Every finding on record at Martine Center for Rehabilitation and Nursing

Based on record review and interviews during an abbreviated survey (2738206) the facility did not ensure that the Minimum Data Set accurately reflected the resident status for one (1) of three (3) residents (Resident #1) reviewed for general skin issues. Specifically, Resident #1 was admitted to the facility on [DATE] and the admission Minimum Data Set staged a wound on the sacrum as stage 2 (two) because it referenced the admission nurse's assessment. On 12/09/2025 the wound care provider assessed the wound as an unstageable wound, but the Minimum Data Set did not reflect this update. The 01/21/2026 Minimum Data Set has the sacral wound as a stage 4 (four).The policy titled MDS 3.0 last revised 8/2019, documented that the MDS 3.0 information will be completed by the Interdisciplinary Team (IDT). Each discipline will be responsible for completion of their sections and will follow the MDS Resident Assessment Instrument (RAI) manual guidelines. All disciplines that make entries on the MDS 3.0 are responsible to electronically sign and date. Resident #1 admitted on [DATE] had diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a term for lung and airway diseases that restrict your breathing), other Vasculitis (an inflammation of blood vessels) limited to the skin, and Cellulitis (bacterial infection affecting the deeper layers of the skin and underlying tissue) of unspecified part of limb.The admission Minimum Data Set, dated [DATE] with an assessment reference date of 12/15/2025 documented under Section M - skin conditions M0300, that Resident #1 had a stage two (2) pressure ulcer.The wound evaluation management summary dated 12/15/2025 documented on page 5 of 19 that Resident #1 had a wound on the sacrum that was identified as unstageable (due to necrosis). This document was electronically signed by the wound care provider on 12/22/2025 at 10:26 PM. A care plan with a focus as alteration in skin integrity documented that Resident #1 had an actual pressure injury related to (r/t): Sacral stage 4 (necrotic tissue) date initiated 12/09/2025. During an interview on 02/11/2026 at 10:40 AM with the Minimum Data Set Coordinator, they stated that they did not do the assessment for Resident #1, and that as the coordinator they mostly do administrative tasks. During this interview the Minimum Data Set Coordinator reviewed the wound notes for Resident #1 and noted that there was a 12/08/2025 assessment by the admission nurse that documented the wound as sacrum stage 2 (two), and they acknowledged that it was significantly different than the 12/09/2025 assessment by the wound care provider that documented the wound as sacrum unstageable. The Minimum Data Set Coordinator stated that the 12/09/2025 and the 12/15/2025 assessments by the wound care provider were not uploaded until 12/21/2025 and 12/22/2025 respectively, well after the Assessment Reference Date (ARD) 7 (seven) day look back period. The Minimum Data Set Coordinator stated that the 12/09/2025 and the 12/15/2025 assessments by the wound care provider should have been available, but since they were uploaded late the person that did the minimum data set assessment only had available the 12/08/2025 assessment by the admission nurse that documented the wound as sacrum stage 2 (two). NYCRR 415,11 (b)

Based on record review and interviews during an abbreviated survey (2738206) the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for one (1) of three (3) residents (Resident #1) reviewed for general skin issues. Specifically, Resident #1 was admitted to the facility on [DATE] with three (3) different wounds in separate locations, the wound on their sacrum was assessed by the admission nurse as a stage two (2) pressure ulcer, but there were no orders in the electronic medical record for care or treatment until 12/12/2025.The policy titled Skin and Pressure Injury Prevention last reviewed 6/2024 documented that the purpose of the procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Under the heading risk assessment, it further documents that step one (1) is to assess the resident on admission/re-admission for existing pressure/injury risk factors utilizing the Braden Risk Assessment (an evidence-based tool for identifying residents at risk of developing pressure injuries), repeat the Braden Risk Assessment weekly for 4 weeks, quarterly, annually, or as often as is required based on the resident's clinical condition/progress. Resident #1 admitted on [DATE] had diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a term for lung and airway diseases that restrict your breathing), other Vasculitis (an inflammation of blood vessels) limited to the skin, and Cellulitis (bacterial infection affecting the deeper layers of the skin and underlying tissue) of unspecified part of limb.The admission Minimum Data Set, dated [DATE] with an assessment reference date of 12/15/2025 documented under Section M- skin conditions M0300, that Resident #1 had a stage two (2) pressure ulcer.The wound evaluation management summary dated 12/15/2025 documented on page 5 of 19 that there is a wound on the sacrum that was identified as unstageable (due to necrosis). This document was electronically signed by the wound care provider on 12/22/25 at 10:26 PM. A care plan with a focus of alteration in skin integrity documented that Resident #1 had an actual pressure injury related to (r/t): Sacral stage 4 (necrotic tissue) date initiated 12/09/2025. Medication (Phone) order dated 12/11/2025 with and end date 12/15/2025 documented Santyl External Ointment 250 UNIT/GM (Collagenase) apply to Sacrum topically every day shift for wound care. Cleanse area with Normal Saline pat dry, apply Santyl ointment to wound bed, then apply calcium alginate, and cover with DPD. During an interview on 02/11/2026 at 10:40 AM with the Minimum Data Set Coordinator, they stated that they did not do the assessment for Resident #1, and that as the coordinator they mostly do administrative tasks. During this interview the Minimum Data Set Coordinator reviewed the wound notes for Resident #1 and noted that there was a 12/08/2025 assessment by the admission nurse that documented the wound as sacrum stage 2 (two), and they acknowledged that it was significantly different than the 12/09/2025 assessment by the wound care provider that documented the wound as sacrum unstageable. The Minimum Data Set Coordinator stated that the 12/09/2025 and the 12/15/2025 assessments by the wound care provider were not uploaded until 12/21/2025 and 12/22/2025 respectively, well after the Assessment Reference Date (ARD) 7 (seven) day look back period. The Minimum Data Set Coordinator stated that the 12/09/2025 and the 12/15/2025 assessments by the wound care provider should have been available, but since they were uploaded late the person that did the minimum data set assessment only had available the 12/08/2025 assessment by the admission nurse that documented the wound as sacrum stage 2 (two). During an interview on 02/12/2026 at 4:21 PM Registered Nurse #8 stated that they were the Supervisor that was working on 12/11/2025 when it was brought to their attention by Certified Nurse Assistant #5 that Resident #1's sacral wound needed to receive treatment. Registered Nurse #8 stated that they called the on-call physician assistant (PA), they followed their instructions and successfully placed a wound care treatment order in the Electronic Medical Record (EMR) to start the next day. Registered Nurse #8 stated that on 12/11/2025 they followed the wound care treatment order and performed a dressing change but did not write a note to document the treatment. NYCRR 415.12(c)(2)

