2025 at 8:50 AM, Nurse Practitioner #2 stated they had not worked in the facility since 12/08/2025. When they worked at the facility, they made wound rounds weekly with the staff nurses and unit managers for each unit and evaluated all residents with wounds in the facility. Nurse Practitioner #2 stated at the bottom of their progress notes, there is a section where they document the need for turning and positioning, offloading the heels and the need for air mattress. Nurse Practitioner #2 stated these measures are discussed with the unit manager as they are responsible for implementing the orders. Nurse Practitioner #2 stated the unit manager would be the one to pick up the orders for offloading and turning and positioning after informing the Attending Physician of the recommendations from the wound consult. Nurse Practitioner #2 stated they would check the residents orders the same day to ensure they were picked up by staff and the nurses usually pick up the orders before they even leave the unit. Nurse Practitioner #2 stated they were informed there was a protocol for turning/repositioning, but they are not sure how often. They assumed it had to be turning every two (2) hours. Nurse Practitioner #2 stated if they determine a change is needed to the orders for the wound they communicate the changes to the staff, so it is documented. Nurse Practitioner #2 stated they also document their wound round notes in the progress notes. Nurse Practitioner #2 stated they do not recall Resident #1 specifically, but they remember when they would evaluate wounds in the facility, they were staged differently by the previous wound doctor than what they observed. Nurse Practitioner #2 stated they stand by their assessment documented in Resident's medical record. When they saw Resident #1 with the wound nurse, they observed Resident #1's wound was unstageable and that is what they documented. 10 NYCRR 415.12(c)(1)

Based on record review and interviews during an abbreviated survey (2625335), the facility did not ensure assessments accurately reflected the resident's status for 1 out of 3 residents (Resident #1) reviewed for assessments. Specifically, Resident #1 had a Physical Therapy evaluation in the facility on 08/22/2025 and was found to require maximum assistance for bed mobility. However, an admission Minimum Data Set, dated [DATE] documented Resident #1 as dependent for bed mobility on their functional assessment. The findings are: The facility did not have a policy related to the Minimum Data Set assessment.Resident #1 was admitted with diagnoses including but not limited to Dementia, Unspecified Intracapsular fracture of right femur and Type 2 Diabetes Mellitus. An Admission/Medicare 5 Day Minimum Data Set, dated [DATE] documented Resident #1 had severe cognitive impairment. The resident had impairment to the lower extremity on one side and required a walker or a wheelchair for locomotion. The resident required set up assistance with meals and was dependent for toileting, bed mobility and transfers. The resident was not on a turning and positioning program. Review of the activities of daily living care plan dated 08/20/2025 documented Resident #1 had a self-care performance deficit related to activity intolerance, confusion and disease processes. Interventions listed included to encourage the resident to fully participate possible with each interaction and praise all efforts of self-care. Review of a rehabilitation progress note dated 08/22/2025 at 12:32 PM documented Resident #1 was evaluated for Physical Therapy and was found to have the following mobility levels: maximum assistance for bed mobility, sit to stand pivot transfers are a maximum assistant of two people, toilet transfers with extensive assistance of two people. Resident #1 was currently not ambulatory and was dependent for wheelchair mobility. During an interview on 10/09/2025 at 11:37 AM, Licensed Practical Nurse #1 stated Resident #1 was mobility dependent. During an interview on 10/9/2025 at 12:56 PM, Registered Nurse #2 stated in the functional assessment section of the minimum data set, the rehabilitation department completes this section, and it is then signed off by nursing. Registered Nurse #2 stated an entry for Resident #1 was coded as dependent for bed mobility and they would think the resident would have turning and positioning orders or have their heels elevated. Attempts to reach Physical Therapist #1 on 10/23/2025 was unsuccessful. 10 NYCRR 415.11(b)

Based on record review and interviews during an abbreviated survey (2625335), the facility administrator did not ensure they used its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, during an abbreviated survey, the facility did not provide requested facility policies to the Surveyor on-site. The Director of Nursing stated there is no documented facility policy for the following: Braden scale assessments, skin observation, admission assessments or a Minimum Data Set Assessment policy.The findings are: During an interview on 10/9/2025 at 1:00 PM, the Director of Nursing stated they do not have a policy related to Braden scale assessments and it is a Corporate issue. The Director of Nursing stated they are doing their best and will try to address all these issues brought up during the onsite survey. The Director of Nursing stated the facility does not have a skin observation policy or an admission assessment policy. They were not sure if the facility has a minimum data set policy and they know this is a problem, but it is a corporate issue. The Director of Nursing stated they are trying to make changes and update the facility policies. The Director of Nursing stated they asked the Administrator about the policies requested and was informed that they did not need a policy for everything in the facility. 10 NYCRR 415.26

Based on observation, record reviews, and interviews during an abbreviated survey (NY00345910, NY00358013), the facility did not ensure the residents right to be free from abuse for 2 out of 3 residents (Residents #1 & #3) reviewed for abuse. Specifically, (1) on 6/19/2024, Certified Nurse Assistant #1 was observed on video surveillance engaging in a verbal altercation with Resident #1 and taunting them in the dining room. Certified Nurse Assistant #1 was also observed engaging in a shoving match at a table in the dining room with Resident #1. Resident #1 and Certified Nurse Assistant #1 later engaged in a physical altercation at the nurse's station where Resident #1 was seen grabbing Certified Nurse Assistant #1 by their shirt and Certified Nurse #1 and Resident #1began tussling; (2) on 10/4/2024, Resident #3 reported Physical Therapy Assistant #2 was verbally aggressive with them causing them to lose sleep and endure psychological distress requiring antianxiety medication intervention. The findings are: The facility Abuse Prohibition Protocol last revised 3/2024 documented each resident has the right to be free from abuse, neglect, and mistreatment. The facility will do everything in its control to prevent occurrences, and will conduct prompt, thorough investigations for all cases of any type of alleged abuse in compliance with state laws and regulations. 1) Resident #1 was admitted with diagnoses including but not limited to Dementia, Alzheimer's disease, and Difficulty in Walking. An Annual Minimum Data Set (an assessment tool that measures health status) dated 4/17/2024 documented the resident had severe cognitive impairment. The resident had impairment to the upper extremities on both sides and required a wheelchair for ambulation. The resident required set up assistance for eating, maximal assistance with toileting and supervision with bed mobility and transfers. There was no evidence of an abuse, victim, or potential victim care plan in place for Resident #1 prior to the incident on 6/19/2024. Review of the surveillance video from 6/19/2024 revealed at 16:08 Resident #1 was observed rolling their self over to the table where the other resident was working on a puzzle with Certified Nurse Assistant #1 at their side. Resident #1 proceeded to push the table the other residents were sitting at. Certified Nurse Assistant #1 then attempted to grab the table and pulled it back into place. At 16:15:20, Resident #1 is seen attempting to go for Certified Nurse Assistant #1. Certified Nurse Assistant #1 moved the resident's doll and Resident #1 attempted to chase them. Certified Nurse Assistant #1was observed taunting Resident #1. Resident #1 was visibly agitated trying to get around the table to Certified Nurse Assistant #1, Resident #1 then reached out and threw the puzzle (which was been completed by another resident) on the floor. At 16:26, Certified Nurse Assistant #1 was seen seated at the nurse's station on the computer and Resident #1 is observed wheeling into the nurse's station and grabbing the Certified Nurse Assistant by the shirt lifting them off the chair. Certified Nurse Assistant #1 and Resident #1 begin tussling. Certified Nurse Assistant #1 stood up and pushed Resident #1 to get them off of their shirt and continued to tussle with Resident #1 as they held Certified Nurse Assistant #1's shirt. Certified Nurse Assistant #1 then grabbed Resident #1 by their hands and Resident #1 kicked at Certified Nurse Assistant #1. Other staff members are seen entering the nurses station trying to release Resident #1's hands from Certified Nurse Assistant #1. Staff is seen rolling Resident #1 out of the nurse's station. Certified Nurse Assistant #1 then kicked Resident #1's baby doll on the floor and proceeded to sit back at the computer. Review of the investigative findings submitted to the New York State Department of Health on 6/20/2024 documented on 6/19/2024 Certified Nurse Assistant #1 was witnessed by other staff teasing, provoking and making faces at Resident #1. At about 4:10pm Certified Nurse Assistant is witnessed holding on to a table in the dining room while Resident #1 was trying to pull the table away and the resident was visibly agitated and upset. Certified Nurse Assistant #1 was asked by registered nurse Supervisor to relocate the other resident on the table to another area but Certified Nurse Assistant #1 disregarded the instruction stating, he has to learn. At approximately 4:15 PM, Resident #1 was observed asking Certified Nurse Assistant #1 for something, but Certified Nurse Assistant #1 kept on arguing with Resident #1 and provoking them. Resident #1 got up from their wheelchair trying to get it from Certified Nurse Assistant #1, but they would not give it to them. Certified Nurse Assistant #1 kept antagonizing Resident #1 for approximately 10 minutes as a result Resident #1 got aggressive and tried to hit Certified Nurse Assistant #1. As per staff statements, Certified Nurse Assistant #1 kicked Resident #1's doll (who they think is their baby daughter) on the table. Resident #1 got aggressive and started following Certified Nurse Assistant #1 speaking in their language as they were very upset. During an interview on 1/6/2025 at 11:20 AM, the Director of Nursing stated there is video footage of the incident that occurred with Resident #1, and that the family have reviewed the footage, and they were very upset by it. The Director of Nursing stated Certified Nurse Assistant #1 was terminated, and they are fighting the termination with the union. During an interview on 1/8/2025 at 4:42 PM, the Director of Nursing stated they tried to get Certified Nurse Assistant #1 out of the facility, but the union fought with them to keep the staff in the building. 2) Resident #3 admitted to the facility 9/20/2024 with diagnoses including and not limited to Pneumonia, Obsessive Compulsive Disorder and Heart Failure. A 5 -day Admission Minimum Data Set (an assessment tool that measures health assessment) dated 9/26/2024 documented the resident was cognitively intact. The resident required a walker for ambulation. The resident required set up assistance with meals, moderate assistance with toileting, supervision with bed mobility and transferring. Review of a grievance form dated 10/10/2024 documented Resident #3 reported that on 10/4/2024 they went to the therapy gym for therapy at around 4:20 PM and it was a Friday. Resident #3 stated they asked Physical Therapy Assistant #2 when they would be able to go home and Physical Therapy Assistant #2 in a stern manner responded they had 2 options: Assisted Living Facility or 24 hour care with supervision. Resident #3 stated the answer made them very upset because it was never mentioned during the care plan meeting that was held on 10/2/2024 where Physical Therapist #2 was present. Resident #3 satted after they told Physical Therapist #2 that they could not do 24 hour care with suoervision, Physical Therapist #2 responded then they will call Adult Protective Service if the resident kleft without 24 hour care with supervision in place.Resident #3 stated as they tried to continue to speak to Physical Therapist #2, they were trying to get them out of the gym stating it was 5 PM and time to go. Resident #3 stated Physical Therapist #2 got them to the door and then closed the door in their face. Resident #3 reported this interaction caused them to be unable to sleep the entire weekend as they tried to reach out to 411 to find 24 hour care. The grievance form also revealed that it was also reported by nursing staff and a family member of the reisdent that Resident #3 was worried all weekend and was psycholigically affected by the incident. Resident #3 reported that on Sunday 10/6/2024 Physical Therapy Assistant #2 came to them for therapy, and they refused because they did not want to work with them. During an interview on 1/8/2025 at 11:35 AM, the Certified Occupational Therapy Aide stated it was the end of the day on a Friday, and Resident #3 came into the therapy room to speak with Physical Therapy Assistant #2 and was asking about their discharge planning in which they had a conversation about previously. The Certified Occupational Therapy Aide stated Physical Therapy Assistant #2 did not want to talk about Resident #3's discharge. The Certified Occupational Therapy Aide stated Resident #3 began to get frustrated and upset and Physical Therapy Assistant #2 stated they would figure it out on Monday but Resident #3 wanted to talk about it, and Physical Therapy Assistant #2 was trying to leave and told the resident it was the end of the day on Friday, and they needed to leave and they did not want to talk about. During an interview on 1/8/2025 at 11:50 AM, Physical Therapy Assistant #1 stated was late on a Friday and Resident #3 came into the therapy room to speak with Physical Therapy Assistant #2, and that Resident #3 wanted to discuss their discharge with the therapist. Physical Therapy Assistant #1 stated Resident #3 and Physical Therapy Assistant #2 were arguing back and forth and the resident was upset. Physical Therapy Assistant #1 stated Resident #3 was talking loud and Physical Therapy Assistant #2 got louder. Physical Therapy Assistant #1 stated Resident #3 did have some difficulty hearing and they had asked Physical Therapy Assistant #2 what their name was several times, but they did not tell them and stated they knew what their name was. Physical Therapy Assistant #1 stated Physical Therapy Assistant #2 told Resident #3 it was late in the day, and they needed to go and then pushed the resident's wheelchair out of the therapy room and closed the door and the resident was still upset. During a telephone interview on 1/8/2025 at 1:20 PM, Physical Therapy Assistant #2 stated Resident #3 was very difficult and narcissistic with a history of verbal aggression. Physical Therapy Assistant #3 stated they had multiple discussions with Resident #3 regarding their discharge. Physical Therapy Assistant #2 stated they had a care plan meeting with Resident #3 and their family over the phone and discussed placement for the resident as they had 14 stairs in their home. Physical Therapy Assistant #3 stated they spoke with Resident #3 during their therapy session, and they stated they were going home and there was nothing they could do about it. Physical Therapy Assistant #2 stated they in a stern voice, told Resident #3 that they had not discussed them going home, and the resident continued stating they are going to do what they want. Physical Therapy Assistant #2 stated they told Resident #3 they did not feel they were safe to go up and down their stairs. Physical Therapy Assistant #2 stated Resident #3 stated they were going to go home if they want to, and they could not stop them. Physical Therapy Assistant #2 stated they told Resident #3 they were correct, and they could not stop them from going home, but that it would not be a safe discharge and in that case, they would have to inform Adult Protective Services. Physical Therapy Assistant #2 stated that was the breaking point and Resident #3 started screaming, and they walked away and got a drink of water and then Resident #3 became more upset. Physical Therapy Assistant #2 stated they did not interact with Resident #3 the rest of the day. During an interview on 1/8/2025 at 12:03 PM, the Director of Rehabilitation stated they were informed on Tuesday by the other therapists of the incident, and they then informed the Human Resource Director, who requested the therapists write statements, so the staff wrote their statements the next morning. The Director of Rehabilitation stated Physical Therapy Assistant #2 happened to be on paid time off the next day and the following day after the incident and usually the alleged staff would be suspended immediately pending an investigation. The Director of Rehabilitation stated Physical Therapy Assistant #2 was suspended over the telephone and they did not provide them with much detail, but they informed them it had to do with a resident's grievance. During a telephone interview on 1/23/2025 at 10:43 AM, Licensed Practical Nurse #3 stated the incident with Resident #3 happened on Sunday with Physical Therapy Assistant #2 and they were informed on Monday 12/9/2024 and they wrote a statement. Licensed Practical Nurse #3 stated they were informed by the staff nurse and informed that Resident #3 was upset because Physical Therapy Assistant #2 made a comment that they were not going to go home if there was no 24-hour supervision for them at home. Licensed Practical Nurse #3 stated Resident #3 stated they were told by Physical Therapy Assistant #2 if they insist on going home, then they are going to call the lawyer and tell Adult Protective Services. Licensed Practical Nurse #3 stated they spoke with Resident #3, and they stated they did not want Physical Therapy Assistant #2 to get in trouble, but they just want to leave the facility and go to their apartment. Licensed Practical Nurse #3 stated when they spoke with Resident #3, they were no longer upset, and they usually were able to calm them down by sitting and talking with them. Licensed Practical Nurse #3 stated Resident #3 kept saying they were upset about the situation with Physical Therapy Assistant #3, and they just want to go home. 10NYCRR 415.4(b)(1)(i)