Based on observations, interviews and record reviews conducted during the recertification survey from 01/05/2026 to 01/12/2026, the facility did not ensure proper storage, preparation, distribution, and service of food in accordance with professional standards for food safety. Specifically, the kitchen refrigerators, freezers, spice/seasoning areas and dry storage areas contained food items that were expired, not labeled or dated with opened/prepared/expiration dates.The findings included: The facility policy titled Food Storage last revised 05/10/2024 documented: Sufficient storage facilities will be provided to keep foods safe, wholesome and appetizing. Food will be stored in an area that is clean, dry and free from contaminants. Refrigerator food storage: All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed b their safe use-by dates, and frozen (where applicable) or discarded. Frozen foods: All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use-by dates or discarded. During an initial kitchen observation of storage freezers, refrigerators, dry storage and seasoning area on 01/05/2026 at 9:32 AM with [NAME] Staff #1, Assistant [NAME] Staff #5, and Registered Dietician, the following was observed: Storage Freezers #1 and #2:-a six (6)-pound bag of [NAME] Brand plantains with half left in bag was observed with freezer burn, not dated when opened and did not have an expiration date.-a container of eight (8) cupcakes was observed with no date prepared or use by date.- a 4.69-pound package of goat meat was not labelled, was observed with freezer burn and did not contain a use by date. The package was labelled with a packed date of 10/12/2025.-An approximately 1 (one) pound bag of goat bones was observed in a plastic bag which was not properly sealed and had freezer burn. Seasoning area:-A five (5) pound container of Spur Tree brand curry powder was not labeled when opened and did not contain an expiration date.-An unlabeled five (5) pound container of a seasoning product was not dated when prepared and did not contain an expiration date.-A metal container containing [NAME] Moss was not labeled and did not contain a date prepared or expiration date.During an initial kitchen observation on 01/05/2025 at 09:32 AM of the produce refrigerator, dairy refrigerator, walk in freezer and dry storage area the following was observed:An approximately three (3) pound metal container of vanilla pudding that was not labeled and had a use by date of 12/26/2025. A metal container tray of shredded cabbage dated 01/03/2026 was not labeled and did not have a use by date.A metal tray of diced apples with an expiration date of 01/04/2026.A tray of diced apples was dated 02/19/2025. Dairy refrigerator: -A one-half block of yellow American cheese was not dated when opened and did not have a use by date.- A five-pound block of American cheese with approximately 3/4 remaining, was not sealed/closed. was not dated when opened and did not have a use by date.-an 11.29-pound block of cheddar cheese was not dated when opened. -a package of four (4) tortilla wraps was not labeled, did not have an expiration date and was not dated when opened.-A five (5) pound container of Cream O'Land Cottage Cheese with approximately 1/3 remaining was not dated when opened. -A five (5) pound bag of Parmesan Cheese was not dated when opened. Walk-in Freezer: -Approximately three (3) pounds of raw salmon was observed freezer burned and not labelled or dated. -Approximately two (2) pounds of French Toast sticks were not labeled and were not dated when opened.-Four (4) toasted cheese sandwiches were not labeled or dated when prepared and did not have a use by date.-An approximately three (3) pound cooked beef product was not labelled, not dated when prepared, did not have a use by date and was observed with freezer burn. The product was wrapped in a cling wrap only. -An approximately one (1) pound cooked beef product was not labelled and did not have a date prepared or expiration date. -A 28-ounce bag of Garden Mills diced onions with approximately half remaining was not dated when opened and did not have an expiration date. The bag was observed opened and not sealed. Dry storage area:-A two (2) bag creamy rice product was not dated when opened.During interview and observation on 01/05/2026 at 9:36 AM [NAME] Staff #4 stated food items should be labeled, dated when opened and have a use by date before being placed in freezers/refrigerators. They stated to prevent freezer burn, food items should be properly stored in cling and freezer storage bags and not in hand tied plastic bags. During an interview and observation on 01/05/2026 at 9:36 AM, Assistant [NAME] #5 stated food items should be labeled, dated when opened and have a use by date before being placed in freezers/refrigerators. They stated foods should be disposed of if not used by the expiration date.During interviews on 01/06/206 at 4:40 PM and 01/09/2026 at 5:45 PM, the Director of Food Services stated they were aware of unlabeled, undated, expired and freezer-burn observations during initial tour of the facility kitchen. They stated food items should be labelled and dated when opened/prepared/expiration and properly sealed before being placed in the refrigerator/freezer. 10NYCRR 415.14(h)

Based on observations, interviews, and record review the facility did not ensure the resident's right to be treated with dignity and respect. This was evident for one (Resident #206) of five residents reviewed for Dignity. Specifically, Resident #206 was placed in common areas of the unit while wearing a hospital gown.The findings are:The policy titled Resident Rights dated 05/28/2024 documented residents have a basic right to a dignified existence.Resident #206 was admitted to the facility with diagnoses of bipolar disorder and schizoaffective disorder.The Social Work Note dated 01/05/2026 documented Resident #206 was cognitively impaired.On 01/05/2026 at 11:24 AM Resident #206 was observed wearing a hospital gown and using their left hand to grab the bottom of the gown to cover their genital area as they sat amongst four other residents in public view of anyone entering or leaving the unit. Resident #206 remained in the common area until 12:30 PM when a Certified Nurse Aide wheeled Resident #206's wheelchair in the dining room for lunch. There were seven residents eating lunch in the dining room and Resident #206 was placed at a table with a female resident seated across from them. Resident #206 continued to hold their hospital gown in place as they sat and ate lunch.On 01/12/2026 at 10:03 AM, the Unit Manager, Registered Nurse #11, was interviewed and stated Resident #206 was dressed in a hospital gown because they did not have any of their own clothing available to wear at the facility. They stated the facility's Concierge usually helped obtain donated clothing for new admissions, so they did not have to wear only a hospital gown, but the Concierge did not work over the weekend. They stated they did not obtain any donated clothing for Resident #206 prior to the resident being taken out of their room on 01/05/2026. Registered Nurse #11 stated, to respect their right to be treated with dignity, residents should not be placed in public view in only a hospital gown.On 01/12/2026 at 11:17 AM, the Director of Nursing was interviewed and stated residents in hospital gowns may be placed outside of their rooms in public view to promote safety and staff supervision. The Director of Nursing stated that a blanket or sheet could be used to promote the resident's dignity if the resident had nothing more to wear than a hospital gown.10 NYCRR 415.3(d)(1)(i)

Based on observations, interviews, and record review the facility did not ensure each resident with a mental disorder was evaluated and received care and services in the most integrated setting appropriate to their needs for one (Resident #85) of three residents reviewed for Preadmission Screening and Resident Review. Specifically, Resident #85 was not referred for Level II specialized services once their facility stay was no longer brief or finite.The findings are:Resident #85 was admitted with diagnoses of attention deficit disorder, post-traumatic stress disorder, schizoaffective disorder, anxiety, and major depressive disorder.The Hospital Discharge summary dated [DATE] documented Resident #85 formerly lived at a group home with a ramp available to enter and had a rolling walker at home. The resident was in usual state of health besides a fall with facial injury caused by vertigo.The Patient Review Instrument dated 09/23/2025 documented Resident #85 required supervision with toileting and was chairfast or wheeled by someone else for mobility. Diagnoses included unspecified fall, anxiety, seizure disorder, schizoaffective disorder, dystonic tremor, and vertigo.The Preadmission Screening and Resident Review Level I screen dated 09/25/2025 documented Resident #85 had a home in the community to return to and had a serious mental illness. Resident #85 would be admitted to the facility for a very brief, finite stay.The Hospital Discharge Summary #2 dated 09/29/2025 documented Resident #85 required discharge to a rehabilitation facility due to facial injury and vertigo.The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #85 had a diagnosis of Post Traumatic Stress Disorder.The care plan related to short-term stay dated 10/01/2025 documented Resident #85 wanted to be asked about returning to the community on each assessment. Interventions included assist with discharge planning,The Social Work note dated 11/05/2025 documented the Social Worker called Resident #85's mother and was informed that the family was requesting the resident not return to the previous group home.There was no documented evidence Resident #85 was referred for Level II specialized services once their stay in the facility surpassed brief and finite.On 01/12/2026 at 10:09 AM, Registered Nurse #11 was interviewed and stated Resident #85 previously resided in a group home and was unable to be discharged to their former residence. Resident #85 did not receive physical therapy or any other skilled services and was mainly at the facility for medication management. Resident #85 did not require staff assistance with activities of daily living and ambulated independently throughout the unit without assistive devices. On 01/12/2026 at 2:38 PM, the Social Worker was interviewed and stated the Social Work Department was responsible for reviewing the Preadmission Screening and Resident Review information for new admissions and for long term residents that required Level II specialized services. The Social Worker stated Resident #85 should have been referred for Level II specialized services after it was determined they could no longer return to their former residence. The Social Worker stated they were only recently assigned Resident #85's case and the social worker that previously worked with Resident #85 no longer worked for the facility.10 NYCRR 415.11(e)

Based on observations, record review and interviews the facility did not ensure each resident received treatment and care in accordance with the professional standards of practice and the comprehensive person-centered care plan for one (1) of three (3) residents (Resident #108) reviewed for Skin Conditions. Specifically, 1.) wound care was not provided as per physician order for Resident #108. In addition, Licensed Practical Nurse #1 documented 01/05/2026 through 01/07/2026 administration of wound care that was not provided. The findings included:Resident #108's diagnoses included unspecified cellulitis, chronic venous insufficiency, and idiopathic gout.The quarterly Minimum Data Set, dated [DATE] documented Resident #108 was cognitively intact, had no rejection of cares, had no pressure ulcers or venous ulcers and had applications of ointments/medications other than to feet and no dressing applied to feet. A care plan dated 03/03/2025 documented Resident #108 had impaired skin integrity related to a venous wound of the right dorsal foot. Apply treatment as ordered. A physician order dated 12/12/2025 documented triamcinolone acetonide external cream 0.1%. Apply to right foot topically two (2) times a day and as needed for wound care treatment. Cleanse site with normal saline, pat dry, then apply triamcinolone ointment.During an observation and interview on 01/05/2026 at 12:15 PM, Resident #108 applied triamcinolone 0.1% gel topical to the right shin and dorsal foot area. Reddened open areas were on the dorsal right foot. Resident #108 stated they kept the wound care medication in their room and applied the medication to their right lower leg and foot a couple of times a day. They stated they received the topical medications from nursing staff. Resident#108 stated they had a history of cellulitis, and the wounds were cellulitis related. During an observation on 01/06/2026 at 8:53 AM Resident #108 had reddened open areas on the dorsal right foot. During an interview and observation on 01/07/2026 at 11:07 AM and 01/09/2026 at 9:42 AM one 15-gram tube of triamcinolone cream was on Resident #108's bed. Licensed Practical Nurse #1 stated they were aware that the medication was left in Resident #108's room. They stated Resident #108 liked to complete wound care treatments independently. They stated Resident #108 applied the prescribed treatment and cleansed the area. During a follow up interview and observation on 01/09/2026 at 9:42 AM, Licensed Practical Nurse #1 stated they did not apply or observe Resident #108 applying the triamcinolone ointment 01/05/2026 through 01/07/2026. They stated Resident #108 completed wound care independently during this time. They stated they documented completion of wound care on the electronic medical record during these dates. Licensed Practical Nurse #1 stated they were aware they should not have documented task completion if they did not actually complete wound care. During interviews and observations on 01/07/2026 at 11:56 AM and 01/09/2026 at 11:09 AM, Registered Nurse Unit Manager #2 stated they were not aware that Resident #108's topical medication was left in their room, and that Resident #108 completed wound care independently. They stated Resident #108 did not have a physician order or care plan to perform wound care independently. Registered Nurse Unit Manager #2 stated Licensed Practical Nurse #1 should not have documented they completed wound care if they did not actually complete it on 01/05/2026- 01/07/2026. They stated Licensed Practical Nure #1 should have reported that Resident #108 completed their own wound care. They stated they would have contacted the Nurse Practitioner to assess Resident #108. 10 NYCRR 415.12

Based on observation, interview, and record review conducted during the Recertification Survey and Abbreviated survey (#2638932) on 01/05/2026 to 01/12/2026, the facility did not ensure the necessary treatment and services to promote healing and/or prevent new ulcers from developing for 3 of 3 residents (Resident #12, #8 and #169) reviewed for Pressure Ulcers. Specifically, for Resident # 12 with a left buttock stage two pressure ulcer, calcium alginate was not applied as per physician order, 2) for Resident #8 assessed at risk for pressure ulcers, heel offloading was not implemented as per care plan, and 3) for Resident #169 assessed at risk for pressure ulcers, heel offloading was not implemented as per care plan. Additionally, although offloading of Resident #8's heels was not observed on 01/05/2026 and 01/09/2026 the certified nurse aide tasks documented offloading had been provided. The findings include: The policy titled Skin and Pressure Injury Prevention, last revised 06/27/2024, documented: This facility will assess residents for risk in the development of pressure injuries and implement preventative measures in accordance with current standards of practice. The purpose is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Risk assessment included weekly skin monitoring by licensed nurse. Prevention measures included when in bed, every attempt should be made to off load pressure to heels (keep heels off the bed), placing a pillow from knee to ankle, heel boots or heel booties, and heel suspension boots/device. 