Based on record review and interviews conducted during an abbreviated survey (NY00345910, NY00333580, NY00358013) the facility did not ensure the report of the results of an investigation to the New York State Department of Health in accordance with State law within 5 working days of the incident or report an allegation of abuse within the regulatory timeframe for 3 of 4 residents (Resident #1, #2, #3) reviewed for abuse. Specifically, (1) On 6/19/2024 Certified Nurse Assistant #1 was observed on video surveillance engaging in a verbal altercation and the pushing and pulling of a table back and forth with Resident #1. Review of the 5-day investigative conclusion submission revealed it was not submitted to the New York State Department of Health until 7/25/2024; (2) On 2/13/2024 Resident #2 reported alleged inappropriate contact by Certified Nurse Assistant #3. Review of the 5-day investigative conclusion submission revealed it was not submitted until 3/6/2024; (3) On 10/6/2024 Resident #3 reported to the social worker that Physical Therapy Assistant #2 spoke to them in a manner that made them upset and experience mental anguish. Review of the 5-day investigative conclusion submission revealed it was not submitted until 10/22/2024. The findings are: The facility Abuse Prohibition Protocol last reviewed 3/2024 documented all alleged incidents of abuse, neglect and mistreatment must be reported to your immediate supervisor investigated and reported to the Administrator who is the abuse prevention coordinator or designee. When required by law or regulation, the Administrator/Designee shall ensure timely notification of the incident to the Department of Health. 1) Resident #1 had diagnoses including but not limited to Dementia, Alzheimer's disease, and Difficulty in Walking. An Annual Minimum Data Set (an assessment tool that measures health status) dated 4/17/2024 documented the resident had severe cognitive impairment. The resident had impairment to the upper extremities on both sides and required a wheelchair for ambulation. The resident required set up assistance for eating, maximal assistance with toileting and supervision with bed mobility and transfers. Review of the investigative findings submitted to the New York State Department of Health on 6/20/2024 documented on 6/19/2024 at approximately 4:10 PM Resident #1 tried to pull one of the tables when Certified Nurse Assistant #1 tried to pull it back and kept on arguing with the resident. At approximately 4:15 PM Resident #1 was observed asking Certified Nurse Assistant #1 for something but they kept on arguing with Resident #1 trying to provoke them. Resident #1 gets up from their wheelchair trying to get it from Certified Nurse Assistant #1, but they would not give it to them. Certified Nurse Assistant #1 kept antagonizing Resident #1 for approximately 10 minutes as a result Resident #1 got aggressive and tried to hit Certified Nurse Assistant #1. As per staff statements Certified Nurse Assistant #1 threw Resident #1's doll on the table, who they think was their daughter. Resident #1 got so aggressive and started following Certified Nurse Assistant #1 speaking in their language as they were very upset. Review of the 5-day investigative conclusion submission revealed it was not submitted to the New York State Department of Health until 7/25/2024. 2) Resident #2 had diagnoses including but not limited to Macular Degeneration, Hypertensive Heart Disease without Heart Failure and Unspecified Fall. An Admission Minimum Data Set (an assessment tool that measures health status) dated 2/5/2024 documented Resident #2 had moderate cognitive impairment. No behaviors noted. The resident used a walker and a wheelchair for locomotion and had impairment to the lower extremity on one side. The required set up assistance with eating, moderate assistance with bed mobility and dependent for toileting and transfers. Review of the investigative summary of the incident documented Resident #2 on 2/13/2024, reported that on 2/2/2024 they were lying in bed and saw 2 male figures. Resident #2 stated they thought it was their vision due to their history of macular degeneration. Resident #2 stated while they were lying down Certified Nurse Assistant #3 was on the side of them. Resident #2 stated Certified Nurse Assistant #3 started pecking them on their cheek, but not aggressively. Resident #2 stated that Certified Nurse Assistant #3 realized they were growing suspicious but continued to peck them on their cheek. Resident #2 stated they informed Certified Nurse Assistant #3 that this was not them, they are above this and do not do this to their self. Resident #3 then stated they can put this in the past and in the morning, they will look at it as it was the past. Resident #2 stated while saying this to Certified Nurse Assistant #3 they continued to peck them on the cheek but could tell Certified Nurse Assistant #3 was giving up. Resident #2 stated Certified Nurse Assistant #3 eventually pulled away from them and stopped. The investigative conclusion dated 2/16/2024 documented after reviewing the incident, staff changes and Resident #2's health condition, it is concluded that there was no evidence of sexual abuse, mistreatment, or neglect. Review of the investigation file revealed the 5-day conclusion was submitted on 3/6/2024. 3) Resident #3 had diagnoses including and not limited to Pneumonia, Obsessive Compulsive Disorder and Heart Failure. A 5 -day Admission Minimum Data Set (an assessment tool that measures health assessment) dated 9/26/2024 documented the resident was cognitively intact. The resident required a walker for ambulation. The resident required set up assistance with meals, moderate assistance with toileting, supervision with bed mobility and transferring. Review of a grievance form dated 10/10/2024 documented Resident #3 reported on Friday 10/4/2024 they went to the therapy gym for therapy at around 4:20 PM and they were talking to Physical Therapy Assistant #2. Resident #3 stated they were asking when they were going to be going home and Physical Therapy Assistant #2 in a stern manner responded to them, they had 2 options, 24-hour care with supervision or go to an assisted living facility. Resident #3 stated they were very upset with this answer and responded they cannot do that with the 24-hour care and supervision. Resident #3 reported Physical Therapist Assistant #2 responded if they did not choose one of the options then they would have to get the law on them. Resident #3 reported they were trying to talk to Physical Therapist Assistant #2 and they were trying to get them out of the gym stating it is 5 PM and time to go. Resident #3 stated Physical Therapist #2 got them to the door and then closed the door in their face. Resident #3 reported this interaction caused them to not be able to sleep because they kept thinking about it. Resident #3 reported that on Sunday 10/6/2024 Physical Therapy Assistant #2 came to them for therapy, and they refused because they did not want to work with them. Review of the investigation file revealed the 5-day conclusion was submitted on 10/22/2024. During an interview on 1/6/2025 at 11:20 AM, the Director of Nursing stated they submit the reports to the Department of Health, and they also submit the 5-day conclusion. During an interview on 1/8/2025 at 4:42 PM, the Director of Nursing stated they are responsible for the submission of the reportable. The Director of Nursing stated if there is an injury then they call the hotline for an incident and if there is no injury and someone reports an incident, they complete the submission online within 24 hours. After submission, they will usually receive the second follow up email from the Department of Health and then they would submit the 5-day investigative conclusion. The 5-day report is submitted once they receive the email informing them to submit. The Director of Nursing stated they were not aware that they had 5 working days to submit the 5-day investigative summary and therefore they were waiting for the email from Department of Health before submitting the conclusion. 10NYCRR 415.4(b)(1)(ii)

Based on observations and interviews during an abbreviated survey (NY00333580), the facility did not ensure that each residents had the right to a dignified existence and each resident was cared for in a manner and environment that promoted maintenance or enhancement of their quality of life. This was evident for 1 of 3 residents (Resident #4) reviewed for dignity. Specifically, during an observation on Unit 1 South on 1/6/2025 Certified Nurse Assistant #2 was standing over Resident #4 while assisting them with their meal in the alcove in the hallway. The findings are: The facility Resident Rights policy last revised 9/2024 documented the facility strives to make sure that each resident is afforded a dignified existence, is treated with respect and dignity, and receives care in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life. Resident #4 admitted to the facility on [DATE] with diagnoses including but not limited to Schizoaffective Disorder, Unspecified Intellectual Disabilities and Hypothyroidism. A Quarterly Minimum Data Set (an assessment tool that measures health status) dated 12/16/2024 documented the resident had severe cognitive impairment. The resident required a wheelchair for locomotion. The resident was dependent for eating, toileting and independent with bed mobility and moderate assistance with transfers. Review of a preference care plan last revised 7/12/2024 documented to respect Resident #4's wishes to have meals in the hallway or their room fed by staff. Interventions listed included the resident will consume meals in a dignified manner. Review of an activities of daily living care plan last revised 7/27/2023 documented Resident #4 had a self-performance deficit related to intellectual deficit. Interventions listed included for eating the resident is totally dependent on 1 staff and requires 1 staff assistance. During rounds on the unit on 1/6/2024 from 12:20 PM to 1:00PM, Certified Nurse Assistant #2 was observed in the alcove by a room standing while assisting Resident #4 with their meal. During an interview on 1/6/2024 at 12:50 AM, Licensed Practical Nurse #1 stated the staff should be sitting when they are assisting a resident with a meal. Licensed Practical Nurse #1 stated they did not see the staff standing. During an interview on 1/6/2024 at 1:02 PM, Certified Nurse Assistant #2 stated they are aware that they should not be standing while assisting residents during meals. Certified Nurse Assistant #2 stated they have been a certified nurse assistant for a long time, and they received the right training and know they should be seated when assisting a resident with their meal. During an interview on 1/7/2024 at 11:42 AM, the Director of Nursing stated that staff should be seated when they are assisting residents with their meals, and they are aware of this. The Director of Nursing stated staff receive training on this and they will speak with Certified Nurse Assistant #2. 10 NYCRR 415.3(d)(1)(i)