1.Resident # 12 was admitted to the facility with diagnoses including but not limited to multiple sclerosis, paraplegia, acute respiratory distress. The admission Minimum Data Set (MDS; a resident assessment tool) dated 5/30/2025 documented Resident #12 had moderate cognitive impairment, was at risk for developing pressure ulcers, and had no pressure ulcers The 12/19/2025 physician order documented calcium alginate applied to the left buttock every day. The 12/25/2025 care plan titled Actual Pressure Injury Left Buttock Stage 2 documented monitor wound daily for signs of infection, monitor/document/report to physician as needed changes in skin appearance, color, wound healing, signs of infection, wound size and stage. The January 2026 Treatment Administration Record documented calcium alginate, apply to the left buttock topically daily. Cleanse area with normal saline, pat dry, apply calcium alginate, then cover with a dry protective dressing. During observation on 01/07/2026 at 11:04 AM, Resident #12 was positioned on their right side for treatment administration to the left buttock. Registered Nurse # 13 applied zinc oxide to the left buttock. During interview on 01/08/2026 at 12:29 PM the Wound Care Nurse stated Resident #12 had a physician order for calcium alginate to the left buttock stage 2 pressure ulcer. During interview on 01/08/2026 at 3:09 PM Registered Nurse # 13 stated that although they saw the calcium alginate order for the left buttock, they applied zinc oxide instead. They stated zinc oxide was used as a skin protectant. 2) Resident #8 had diagnoses including acute osteomyelitis, left ankle and foot acquired absence of other left toes, and cellulitis of the left lower limb. The quarterly Minimum Data Set, dated [DATE] documented Resident #8 had severe cognitive impairment, bilateral lower extremity impairment, was dependent on staff for bed mobility and transfers, had one (1) stage two pressure ulcer present on admission and was at risk for pressure ulcers. The care plan titled Risk for Pressure Ulcers dated 07/22/2022 documented heel protection, offload heels with pillows or boots as tolerated. During on observation on 01/05/2026 at 1:15 PM, 01/07/2026 at 9:10 AM, and 01/09/2026 at 8:54 AM and 10:06 AM Resident #8 was sleeping in bed on their back. Both heels rested on the mattress. There were no pillows or boots to provide offloading. During an observation and interview on 01/09/2026 at 10:08 AM, Certified Nurse Aide #17 stated Resident #8's heels were resting on the mattress and not offloaded. They stated they provided cares for Resident #8 at approximately 6:45 AM on 01/05/2026 and 01/09/2026 and forgot to apply heel boots. Certified Nurse Aide #17 stated the certified nurse tasks documented Resident #8's heels were to be offloaded with pillows or boots as tolerated. Certified Nurse Aide #17 stated although they documented Resident #8's heels were offloaded with pillows or boots on 01/05/2026 at 8:12 AM and 01/09/2026 at 8:08 AM they did not complete the task. During an interview on 01/09/2026 10:40 AM, Licensed Practical Nurse #8 stated Resident #8 was at risk for pressure ulcers, and both heels should be offloaded with pillows or booties. They stated they have observed Resident #8's heels not offloaded with pillows or boots in the past. Licensed Practical Nurse #8 stated when they observed Resident #8's heels not offloaded they would offload them and remind certified nurse aide/s that the resident's heels should be offloaded. During an interview on 01/09/2026 at 10:47 AM, Registered Nurse Unit Manager #2 stated Resident #8's heels should be offloaded except during cares. They stated staff did not report concerns regarding offloading Resident #8's heels or that Resident #8 rejected offloading of the heels. They stated they completed rounds daily but did not always remove sheets to check if offloading was completed. They stated staff should not document completion of tasks if they did not complete the task. 3) Resident #169 diagnoses included hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage affecting left non-dominant side. The quarterly Minimum Data Set, dated [DATE] documented Resident #169 had severe cognitive impairment, no rejection of cares, was dependent on staff with bed mobility and was at risk for pressure ulcers. The current care plan titled Risk for Pressure Ulcers documented heels offloaded with pillows or boots as tolerated. The current certified nurse aide Kardex tasks documented heels offloaded with pillows or boots as tolerated. During observation on 01/05/2026 at 1:23 PM, 01/05/2026 at 5:10 PM, 01/06/2026 at 9:13 AM, 01/07/2026 at 9:05 AM, and 01/07/2026 at 3:11 PM, Resident #169 was in bed with both heels resting on the mattress. There were no pillows or boots to provide offloading. During an interview and observation on 01/07/2026 3:56 PM, Certified Nurse Aide #18 stated Resident #169's heels were not offloaded. They stated they could not recall if Resident #169's heels should be offloaded or if the directive to offload heels was included on the certified nurse aide Kardex. They stated they were not aware when they last offloaded Resident #169's heels. During an interview and observation on 01/07/2026 at 4:03 PM, Registered Nurse Unit Manager #2 stated Resident #169's heels were on the mattress, not offloaded and the resident had no booties in place. Registered Nurse Unit Manager #2 stated they and unit nurses were responsible for oversight of certified nurse aide task completion. Registered Nurse Unit Manager #2 s stated as per care plan intervention and certified nurse aide Kardex Resident #169's heels should be offloaded. They stated staff did not report Resident #169's heels were not offloaded or that there were no booties in the resident's room. During an interview on 01/08/2026 at 10:20 AM, Certified Nurse Aide #9 stated they did not apply booties or offload heels with pillows for Resident #169 on Monday 1/5/2025 or 01/07/2025. They stated there were no booties present in Resident #169's room and they had not used pillows to offload the resident's heels in a while. During an interview on 01/08/2026 at 11:51 AM Licensed Practical Nurse #8 stated they could not recall if Resident #169 had a physician order or care plan intervention for heel offloading or booties. They stated they did not recall observation of Resident #169 with booties or offloaded heels. They stated residents who were primarily bed bound should have heels offloaded. 10NYCRR 415.12(c)(1)

Based on observation, interview, and record review conducted during the Recertification and Abbreviated Survey (#2638932), the facility did not ensure each resident received necessary respiratory care in accordance with professional standards of practice for two (2) of three (3) residents (Resident #12 and Resident #149) reviewed for Respiratory Care. Specifically, 1. Resident # 12 did not receive the correct oxygen flow rate of 6 liters per minute as per physician order and 2. Resident #149 did not receive the correct oxygen flow rate of 3 liters per minute as per physician order.The findings include The policy titled Oxygen Therapy Administration reviewed 9/2025 documented oxygen therapy is administered by licensed nurses or respiratory therapists in accordance with healthcare provider orders and in accordance with the state scope of practice and nurse practice act. Method of oxygen delivery includes oxygen concentrator often used for residents who require low flow oxygen on a regular basis. Oxygen delivery system include Venturi (Venti) Mask designed to deliver a specific concentration of oxygen (e.g., 24%, 28%, 31%, 35%, 40%, 50%, etc.) 1.Resident # 12 was admitted with diagnoses including but not limited to acute respiratory failure, multiple sclerosis and paraplegia. The 5/27/25 care plan titled Alteration in Respiratory System documented provide oxygen as per physician's orders. The 5/29/2025 physician order documented continuous oxygen at 6 Liters per minute and 35% humidification via tracheostomy. The 10/5/2025 Quarterly Minimum Data Set (an assessment tool) documented Resident #12 was cognitively intact, received oxygen, suctioning, and tracheostomy care. During observation on 01/05/2026 at 9:46 AM Resident #12 was in bed with the head of bed elevated at 30 degrees. Resident #12 was awake and had a tracheostomy. The bedside oxygen concentrator was set at 10 liters per minute. The oxygen was being administered via tracheostomy. During observation on 01/06/2026 at 1:06 PM Resident #12's bedside oxygen concentrator was set at 10 liters per minute. The oxygen was being administered via tracheostomy. During observation and interview on 01/07/2026 at 3:27PM, Resident #12 was observed in the hallway sitting in a wheelchair. Oxygen was being administered via tracheostomy at 8 liters per minute. Registered Nurse Unit Manager #14 checked the oxygen flow rate and stated it was being administered at 8 liters per minute. Registered Nurse Unit Manager #14 stated the resident was not receiving the correct oxygen amount per the physician order. Registered Nurse Unit Manager #14 stated it was their responsibility to ensure Resident #12 received the oxygen as per physician order. During interview on 01/12/2026 at 1:18 PM, the Medical Director stated the nurses should check the physician order to make sure residents receive the correct amount of oxygen. 