Based on record review and interview during an abbreviated survey (NY00345910, NY00358013), the facility did not ensure that a comprehensive person-centered care plan was developed and implemented to ensure services were provided to maintain the residents' highest practicable physical, mental, and psychosocial well-being for 2 out of 3 residents (Resident #1, #3) reviewed for care planning. Specifically, (1) On 6/19/2024 Certified Nurse Assistant #1 was observed on surveillance footage engaging in a verbal altercation and taunting Resident #1. Certified Nurse Assistant #1 and Resident #1 then engaged in a physical tussle at the nurse's station. Review of Resident #1's care plans revealed they did not have an abuse, victim, or potential victim care plan initiated until after the incident on 6/19/2024; (2) Resident #3 reported that on 10/4/2024 they had a verbal altercation with Physical Therapy Assistant #2 which led them to become angry and suffer mental anguish. Review of Resident #3 care plans revealed they did not have a risk to be victimized care plan before and after the verbal altercation incident occurred. The findings are: The Facility Policy titled Baseline care Plan and Summary, last revised 11/2023 documented the facility ensures that a baseline care plan is completed for all residents within 48 hours of admission. The is intended to focus on the resident as the center of control. The baseline care plan promotes continuity of care and communication among staff , and increases resident safety and safeguards against adverse events that are most likely to occur after admission. 1) Resident #1 had diagnoses including but not limited to Dementia, Alzheimer's disease and Difficulty in Walking. An Annual Minimum Data Set (an assessment tool that measures health status) dated 4/17/2024 documented the resident had severe cognitive impairment. The resident exhibited wandering behaviors. The resident had impairment to the upper extremities on both sides and required a wheelchair for ambulation. The resident required set up assistance for eating, maximal assistance with toileting and supervision with bed mobility and transfers. There was no evidence of an abuse, victim, or potential victim care plan in place for Resident #1 prior to the incident that occurred on 6/19/2024. Review of the surveillance video from 6/19/2024 revealed at 16:08 Resident #1 was observed rolling themself over to the table where another resident was working on a puzzle with Certified Nurse Assistant #1. Resident #1 proceeded to push the table the other residents were sitting at, and Certified Nurse Assistant #1 is seen grabbing the table and pulling it back into place. At 16:15:20, Resident #1 is seen going towards Certified Nurse Assistant #1. Certified Nurse Assistant #1 is seen moving a doll and Resident #1 attempted to chase behind them. Certified Nurse Assistant #1 was observed taunting Resident #1. Resident #1 was visibly agitated trying to get around the table to Certified Nurse Assistant #. Resident #1 reached out and threw the puzzle(been worked on by another reisdent) on the floor. At 16:26, Certified Nurse Assistant #1 was seen seated at the nurse's station on the computer. Resident #1 wheeled into the nurse's station and grabbed Certified Nurse Assistant #1 by the shirt lifting them off the chair. Certified Nurse Assistant #1 and Resident #1 began tussling. Certified Nurse Assistant #1 then stood up and pushed Resident #1 to get them off of their shirt and continued to tussle with Resident #1 as they wre still holdng onto them. Certified Nurse Assistant #1 grabbed Resident #1 by their hands and Resident #1 kicked at Certified Nurse Assistant #1. Other staff members are seen entering the nurses station trying to release Resident #1's hands from Certified Nurse Assistant #1. Resident #1 is seen been rolled out of the nurse's station. Certified Nurse Assistant #1 then kicked Resident #1's baby doll to the floor and proceeded to go back and sit at the computer. 2) Resident #3 admitted to the facility 9/20/2024 with diagnoses including and not limited to Pneumonia, Obsessive Compulsive Disorder and Heart Failure. A 5 -day Admission Minimum Data Set (an assessment tool that measures health assessment) dated 9/26/2024 documented the resident was cognitively intact. The resident required a walker for ambulation. The resident required set up assistance with meals, moderate assistance with toileting, supervision with bed mobility and transferring. Review of a needs care plan last revised 12/11/2024 documented Resident #3 was dependent on staff for meeting their emotional, intellectual, physical, and social needs related to their physical limitations. Interventions listed included provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression, and responsibility. There was no documented evidence of Resident #3 having a risk to be victimized care plan in place. There was no documentation of the incident that occurred being reflected in any of the resident's care plans. Review of a grievance form dated 10/10/2024 documented Resident #3 reported that on 10/4/2024 they went to the therapy gym for therapy at around 4:20 PM and it was a Friday. Resident #3 stated they asked Physical Therapy Assistant #2 when they would be able to go home and Physical Therapy Assistant #2 in a stern manner responded they had 2 options: Assisted Living Facility or 24 hour care with supervision. Resident #3 stated the answer made them very upset because it was never mentioned during the care plan meeting that was held on 10/2/2024 where Physical Therapist #2 was present. Resident #3 satted after they told Physical Therapist #2 that they could not do 24 hour care with suoervision, Physical Therapist #2 responded, then they will call Adult Protective Service if the resident left without 24 hour care with supervision in place.Resident #3 stated as they tried to continue to speak to Physical Therapist #2, they were trying to get them out of the gym stating it was 5 PM and time to go. Resident #3 stated Physical Therapist #2 got them to the door and then closed the door in their face. Resident #3 reported this interaction caused them to be unable to sleep the entire weekend as they tried to reach out to 411 to find 24 hour care. The grievance form also revealed that it was also reported by nursing staff and a family member of the reisdent that Resident #3 was worried all weekend and was psycholigically affected by the incident. Resident #3 reported that on Sunday 10/6/2024 Physical Therapy Assistant #2 came to them for therapy, and they refused because they did not want to work with them. During an interview on 1/8/2025 at 4:42 PM, the Director of Nursing stated for Resident #3's care plan for risk to be victimized should have been initiated after the incident with Physical Therapy Assistant #2. The Director of Nursing stated the unit manager would have been the one to initiate this care plan. During a telephone interview on 1/23/2025 at 10:43 AM, Licensed Practical Nurse #3 stated they update the care plans most of the time for the residents on their unit, but for this incident with Resident #3, they spoke with the social worker. Licensed Practical Nurse #3 stated they did not initiate an abuse care plan because Resident #3 was alert and oriented with a high Brief Interview of Mental Status score. Licensed Practical Nurse #3 stated they spoke about this with the social worker, and they stated an abuse care plan was not needed because the issue was more related to the staff. Licensed Practical Nurse #3 stated the social worker usually updates the behavior and abuse care plans, unless it is otherwise determined in a meeting. Licensed Practical Nurse #3 stated they meet with the social worker and decide together if an abuse care plan is needed for a resident. Licensed Practical Nurse #3 stated they remember a surveyor told them a victim care plan is only initiated for residents with dementia diagnosis or issues with cognition. Licensed Practical Nurse #3 stated when Resident #3 was discharged and returned to the facility after another hospitalization , they initiated a high risk to be victimized care plan due to their impulsivity. During a telephone interview on 1/23/2025 at 12:48 PM, the Director of Nursing stated the baseline care plan policy is the only care plan policy they have, they do not have a policy for updating and reviewing care plans. The Director of Nursing stated it is the responsibility of the unit managers to complete the comprehensive care plan and the social worker completes the abuse/risk to be a victim care plans, however if the social worker was not available, the unit managers would be expected to complete the abuse care plans. The Director of Nursing stated the unit manager is the oversight for the social worker completing the abuse care plans and the unit manager should be checking to be sure the care plans are initiated. The Director of Nursing stated they do not check the unit managers to ensure they are doing their job. The Director of Nursing stated they spoke with the social worker and were told the care plans were completed. Based on the residents Brief Interview of Mental Status scorethere was no need for a risk to be a victim care plan because the residnets can speak up when something happens. The Director of Nursing stated care plans are updated for a change in condition. If there are changes during the morning meetings, issues are discussed, then a care plan meeting is set up. The Director of Nursing stated they did speak with the interdisciplinary team about Resident #3 during morning report and reported the incident to the Department of Health, but because the resident was alert and oriented an at risk for abuse and victim care plan were not initiated. The Director of Nursing stated they will be initiating the potential victim care plan for all residents going forward. The Director of Nursing stated they try to check that everything is in place following an incident but if it was missed then it was missed. 10 NYCRR 415.11(c)(1)

Based on observation, record review and interview conducted during the recertification survey, the facility did not ensure each resident was treated with respect and dignity in an environment that promotes maintenance of their quality of life for 2 of 4 residents (Residents #49, and #116) reviewed for dignity. Specifically, 1. Resident #49 was observed on several occasions wearing a food-stained gown; 2. signs that were visible to staff and visitors detailing how to feed Resident #116 were placed above the bed. The findings are: The facility policy titled Resident Rights and revised 11/2023 documented the facility strives to make sure each resident is afforded a dignified existence, is treated with respect and dignity and receives care in a manner and environment that promotes maintenance or enhancement of his/her quality of life. 1. Resident #49 was admitted to the facility and had diagnoses including but not limited to multiple sclerosis, rheumatoid arthritis, and hypothyroidism. The 12/5/23 Minimum Data Set documented Resident #49 had moderately impaired cognition, and was dependent on staff for eating and personal hygiene. The current care plan titled Activities of Daily Living documented limited physical mobility and nutritional problem, required texture of pureed food and thicken liquids for meals. The 11/7/22 intervention documented Resident #49 should wear a hospital gown during meals to increase independence. During an observation on 1/30/24 at 11:42 AM, Resident #49 was sitting in the dining room with tablemate's, wearing a hospital gown (as a clothing protector) over their clothes. There were several food items that had fallen from the resident's mouth and on to the hospital gown. Resident #49 continued wearing the hospital gown into lunch time with multiple food items. Staff #1 (Certified Nurse Aide) who assisted the residents at the table with hand hygiene for lunch meals, did not remove the food soiled hospital gown from Resident #49. Staff #2 (Certified Nurse Aide) placed a paper clothing protector on the other residents at the table, but did not remove the food soiled hospital gown from Resident#49. During an interview on 1/30/24 at 12:12 PM Staff #1 (Certified Nurse Assistant) stated they assisted with lunch set up of the table where Resident # 49 and tablemate's were seated. Staff #1 stated the resident used the gown over their clothing because the paper clothing protector was too thin. During an interview on 1/30/24 at 1:11 PM Staff #2 (Certified Nurse Assistant) stated they had assisted in serving the resident's their lunch meals from table to table and stated, Resident #49 should have been taken care of as soon as possible. 2. Resident #116 was admitted with hypertension, chronic kidney disease and diabetes mellitus. The Minimum Data Set (MDS) quarterly assessment documents the resident had moderate cognitive impairment and is dependent on staff to be fed meals. During a wound dressing change observation, a large sign on two pieces of paper was observed over Resident #116's bed and in bold letters documented instructions to staff for feeding the resident. During an interview on 02/02/24 at 12:21 PM, Staff #27, (Registered Nurse Unit Manager) stated the sign was meant for Resident #116 and thinks it is a dignity issue and does not know why they never noticed it. Staff #27 stated it was put there by the speech pathologist but would be better if it was on the certified nurses assistant kardex. During an interview on 02/02/24 at 02:37 PM Staff #15, (Speech Pathologist), stated the sign was put on the wall by them as a reminder because there was a lot of new staff. Staff #15 stated they felt it was a cue for staff but could see that a visitor coming in to visit the roommate could easily view the information which is very personal. 415.3(d)(1)(i) 41666

Based on record review and interviews conducted during the recertification survey process from 1/30/2024 through 2/6/2024, the facility did not ensure that all alleged violations involving abuse were reported no later than 24 hours even if the events did not result in serious bodily injury, to other officials (including to the State Survey Agency) in accordance with State law through established procedures. Specifically, the facility did not report 3 resident-to-resident altercations involving Resident #126 as the victim. Findings include: Resident #126 was admitted to facility with the following diagnoses and conditions: schizoaffective disorder, unspecified intellectual disability, and suspected adult neglect or abandonment. The 10/25/23 quarterly minimum data set (MDS, an assessment tool) documented Resident #126's cognitive skills for daily decision making were severely impaired and displayed other behaviors such as hitting/scratching self, pacing and disrobing in public. The accident/incident report dated 8/14/23 documented Resident #126 was in their wheelchair in the hallway when another resident was observed aggressively pushing Resident #126 wheelchair into a wall, then grabbed Resident #126 by the right side of neck and shoulder. The accident/incident report dated 8/26/23 documented Resident #126 was observed being pushed into a wall by a male resident where Resident #126 hit their left knee on wall. Nursing note dated 8/26/23 documented Resident #126 stated that they were scared prior to incident. The accident/incident report dated 9/25/23 documented Resident #126 was found in a male resident room. Male resident was hitting Resident #126 in the face with a pillow with one hand and punching resident with the other. There was no documented evidence that New York State Department of Health (NYSDOH) was contacted regarding the 8/14/23, 8/26/23 and 9/25/23 resident-to-resident altercations involving Resident #126. During an interview conducted on 02/05/24 at 02:56 PM with the Director of Nursing regarding the three incidents involving Resident #126. Stated that the incidents were not reported to the Department of Health because the incidents happened quickly and there was no injury to the resident. 10 NYCRR 415.4 (b)