2. Resident #149 had diagnoses including chronic pulmonary obstructive disease, Type II diabetes mellitus and history of chronic respiratory failure with hypoxia. The care plan titled Alteration in Respiratory System last revised 07/09/2025 documented administer treatments and medications as per physician orders. The physician order dated 12/29/23 documented supplemental oxygen via nasal cannula at three (3) liters/minute to maintain oxygen status. The quarterly Minimum Data Set (a resident assessment tool) dated 11/16/2025 documented Resident #149 was cognitively intact, had no shortness of breath, and received oxygen therapy. During an observation on 01/05/2026 at 11:57 AM, 01/05/2026 at 1:54 PM, and 01/06/2026 at 9:35 AM Resident #149 was ambulating in the hall. Oxygen was being administered via nasal cannula at two (2) liters per minute. During an observation on 01/07/2026 at 9:20 AM Resident #149 was seated in the dining room. Oxygen was being administered at two (2) liters per minute via nasal cannula. During an interview on 01/06/2026 at 9:42 AM Resident #149 stated they changed the oxygen administration flow rate on their portable tank independently from three (3) liters to two (2) liters. They stated they did not discuss changing the oxygen flow rate with the staff. During an interview on 01/08/2026 at 10:33 AM, Certified Nurse Aide #9 stated they observed Resident #149 adjusting the oxygen level dials on the tank frequently but did not report this to the nurses. During an interview on 01/08/2026 at 11:28 AM, Licensed Practical Nurse #8 stated they checked the oxygen administration rate during medication rounds and throughout the shift. Licensed Practical Nurse #8 stated Resident #149 had a physician order for oxygen at two (3) liters/minute. They stated they were aware Resident #149 changed the oxygen flow rate to two (2) liters/minute. They stated Resident #149 was educated on the importance of not adjusting the oxygen flow rate. Licensed Practical Nurse #8 stated they requested Resident #149 to report any oxygen flow rate concerns. They stated they verbally discussed Resident #149 changing the oxygen flow rate with the physician but were not sure if it was documented in the electronic medical record. During an interview on 01/09/2026 at 11:18 AM, Registered Nurse Unit Manager #2 stated they were not aware that Resident #149 changed the oxygen flow rate. They stated unit staff should have immediately reported the concern. NYCRR415.12 (k) (6)

Based on observation, interview and record review conducted during the recertification survey from the facility did not ensure that drugs and biologicals were maintained in accordance with current professional standards for storage, labeling and expiration dates. Specifically, 1. observation of the fifth-floor medication cart revealed an insulin pen with no open date or discard date, and 2. one 15-gram tube of triamcinolone cream 0.1%, and one tube of diclofenac gel 1% were on the bedside table in Resident 108's room. The findings include: The policy titled Medication Administration dated 12/2019 documented the expiration date on the medication label must be checked prior to administering. When opening a multi dose container, the date shall be recorded on the container. The policy titled Insulin Administration dated 1/2020 documented check the expiration date, if opening a new vial, record the expiration date and time on the vial (follow manufacturers recommendations for expiration after opening). 1.The physician order dated 09/18/2024 documented Insulin Glargine Subcutaneous Solution Pen-Injector (Insulin Glargine) inject 38 units subcutaneously twice a day for Type 2 Diabetes Mellitus. Resident # 144 admitted with a diagnosis of Type 2 Diabetes Mellitus, chronic systolic heart failure and end stage renal disease. The quarterly minimum data set (an assessment tool) dated 10/28/2025 documented Resident #144 received seven insulin injections out of seven days observed. During an observation of the fifth-floor medication cart on 01/05/2026 at 3:40 PM a Lantus Solostar insulin Pen was found with no open or discard date written on the label for Resident #144. During an interview on 01/05/2026 at 3:41 PM, Licensed Practical Nurse # 10 stated whoever opened the insulin pen did not date it. They stated when the insulin pen was opened it was supposed to be dated. They stated the insulin pen was last administered on 01/05/2026 at 8:51 AM. Additionally, they stated the insulin pen was good for 28 days after opened. During an interview on 01/05/2026 at 4:02 PM, Registered Nurse Unit Manager #11 stated the registered nurse was responsible for labeling the insulin pen when received from the pharmacy. They stated they did not know why the insulin pen was not dated properly. During an interview on 01/12/2026 at 12:15 PM the Director of Nursing stated they did not know why there was no date on the insulin pen. They stated that they, the nursing educator and the nursing supervisors were responsible for educating the staff regarding proper labeling of insulin pens. 2) Resident #108's diagnoses included unspecified cellulitis, chronic venous insufficiency, and idiopathic gout. The quarterly Minimum Data Set, dated [DATE] documented Resident #108 was cognitively intact. During an observation on 01/05/2026 at 12:15 PM, a tube of diclofenac sodium topical gel 10% was observed on Resident's bed. There was no staff present in Resident 108's room during observation. Resident #108 stated they kept the medications in their room. They stated they received the topical medication from nursing staff. During an observation on 01/06/2026 at 8:53 AM, a tube of diclofenac sodium topical gel 10% and a tube of triamcinolone 0.1% topical gel was observed in a round basin on top of the bedside table in Resident #108's room. There was no staff present in Resident #108's room. Resident #108 stated they stored the medications in their room. During an interview and observation on 01/07/2026 at 11:07 AM and 01/09/2026 at 9:42 AM, one 15-gram tube of triamcinolone cream 0.1%, and one tube of diclofenac gel 1% were on Resident #108's bed. Licensed Practical Nurse #1 stated they were aware the medications were left in Resident #108's room. They stated Resident #108 liked to apply their skin care medications. They stated they were aware that medication should not be left in a resident room. During interviews on 01/07/2026 11:56 AM and 01/09/2026 11:09 AM Registered Nurse Unit Manager #2 stated they were not aware that Resident 108's topical medications were left in Resident #108's room. NYCRR 415.18(d)

Based on observations and interviews during an abbreviated survey (NY00338612/591526, NY00355525/591523) the facility did not ensure the environment was functional, sanitary, and comfortable for residents, staff, and the public. Specifically, on every unit in the facility there were multiple areas of chipped paint, scuff marks, visible dirt and stains on the walls and floors, base boards coming off the wall, wallpaper bubbling up and foul odors noted. The findings are:The facility Maintenance-Preventative policy last reviewed 5/2025 documented the facility provides preventative maintenance services to the facility, grounds, and equipment in accordance with current standards of practice and State and Federal Regulations. The Maintenance Director/designee will provide education to the maintenance staff upon hire and as needed regarding the provision of preventative maintenance tasks.During an interview on 6/13/2025 at 11:16 AM the Administrator stated they do environmental rounds two times daily with the Assistant Administrator in the morning and they also round in the afternoon. The Administrator stated if they see something that needs to be addressed, they inform the Director of Environmental/Housekeeping.During environmental rounds in the facility, with the Administrator and the Director of Environmental/Housekeeping, on 6/13/2025 from 11:40 AM to 12:34 PM the following were observed:6th floor Observation from 11:40 AM to 11:45 PM: Scuff marks were noted along the walls with visible dirt and debris. The plaster on the wall was chipped5th floor observation from 11:50 AM to 12 PM: Room # 504 was noted with chipped paint on the walls; Room # 521 noted with chipped paint on the door; Rm #526 noted with books and other materials all over the resident's room. There were crumbs noted all over the floor. There was mouse traps observed in the corners of the room. In Rm # 529- there was no shower head in the bathroom. Radiator covers were missing in the dining room.4th floor observation from12:02 PM to 12:08 PM the hallway floor and shower room had visible dirt and debris, the dining room and hallway floors were sticky; baseboards along the hallway were peeling off the wall and the wallpaper was bubbling up.3rd floor observation from 12:10 PM to 12:15: Metal panel along the hallway was missing screws.2nd floor observation from12:16 PM to 12:34 PM: foul odor noted at the end of the hallway by room [ROOM NUMBER]; a hole noted at the bottom of the wall in the bathroom.All areas observed discussed with the Administrator and the Director of Environmental/Housekeeping while rounding and they stated all areas would be addressed. During rounds, the Director of Environmental/Housekeeping stated the higher side rooms have not been renovated yet, but they will be completed soon. The Director of Environmental/Housekeeping stated that the scuff marks on the floors can be buffed out and they would assign staff to do this. The Director of Environmental/Housekeeping stated they think the stickiness on the floors is from the wax that they currently use, so they will investigate the product and possibly change products. During an interview on 6/13/2025 at 12:41 PM the Director of Environmental/Housekeeping stated they provide oversight to 15 housekeeping staff and 2 maintenance staff. The Director of Environmental/Housekeeping stated the housekeepers are given a daily cleaning list which includes deep cleaning of certain rooms. Deep cleanings are done one daily for a total of 5 rooms weekly. Deep cleaning also includes waxing and waxing is done in 3 rooms daily, 3 times a week until every room on the unit is done. The Director of Environmental/Housekeeping stated there is a maintenance book on each unit at the nurses' station where tasks can be requested. Staff can also text, call or inform the department by word of mouth if something is needed on a unit. Once a request is received, they report to the area to evaluate the job and the required equipment to complete the request. Time of completion is determined by the degree of repair needed. The Director of Environmental/Housekeeping stated they do have mice in the facility, but it is not a big issue and there are very few sightings, but enough to worry people. The Director of Environmental/Housekeeping stated the second floor, and the third floor are usually where the sightings are seen. The facility uses Allstate for pest control company, and they come to the facility every Tuesday and Thursday for service. The pest company is very diligent and once there is a reported sighting, and the company comes out there is very rarely a sighting after in the same area. Any issues reported are logged in a book, kept at the front desk. the pest company addresses issues the logbook first, then they make rounds in the kitchen, basement, outside the permitter and dining rooms. 10 NYCRR 415.29

Based on record review and interview during an abbreviated survey (NY00367889/591527, NY00333553/591524, NY00349962/591497) 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 3 of 5 residents (Resident #1, #2, #5) reviewed for care planning. Specifically, 1) Resident #1 had an unwitnessed fall on 01/1/2025 and sustained skin tears to both arms. Resident #1 had no documented fall risk or actual fall care plan initiated before or after the incident. 2) Resident #2 was noted to have eschar to their left heel on 02/11/2024. Resident #2's pressure injury care plan had not updated with the presence of the left heel eschar, measurements and/or tracking. 3)After a meeting with Resident #5's representatives on 04/18/2025, it was determined the resident would have a two person assist for all cares. Review of Resident #5's self-care care plan revealed it was not updated to reflect the two-person assistance for all cares. The findings are:The facility Care Plan Comprehensive policy last reviewed 08/2/2024 documented a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan will incorporate identified problem areas, and the risk factor associated with them.1) Resident #1 was admitted with diagnoses including but not limited to Polymyalgia Rheumatica, Asthma and Depression.An admission Minimum Data Set, dated [DATE] documented the resident had moderate cognitive impairment. The resident required a walker or a wheelchair for locomotion. The resident required set-up assistance with meals, moderate assistance with bed mobility and dependent for toileting, upper and lower body dressing and transfers.Review of an accident/incident report dated 01/01/2025 documented Resident #1 had an unwitnessed fall in their room. 0n 01/01/2025. The report documented the resident's bed was in the lowest position and the call bell was within reach.There was documented evidence of an actual fall care plan or risk for fall care plan initiated before and after the fall on 01/01/2025. There was no safety measures to prevent falls in place for the resident. During a telephone interview on 08/15/2025 at 11:50 AM, Registered Nurse #1 stated the nursing supervisor who responded to the incident is responsible to complete the incident report and update the fall care plans with interventions. Registered Nurse #1 stated the fall care plan should be updated with fall incident and should document a goal, intervention, and if any injuries were sustained it should be documented. Any orders obtained from the physician for treatment should also be documented.During a telephone interview on 08/15/2025 at 1: 50 PM The Director of Nursing #2 stated whoever completes the incident report is responsible to update the care plans. The risk for falls or actual fall care plans should be updated. The Director of Nursing #2 stated all residents should have a risk for fall care plan in place and then if they have a fall then it gets changed to actual fall care plan. All residents are at risk for fall so they should at a minimum have a risk for fall care plan in place on admission. The Director of Nursing #2 stated they and the Assistant Director of Nursing also go behind the staff to be sure the care plans are updated, and interventions are listed and implemented. it is weird that Resident #1 does not have a fall care plan. 2) Resident #2 admitted to the facility 01/29/2024 with diagnoses including but not limited to COVID-19, Dementia and Cerebral Infarction. A Modification of Admission/Medicare- 5-Day Minimum Data Set, dated [DATE] documented Resident #2 had a BIMS score of 11. The resident had impairment to their lower extremity on one side and used a wheelchair for locomotion. The resident required supervision for eating, moderate assistance for toileting, bed mobility and transfers. Resident #2 was at risk for pressure injuries but had no pressure injuries on admission. Review of a risk for pressure injury care plan initiated 02/9/2024 documented Resident #2 was at risk related to impaired mobility. Interventions listed included to inform the resident/family of any new areas of skin breakdown and monitor/document/report to Physician any changes in skin status.On Resident #2's risk for pressure