Based on observations, interviews, and record reviews conducted during the recertification and abbreviated surveys (NY00326854), the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents for two of three residents (Resident # 24 and #62) reviewed for accidents. Specifically, 1. staff did not ensure that Resident #24 received the correct meal texture based on physician order; and 2. the plan of care for Resident #62 was not implemented resulting in the resident sustaining a fall with major injury. The findings are: The revised 9/2023 policy entitled, Feeding-at Risk Residents, documented that assigned staff were to distribute trays and verify all food and liquids provided matched the meal ticket to ensure correct diet and food consistency. The education hand-out entitled, Proper distribution of Meal Trays and Set Up for Residents, directed nurse to check and compare consistency of meal to the meal ticket included before tray served. 1. Resident #24 was admitted with diagnoses including but not limited to dementia with other behavioral disturbance, and hypertension. The 4/21/22 care plan titled Activity of Daily Living documented the resident could feed themselves with supervision and physical support and required constant monitoring. The 11/3/23 physician's order documented no added salt, mechanical soft texture, ground meats, added gravy. The 11/28/23 revised care plan documented resident presented with mild dysphagia (difficulty swallowing) monitor for aspiration, coughing, throat clearing, changes in breathing while consuming foods. The 1/9/24 dietary note documented resident required assistance with meals and their diet was mechanical soft with ground meat, added gravy. The 1/17/24 quarterly Minimum Data Set (an assessment tool) documented that Resident #24 had severely impaired cognition and required partial to moderate assistance with eating. The 1/30/24 lunch meal ticket documented no added salt, mechanical soft diet, ground meat with gravy, 3 oz of ground Kielbasa. During observation on 1/30/24 at 12:23 PM Resident #24 was served kielbasa that was cut into round pieces. and no gravy was present on the tray. During an observation and interview on 1/3-/24 at 12:23PM Staff #8 (Licensed Practical Nurse) was assisting Resident #24 and stated that the resident's diet was mechanical soft and chopped regular. Staff #8 was observed encouraging Resident #24 to spit out the food if they were having a hard time chewing. Resident #24 was observed pushing food out of their mouth and then continued to chew the same bite. Staff #8 stated they noted that the resident had been chewing for a long time. During an interview on 1/31/24 at 3:43 PM, Staff # 13 (Cook) stated each unit had a list of modified diets; the meal tickets were used to provide the quantity and consistency of foods needed for each unit; the cook supervisor would check to ensure all consistencies were correct prior to being sent to the units. Staff #13 stated on 1/30/24 there was an error and a resident received chopped kielbasa (sausage) instead of ground meat as per order. During an interviews on 1/31/2024 at 3:39 PM, 3:54 PM, and 4:27 PM, Staff #15 (Speech Therapist) stated ground meat was for residents with difficulty chewing; meat was ground in a blender, and the skin on the sausage was removed. Staff #15 stated Resident #24 was on a mechanical soft/ground meat diet and cut up kielbasa sausage would not be appropriate for the resident. Staff #15 stated all Resident #24's meat must be ground because the resident had oral mastication dysphagia (pro-longed chewing). Staff #15 stated this problem was noted by the resident family and staff which led to their evaluation. Staff #15 stated that staff should check the ticket on the tray against the meal served on the plate to ensure the correct diet. During a telephone interview conduction 02/01/24 at 11:34 AM, Staff # 8 stated the nurses and certified nurse aides are supposed to check the trays and ensure the diet was correct; if staff was assisting a resident with eating, they should also check the ticket and meal to confirm it was correct prior to assisting the resident with eating. Staff #8 stated they did not check Resident #24's meal or ticket on 1/30/24 at noon meal and stated the tray was already in front of resident when they sat down to assist the resident. During an interview on 02/01/24 at 11:47 AM Nurse Practitioner #6 reviewed the resident's chart and stated they were to receive a mechanical soft diet, ground meat with gravy due to prolonged mastication and slow eating. The facility's policy entitled Falls Reduction and Management revised 4/2023 documented the facility strives to assist their staff to reduce falls, minimized injuries, and ultimately improve the quality of life of the residents. 2. Resident #62 was admitted to the facility with diagnoses including cancer, depression, and cataracts. The 10/01/23 certified nurse aide instructions documented Resident #62's mode of transfer from wheelchair to/from bed with a slide board on the side of the bed closest to door with extensive assistance of 1 staff and was to wear [NAME] shoes. A Hoyer lift for transfers with an extensive assist of 2 staff members was required for showers. There were no instructions for transferring from the wheelchair to the toilet. The 10/10/23 Annual Minimum Data Set (an assessment tool) documented Resident #62 was cognitively intact, had no behaviors, had bilateral impairment to lower extremities, used a walker and wheelchair, was dependent for toileting and toileting transfers, substantial /maximum assist for transfers, non-ambulatory, was always incontinent of bowel and bladder. The 10/23/23 accident/incident investigation documented Resident #62 had a witnessed fall at approximately 2 PM. Resident # 62 fall was witnessed by assigned Staff # 1 (Certified Nursing Assistant). Staff #1's written account, documented Resident #62 was sitting in their room in a wheelchair and appeared to be agitated while waiting to be toileted. Staff #1 transported Resident #62 to the bathroom in the wheelchair and instructed Resident #62 to grab onto the grab bars in the bathroom and to stand to use the toilet. Staff #1 was assisting Resident #62 from behind, Resident #62 let go the grab bar and lost their balance. The 10/23/23 physician/nurse practitioner orders documented X-ray left knee post fall and 10/24/24 send to emergency room for evaluation. During an interview on 1/31/24 at 09:27 AM, Resident #62 stated they were not feeling comfortable in their wheelchair and went into the bathroom. Resident #62 stated that Staff #1 came in, but they were not trained, to take them to the bathroom and that is when the fall occurred. During an interview on 1/31/24 at 09:40 AM Staff #3 (Licensed Practical Nurse Manager) stated Resident #62 had a fall on 10/24/23, on the 7-3 shift. Resident #62 was requesting to use the toilet and Staff #1 took them to the bathroom and Resident # 62 fell . An X-ray was done of the left leg and revealed an femur fracture and was sent to the hospital. During an interview on 1/31/24 at 10:10 AM Staff #1 (Certified Nursing Assistant) stated Resident #62 was upset/agitated and requested to be put on the toilet. During transfer Resident #62 grabbed the bar in the bathroom with two hands and slid down. Staff #1 stated they had assisted Resident #62 to the floor. During an interview on 2/2/24 at 10:33 AM Staff #4 (Physical Therapist) stated, Resident #62 was particular and could become anxious, therefore Resident #62 should not have been using the grab bar. 415.12 (h) (i) 49364

Based on observations, record review and interviews on a recertification survey 01/30/24-02/06/24 the facility did not ensure that drugs and biologicals were stored in locked compartments under temperature controls, and only permitted authorized personnel to have access to the keys. Specifically, 8 blister packs of medicines were left on a table in the manager's unlocked office on a unit with wandering residents. The findings are: The facility policy titled storage of medications dated 04/2023 documented medications are stored at proper temperatures and locked at all times, except when under direct supervision of staff. An observation was made on 02/1/24 in the Staff #27 (Registered Nurse Unit Manager), unit office located across from the nurses station which was accessed by Staff #27 without the use of keys or codes and found to be unlocked. On a small table in the room was a stack of 8 blister packs of pills. During an interview on 2/1/24 with Staff #27 they confirmed the office door was unlocked but stated they usually lock the door. Staff #27 stated the meds were from a resident who was discharged , and they were storing the medications in the room temporarily but stated there were wandering residents in the hallway and should have been removed and locked up. 415.18(d)

Based on observation and interview conducted during a recertification survey and abbreviated survey (NY00324752), the facility did not ensure that food contact and non-food contact equipment and kitchenware were maintained in sanitary condition in accordance with standards for food service safety. Specifically (1) dirty and dusty fan blowing on clean dishes that were drying, (2) ovens and stove had caked on particles and grease, (3) dirty and dusty ceiling tiles and vents with dark markings on them, and (3) kitchen had a foul odor. Chapter 1 Sub-Part 14-1 of the State Sanitary Code states that food contact surfaces are to be washed, rinsed and sanitized after each use and when contaminated; non-food contact surfaces are to be cleaned as often as necessary to keep the equipment free of accumulation of dust, dirt, food particles and other debris; and all equipment and utensils are to be air dried after sanitizing. The findings are: During tour of kitchen on 2/01/24 at 2:35 PM, the kitchen was noted to have a foul smell, a dirty/dusty fan was blowing on clean drying dishes, stove and ovens had caked on particles and grease, ceiling tiles and vents had large amounts of dust and black markings on them. The 11/29/23 Customer Service Report documented work order for grease tank- technician noted: 3 bay sink- fair a lot of flies. Kitchen bad smell. Pumped and cleaned (2) 30 gal. traps. The 1/28/23-2/3/24 Sanitation Checklist log documented cleaning tasks that were or were not completed; the oven, hand sinks and floors were documented as not cleaned during this time. There was no other documented evidence or Sanitation checklist for any previous dates in 2023. The was no documented evidence or log of kitchen cleaning tasks for February 2024 including the stove, oven, vents and ceiling tiles. During an interview on 2/1/24 at 2:35 PM, Staff #13 stated the fan should not be blowing on dishes and dishes should just air dry. During an interview on 2/1/24 at 2:38 PM, Staff #33 stated that there was not a cleaning schedule for the ceiling tiles or vents but they were starting to work with Staff #34 to clean more regularly. Staff #33 stated they were unsure of a cleaning schedule for the rest of the kitchen. During an interview on 2/1/24 at 3:35 PM, Staff #34 stated the ceiling tiles and vents were last cleaned August 2023 and were scheduled to be cleaned again sometime in February 2024. 10 NYCRR 415.14(h)