injury there was no documented evidence of the presence of that Resident #2's of Resident #2's risk for pressure injury care plan was updated with the left heel eschar area identified on 02/11/2025. There was also no documented evidence of a actual pressure injury care plan being initiated.Review of Registered Nurse #3's progress note dated 02/11/2024 at 1:53 PM documented follow up for hard skin eschar to left heel, with staff nurse witness, Resident #2 was seen and assessed due to a history of eschar to the left heel, prior to assessment noted Resident #2 pointing to their heel float on top of the bed, gesture acknowledged. During the assessment Resident #2 was calm, no signs and symptoms of pain upon gentle touch to skin, noted left heel with old black eschar, wound bed was hard, no discharge, no erythema to wound edges, no warmth to touch of peri-wound, the eschar measures 3.5 cm x 5.5 cm. Noted hard callous to left bunion. Right foot clean, scaly and dry, as per nurse podiatry consult was already in place, nursing will follow up.During a telephone interview on 08/21/2025 at 1:20 PM Registered Nurse #3 stated they would have been responsible for updating Resident #2's pressure injury care plan with their findings on 2/11/2024. Registered Nurse #3 stated there are only two nursing supervisors on the unit and they believe they did not update Resident #2's care plans. 3) Resident #5 admitted to the facility on [DATE] with diagnoses including but not limited to Type 2 Diabetes Mellitus, Anemia and Essential Hypertension.A Quarterly Minimum Data Set date 02/10/2025 documented Resident #5 had a BIMS score of 13 with no behaviors noted. The resident had impairment to their lower extremity on one side. The resident used a wheelchair for locomotion and had a limb prosthesis. The resident required set up assistance with eating, maximal assistance with toileting, bed mobility and transfers.Review of a self-care care plan last reviewed 07/4/2024 documented Resident #5 required assistance due to bilateral lower extremity impairment and weakness. Interventions listed included encourage resident to participate to fullest extent possible on each interaction.There was no documented evidence of Resident #5's care plan being updated to reflect their two person assist for all cares status.During an interview on 08/1/2025 at 2:21 PM the Administrator stated Resident #5's representatives stated that the resident was being abused in the facility, so they completed an investigation and submitted it to the New York State Department of Health, in April. The Administrator stated Resident #5 was changed to a 2 person assist for all cares to ensure their safety at that time.During a telephone interview on 08/25/2025 at 2:44 PM the Director of Nursing #1 stated Resident #5 required a two person assist for bed mobility, toilet hygiene and transferring. The Director of Nursing #1 stated they reviewed Resident #5's care plans and they do not see the two persons assist for cares documented in the resident's care plan. The Director of Nursing #1 stated the care plan should have updated when the task was updated, and the nursing supervisor or the Registered Nurse is responsible for updating this. The Director of Nursing #1 stated they are going to get up from rehabilitation and update the resident care plan.10 NYCRR 415.11(c)(1)

Based on record review and interviews during an abbreviated survey (NY00367889-591527, NY00367906-591522), the facility did not ensure the resident environment remained as free of accident hazards as is possible; and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for safety and supervision. Specifically, on 01/01/2025 Resident #1 told Certified Nurse Aide #1 that they needed to get out of bed otherwise they were going to jump out. Certified Nurse Aide #1 left the resident alone in their room after the resident made the statement. When Certified Nurse Aide #1 returned to Resident #1's room, the resident was on the floor. Resident #1 sustained skin tears to both upper extremities.The findings are:The facility Safety and Supervision of Residents policy last reviewed 01/2024 documented the facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors. This facility follows current standards of practice to provide care and services designed to promote resident safety and minimize the risks of accidents.Resident #1 had diagnoses including but not limited to Polymyalgia Rheumatica, Asthma and Depression.An admission Minimum Data Set, dated [DATE] documented the resident had moderate cognitive impairment. The resident required a walker or a wheelchair for locomotion. The resident required set-up assistance with meals, moderate assistance with bed mobility and dependent for toileting, dressing and transfers.Review of a self-care care plan initiated 11/5/2024 documented Resident #1 required assistance with self-care and mobility related to limited mobility. Interventions listed included to encourage to participate to the fullest extent possible with each interaction, encourage to use bell to call for assistance, monitor skin for redness, open areas and cuts and report changes to the nurse.Review of a cognition care plan initiated 11/19/2024 documented Resident #1 had impaired cognition which might be impacted by their depression diagnosis. Interventions listed included monitor/document/report to nurse and medical provider any changes in cognitive function.Review of an accident/incident report dated 1/1/2025 documented Resident #1 had an unwitnessed fall, while caring for the resident Certified Nurse Aide #1 had to stop to respond to a code called in the facility. Certified Nurse Aide #1 lowered the bed and informed Resident #1 why they needed to leave. The resident threatened to jump out of the bed. Certified Nurse Aide #1 left the room to get assistance and upon return Resident #1 was observed on the floor of the room and sustained skin tears over their senile purpura as a result. Certified Nurse Aide #1 was educated to call for help by using the call bell or verbally calling out for help instead of leaving the room, especially if Resident #1 voiced that they will come out of the bed. The investigative summary concluded there was no evidence of intent or actual abuse, neglect, mistreatment towards the Resident.Review of Certified Nurse Aide #1's personnel file revealed they received individual education on fall safety precautions on 01/02/2025. The education documented when needing assistance from staff in cases of potential incidents or actual incidents do not leave the resident unattended use the call bell/or yell out for help.Attempt to reach Certified Nurse Aide #1 on 8/12/2025 and 8/15/2025 was unsuccessful.During a telephone interview on 08/15/2025 at 1: 50 PM, the Director of Nursing #2 stated they recall Resident #1 and some of the details from the incident that occurred on 01/01/2025 with Certified Nurse Aide #1.They stated Certified Nurse Aide #1 when interviewed, stated Resident #1 voiced to them that they were going to jump from the bed if left alone. The Director of Nursing #2 stated Certified Nurse Aide #1 left Resident #1's room and should not have left Resident #. They should have used the call bell to get help, especially if the resident threatened to jump out of the bed. 10 NYCFRR 415.12(h)(1)