Based on observation, record review and interviews during the recertification survey 1/30/24-2/6/24, the facility did not ensure that staff maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, staff were observed handling clean linen on a cart with dirty gloves in 2 of 3 rooms, clean PPE (personal protection equipment) carts were located on the inside of contact isolation rooms. The findings are: The facility policy titled Infection Prevention and Control Program revised 11/2023 documented the facility's primary goal is to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development of communicable diseases and infections. During observation on 02/02/24 at 01:18 PM Staff#22 (Certified Nurses Assistant) came out from room N 103 and with gloves on hands grabbed towels from the clean linen cart and brought them back into the resident's room. During an interview on 02/02/24 at 1:20 PM Staff #22 stated they were doing cares for the resident and was in a rush to get a towel and grabbed it with their gloves on. Staff #22 stated they knew they should not be wearing gloves but forgot at that moment. During observation on 02/05/24 at 12:4PM the 2 North unit personal protective equipment carts with gowns and gloves were located on the inside of room N 221 and room N 201. Residents #79 and #99 had physician orders for contact isolation. During an interview with Staff #32 (Registered Nurse Unit Manager), they stated they put the clean carts in the inside of the isolation rooms because the hallway had too much traffic and it looked cleaner inside. Staff#32 stated they did not discuss it with the infection Preventionist but can see why it should go outside since that was a way to separate dirty and clean areas. During an interview with the Staff #28, (Infection Preventionist) they stated the carts needed to be in the hallway outside of the isolation rooms. Staff #28 stated the facility had implemented wearing masks since October and staff were aware and should be doing that. Staff #28 stated they were constantly going over infection control practices and doing re-education on the spot with staff. 415.19(a)(1-3)

Based on record review and interview during the recertification survey conducted 01/30/24-2/6/24, the facility did not ensure each resident was offered pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations for 1 of 5 residents (Residents #49) reviewed. Specifically, there was no documented evidence Resident #49 was offered, declined, or educated on the pneumococcal immunization. Findings include: The facility policy titled Pneumococcal Vaccine last revised 11/11/2023, documented the facility will provide pneumococcal vaccination for all residents who are identified at risk for developing pneumococcal pneumonia and related complications. Resident #49 had a diagnoses history including hypothyroid, hemiparesis, and depression. The 12/05/2023 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, the pneumococcal vaccine was not up to date and not offered by the facility. There was no documented evidence that the resident/resident representative received education, was offered the vaccination, or declined the pneumococcal vaccine. During an interview 02/02/2024 at 10:46 AM, Staff #28 (Infection Preventionist) stated that upon admission residents are asked if they are up to date with their vaccines and if not, the facility would look in the [NAME] State data base but mostly for flu and COVID vaccines. Staff #28 stated they would ask the nurse managers to obtain information from the resident families but indicated they were not concerned if they did not get information regarding the pneumovax. They stated if the information comes with the resident, they will record it but if not does not they search for it and had not been getting declinations from residents or their representatives. Staff #28 stated without the baseline of knowing if the resident received a pneumococcal vaccine they do not know the residents eligibility to receive the vaccine. During an interview with the Director of Nursing on 2/2/2024 at 1:15 PM they stated they did not know that pneumococcal vaccine was part of Infection Control. 10NYCRR 415.19 (a) (1-3)

Based on observation and staff interview during the recertification survey and abbreviated survey (NY00324752) the facility did not ensure that essential equipment was maintained in safe operating condition. Specifically, there were missing floor tiles located in the kitchen on the floor by the 3-bay sink around the grease trap and water was noted pooling in this area that measured approximately 36 x 12. The findings are: During observation of the kitchen on 1/31/2024 at 11:00 AM, there were missing floor tiles located on the floor by the 3-bay sink around the grease trap and water was noted pooling in this area that measured approximately 36 x 12. This measurement was provided by the Food Service Director. Further observation revealed that the drain under the 3-compartment sink overflowed, and the water traveled from the crevice of a floor tiles to the larger area where the missing floor tiles were located above the grease trap. It was also noted that there was a missing floor tiles under the first sink compartment of the 3 bay sink and water was observed pooling in this area, and debris was noted in the pooling water. In addition, it was observed that a separate drain was located adjacent to the grease trap and due to the missing and damaged floor tiles around this drain, water was noted pooling around the drain. The water observed around this drain was observed coming from the water accumulated around the large area with grease trap. The 11/1/2023 Pest Tech Report documented kitchen condition: floor tiles/grout damaged-large gaps in the tile and missing grout by kettle allowing organic build up and pooling water. The drains are filled with grime around all of the kitchen. There was no documented evidence to indicate the pooling water was reported or requests for repair were made. During an interview on 2/1/2024 at 3:09 PM the Administrator stated the pooling water had been happening for at least 6 months, the floor was not level and had been causing the water to pool in certain spots. During an interview on 2/1/2024 at 3:10 PM Staff #34, (Director of Planning) stated they had no leaks in the kitchen, they have retiled certain areas of the kitchen floor. During an interview on 2/1/2024 at 3:13 PM Staff #33, (Food Service Director) stated they emailed a request for pooling water to be fixed, stated they verbally spoke to Staff #34 about pipe cleaning. Staff #33 stated they would just try to maintain the water and cleaning it up. Staff #33 stated even after degreasing, it continued to pool water and they would just squeegee it. Staff #33 stated the odor was coming from drain. During an interview on 2/1/2024 at 3:40 PM with Staff #35, (Cook) stated the pooling water had been happening for over a year. 10 NYCRR 415.5(e)(1)(2)

Based on staff interviews and record review conducted during a Recertification Survey, the facility did not ensure that investigation results of all alleged violations involving misappropriation of property are reported within a timely manner to the New York State Department of Health (NYSDOH). This was evident in 3 out of 5 residents reviewed for personal property (Residents #73, #83 and #286). Specifically, the facility failed to report to the NYSDOH a pattern of misplacing/theft upon discovery and/or after investigating 1) Resident #73's missing necklace, 2) Resident #83's missing rings and 3) Resident #286's missing Grand-Pad within 24 hours. The findings are: The facility Policy and Procedure titled, Abuse Prohibition Protocol with an effective date of [DATE] stated that each resident has a right to be free from misappropriation of property. Misappropriation of resident property was defined as the theft, unauthorized use or removal or embezzlement of a resident's personal property, including but not limited to money, clothing, furniture, appliances, jewelry, art works, and such other possessions and articles belonging to the resident, regardless or monetary value. All alleged incidents of misappropriation of resident property must be reported to the immediate supervisor, investigated, and reported to the Administrator (who is the Abuse Prevention Coordinator), or designee. When required by law or regulation, the Administrator/Designee shall ensure timely notification of the incident to the NYSDOH. Resident #73 was a [AGE] year-old admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS; a resident assessment tool) dated [DATE] documented a BIMS (Brief Interview for Mental Status) score of 3 out of 15, indicating severely impaired cognition. Resident #83 was an [AGE] year-old who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented that Resident #83 had moderate cognitive skill impairment for daily decision making. Resident #286 was an [AGE] year old male who was admitted to the facility on [DATE], was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Resident #286 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #286 was on Hospice care and expired in the facility on [DATE]. The Minimum Data Set (MDS; a resident assessment tool) dated [DATE] documented that Resident #286 was severely cognitively impaired. Review of the Police Field Case Report (#,d+[DATE]) dated [DATE] documented that the police headquarters received a call from the facility reporting multiple residents had their personal belongings stolen. Review of Resident #73's Facility Grievance Report dated [DATE] documented that staff reported the resident was wearing a thinner necklace from what she had previously worn. The resident's room was searched thoroughly to no avail. Law enforcement was notified and conducted an investigation on [DATE]. Review of Resident #83's Facility Grievance Report dated [DATE] documented that the resident stated that 8 silver rings were missing a couple of days ago. The resident's room was searched thoroughly to no avail. Law enforcement was notified and conducted an investigation on [DATE]. Review of Resident #286's Facility Grievance Report dated [DATE] documented that the facility received a call from the resident's daughter after she picked up the resident's belongings. Resident #286's daughter reported that an electronic Grand-Pad was missing. She explained that she was given the empty box with Resident #286's belongings. Resident #286's room and the entire facility were thoroughly searched by several staff including the Administrator, but the item was not located. The Administrator notified the Town Police Department on [DATE] as theft may have been suspected. An undated Misappropriation Investigation Summary signed by the Administrator documented that on [DATE] the town police responded to the facility related to the missing Grand-Pad. During the officers' interview with 1 South Licensed Practical Nurse Unit Manager (LPNUM) and the facility Administrator, the LPNUM reported that recently there were other reports of missing personal belongings. The officer initially assigned case numbers to each of the residents. During the Entrance Conference on [DATE] at 10:51AM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) denied knowledge of any other theft allegations. They both were aware of the investigation into Resident #286's missing Grand-Pad. A follow up interview was conducted on [DATE] around 2:30PM where the DON and ADON continued to deny knowledge of Resident #73's and #83's missing personal property. During an interview conducted with the Director of Social Services (DSS) on [DATE] at 10:30AM, the DSS denied receiving any complaints or investigating any cases of theft or misappropriation of property in the previous 6 months. A follow up interview was conducted on [DATE] at 2:47PM where the DSS continued to deny any knowledge of an investigation surrounding the missing personal belongings of Residents #73 and #83. During in an interview with the LPNUM on [DATE] at 08:45AM, she stated that she was on personal leave when Resident #286 expired. Upon her return to work, she got a message from resident's daughter that the box of the Grand-Pad only had the charger. The LPNUM stated that staff searched the facility for the Grand-Pad to no avail. The Administrator then called the police who came to the facility to investigate. The LPNUM stated that she does not remember the exact dates of the events that transpired. On [DATE] at 11:15AM, the Administrator submitted the police report for Resident #286's case including the Facility Grievance Reports for Residents #73 and #83. The Administrator stated that when she found out about the missing items, she thought they may have been misplaced. She stated that when they had a COVID-19 outbreak in [DATE], they moved non-COVID residents from 2 North to 1 South, which could have resulted in some misplaced personal belongings. All three residents with missing personal belongings were residents of 1 South. Resident #286's Grand-Pad and 5 of Resident #83's 8 rings were recovered. A follow up interview was conducted with the LPNUM on [DATE] at 11:24AM, where she stated that Resident #83 reported on [DATE] that her 8 rings were missing. She stated that she immediately conducted a search of the unit with the staff. As they were performing the search, staff informed her of Resident #73's necklace. The staff searched for the rings, the necklace, and the Grand-Pad. The LPNUM stated that she informed the Administrator of the other missing items. The Administrator then instructed LPNUM to initiate grievance investigations. The Administrator reported the missing Grand-Pad to law enforcement on [DATE]. LPNUM stated that a police officer came to interview her and the Administrator during which she informed the officer of the other missing items. The LPNUM stated that an investigator came a few days later to watch the camera footage. She stated that the Grand-Pad and 5 rings were found, but to date they are still searching for the rest of the missing items. 415.4(b)

Based on record reviews and interviews during a Recertification Survey, the facility did not ensure that resident Comprehensive Care Plans (CCP) were reviewed and revised to meet resident needs consistent with their rights. This was evident in 2 of 5 residents reviewed for personal property (Resident #73 and Resident #83). Specifically, Residents #73 and #83 had no documented evidence of person-centered goals or appropriate interventions specific to missing personal property in the facility. Resident #73 was a [AGE] year-old admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS; a resident assessment tool) dated 3/1/2021 documented a BIMS (Brief Interview for Mental Status) score of 3 out of 15, indicating severely impaired cognition. Review of a CCP dated 1/29/2021 documented that Resident #73 had Cognitive Deficits related to Dementia Progression. There was no documented evidence of person-centered goals and an appropriate intervention specific to an allegation on 2/03/2021 made by Resident #73 that 8 rings were missing. Resident #83 was an [AGE] year-old who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented that Resident #83 had moderate cognitive skill impairment for daily decision making. An undated CCP documented that Resident #83 had decreased cognitive abilities related to a substantial [CONDITION(S)] (TBI) prior to admission and subsequent dementia. There was no documented evidence of person-centered goals and an appropriate intervention specific to the incident that occurred on 2/5/2021 when staff observed that the resident's necklace was missing. An interview was conducted with the facility Administrator on 4/15/2021 at 11:15AM. The Administrator revealed that Residents #73 and #83 had missing property that was reported to the authorities on 2/05/2021. During an interview conducted with the Director of Nursing (DON) on 4/15/2021 at 2:30PM, the DON denied any knowledge of Resident #73 and #83's missing property investigation. During an interview conducted with the Director of Social Services (DSS) on 4/15/2021 at 2:47PM, she denied any knowledge of the investigation into the missing property of Residents #73 and #83, therefore she was not prompted to update their CCPs. The DSS stated that whoever interviewed the residents about their missing property would have provided emotional support. During an interview conducted with the 1 South Licensed Practical Nurse Unit Manager (LPNUM) on 4/16/2021 at 11:24AM, she stated that she reported Resident #73's and Resident #83's missing property to the Administrator after an initial search of the unit. The LPNUM stated that she only documented the incident in the residents' Grievance/Complaint forms as she was instructed to do so by the Administrator. During an interview conducted with the DON on 4/16/2021 at 12:38PM, she stated that she was unaware of the need to include a Risk for Abuse/Victimization CCP, especially for residents with cognitive impairments. 483.21 (b)(1)

Based on record review and interview during a Recertification Survey, the facility did not ensure that catheter care was provided in accordance with professional standards of care. This was evident for 1 of 1 residents (Resident #97) reviewed for urinary catheter. Specifically, Resident #97 had no order for foley catheter care after readmission on 4/5/2021 which resulted in the treatment not being rendered for 3 days. The findings are: Resident #97 is a [AGE] year old, readmitted from the hospital on 4/5/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS (Minimum Data Set; a resident assessment and screening tool) dated 3/16/2021 documented that Resident #97 had severely impaired cognition skills for daily decision making. Resident #97 also required extensive two-person assistance with bed mobility and toilet use. The resident was totally dependent on two-person assistance for transfers and was always incontinent of bowel as well as bladder. Resident #97 used a wheelchair as a mobility device. The facility's Policy and Procedure on Urinary Catheter Use and Care, revised 3/2021 documented that catheter care is performed appropriately to prevent infections and complications caused by the presence of an indwelling catheter. Urinary catheters are cared for by all nursing staff. The Facility's Policy and Procedure on Medication Reconciliation, revised on 5/5/2020, documented that reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors or drug interactions. The procedure includes to read and review the hospital records for information on the Patient Review Instrument (PRI), History and Physical and Medication Administration Records (MAR). Review of Resident #97's Medical Doctor (MD) Orders on 04/08/2021 revealed an order to change foley catheter every night shift, every month. There was no evidence of an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record (TAR) for 4/2021 revealed a treatment order for Foley Catheter Care every shift for Cares. There was no documented evidence that the Foley Catheter treatment was provided from 4/5/2021 through 4/7/2021. The Nursing Progress Notes signed by the Registered Nurse Manager (RNM) dated 4/5/2021 documented that Resident #97 was readmitted to the facility at 3:00PM with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Foley fr16/10cc with 250cc of clear yellow urine (Foley French catheter, size 16 with a 10cc balloon - the amount of normal saline/sterile water that it is injected into the catheter to inflate the balloon at the distal end of the catheter or at the tip of the catheter, for the catheter to stay inside the urinary bladder, 250cc - urine inside the urinary drainage bag that is connected to the catheter to catch/collect the urine). Orders reviewed with MD and approved. Resident resting comfortably and in no apparent distress upon rounding, bed in low position and call bell in place. The Comprehensive Care Plan (CCP) for Indwelling Foley Catheter was initiated on 4/7/2021 with a goal that Resident #97 will not have any complications related to the foley catheter through the review date; interventions included to monitor input and output every shift, monitor clarity, color and odor of urine every shift, monitor for any signs and symptoms of UTI. During in an interview with the RNM on 4/8/2021 at 3:20PM, she stated that Resident #97 had a foley catheter on 4/5/2021 but when the order was put in they failed to document the foley catheter care. She further stated that there was no documentation on the TAR regarding the foley catheter care from Resident #97's admission on 4/5/2021 as there was no order. She stated that the order was entered on 4/8/2021 (after surveyor intervention). During in an interview with Director of Nursing (DON) on 4/8/2021 at 3:30PM, she stated that she became aware that there was no order for the foley catheter care. The DON stated that it was a mistake. 483.25(e)(1)-(3)