Based on record reviews and interviews conducted during an abbreviated survey (NY00362050), the facility did not ensure that all alleged violations involving abuse, and neglect are reported immediately but no later than 2 hours to the New York State Department of Health (NYS DOH). This was evident for 1 of 3 residents (Residents #1) reviewed for accidents. Specifically, Resident #1 who was identified to be at risk for elopement on 10/21/2024 left the facility undetected by facility staff on 11/26/2024. The Facility staff did not realize Resident #1 was not in the facility until dinner time (approximately 5:30pm-6pm) and did not report the incident to State Agency Department until 11/27/2024. The findings are: The Facility Policy on Accident-Incidents created 11/2013 documented that it is the facility policy to monitor and evaluate all occurrences of accidents or incidents or adverse event occurring on the facility premises which is not consistent with the routine operation of the facility or care of a particular resident. These occurrences must be evaluated and investigated. Director of Nursing and Administration are responsible to review incident/investigation and conclusion to determine if incident requires reporting to outside agencies such as Department of Health, OIG CMS etc. Resident #1 was admitted to the facility with diagnoses including Impaired Cognition due to Dementia and schizophrenia. The Quarterly Minimum Data Set, dated dated dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 10 indicating impaired cognition with decision making. Resident was independent with activities of daily living and was ambulatory. The Risk for Elopement Care Plan updated 10/21/2024 documented resident exhibited potential risk for elopement such as going to unsafe areas, risk of injury to self and others, exit seeking, fixation on meeting with mail staff and refusing wander guard. The Facility Incident Report dated 11/26/2024 documented that late afternoon on 11/26/2024, the resident was noted as missing from the unit. Code Gray was initiated with an unsuccessful outcome of the facility search. A call was made to 911 as well as notification to the next of kin. A thorough search of facility, grounds and surrounding area was unsuccessful. Investigation findings documented resident went to the lobby downstairs at approximately 11:30 am to sit by the window to wait for the mailman. At the close of the investigation, the facility determined that the resident exited through the front door during a high traffic period of a holiday week, while the reception staff was occupied. The investigation revealed that there is reasonable cause that abuse, neglect, exploitation or mistreatment may have occurred. The incident was reportable to the Department of Health. During an interview conducted with the Administrator on 12/3/2024 at 1:53pm, the Administrator stated the facility became aware of the incident on 11/26/2024 at 6:00pm. The facility reported the incident to the New York State Department of Health on 11/27/2024 at 1:11AM. The Regional Nurse submitted the report. 10NYCRR 415.4(b)(1)(i)

Based on observation, record review and interviews during an abbreviated survey (NY00362050), the facility did not ensure that residents were provided adequate supervision/monitoring to prevent elopement. This was evident for 1 of 3 (Resident #1) residents reviewed for accidents. Specifically, Resident #1 who was identified to be at risk for elopement on 10/12/2024 exited the facility through the front door on 11/26/2024 at approximately 11:30 am undetected by facility staff. The resident was found on 12/2/2024 by Los Angeles Police Department who called the facility to report that the resident was brought to Los Angeles Police Department General Psych for evaluation. The findings are: The Facility Policy on Elopement Prevention created on 7/2024 documented the facility maintains a process to identify residents at risk for elopement, implement preventative strategies for those identified as an elopement risk and conduct a missing resident procedure when necessary. Interventions that may be implemented for residents identified at risk for elopement may include but are not limited to frequent monitoring of the resident's whereabouts to ensure they remain in the facility, implementation of a wander management device or other electronic alert system. The Facility Policy on Care Plans - Comprehensive created on 10/2015 documented a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan will incorporate risk factors associated with identified problems. Resident #1 was admitted with diagnoses including schizophrenia, unspecified dementia without behavioral disturbances and atherosclerotic heart disease. The Quarterly Minimum Data Set, dated dated dated [DATE] documented Brief Interview Mental Status score of 10 indicating impaired cognition with decision making, no impairment of upper & lower extremities, no mobility device and was independent with activities of daily living. Review of the Risk for Elopement Care Plan updated 10/21/2024 documented resident exhibited potential risk for elopement such as going to unsafe areas, risk of injury to self and others, exit seeking, fixation on meeting with mail staff and refusing wander guard. Review of the Quarterly Elopement evaluation dated 10/12/2024 documented Resident #1 scored 16 as high risk for elopement, not a candidate for wander management device. If the total score is 10 or greater, the resident should be considered to be at high risk for elopement. Prevention protocol should be followed and documented on the care plan which includes enhanced monitoring for exit seeking behavior. The evaluation documented the resident was currently exit seeking. There was no documented evidence that Resident #1 was closely supervised and monitored frequently prior to the incident on 11/26/2024. The Facility Incident Report dated 11/26/2024, documented that on 11/26/2024 during the late afternoon, Resident #1 was noted as missing from the unit. A Code Gray was initiated with an unsuccessful outcome from the facility search. A call was made to 911and the next of kin was notified. A thorough search of facility grounds and surrounding areas was conducted and unsuccessful. Investigation findings documented the resident went to the lobby downstairs at approximately 11:30 am to sit by the window to wait for the mailman. At the close of the investigation, the facility determined that the resident exited through the front door during a high traffic period of a holiday week, while the reception staff was occupied. The investigation revealed that there was reasonable cause that abuse, neglect, exploitation or mistreatment may have occurred. The incident was reported to Department of Health and all staff involved were suspended pending investigation completion. Review of an addendum to the Facility Incident Report documented that on 12/2/2024 at 11:49 pm, Resident #1 was located in Los Angeles California at the Los Angeles Police Department Olympic Division. Resident #1 was admitted to the Los Angeles General Psychiatric Center. According to the officer, Resident #1 took a train to Manhattan and then purchased a bus ticket at Port Authority. Resident #1 proceeded to take a bus from New York to Los Angeles. Review of the Receptionist/Front Desk staff on duty statement documented on 11/26/2024 at 11:30am they saw the resident sitting by the window, once the mailman arrived the resident gave the mailman their mail. The Receptionist documented they thought the resident went to the restroom and did not see the resident again. Review of Certified Nurse Assistant #1 statement documented that they worked the 7:00am - 3:00pm shift and 3:00pm -11:00pm shift on 11/26/2024. Resident #1 was assigned to them on both shifts, but they did not provide care to the resident as the resident was independent with activities of daily living. The resident ate breakfast & lunch in their room. Resident #1 usually went downstairs for activities. At 5:00pm as they were giving out dinner trays, they were told by Certified Nurse Assistant #3 that Resident #1's lunch tray was still in their room. Certified Nurse Assistant #1 and Certified Nurse Assistant # 3 reported this to the nurse immediately. Review of Certified Nurse Assistant # 2 statement documented that they worked 7:00am -3:00pm shift and 3:00pm -11:00pm shift but Resident #1 was not assigned to them. Certified Nurse Assistant # 2 documented they went to deliver the meal tray and did not see Resident #1 in their room. Normally Resident #1 is in their room at dinner time. Certified Nurse Assistant #2 reported to the nurse & they began immediately looking for the resident. Review of Certified Nurse Assistant #3's statement documented Resident #1 was not in their room, but their tray was there. They thought the resident went to activities. At dinner time they went to give dinner trays and the resident was not in their room. They reported it to the nurse and began searching for the resident. Review of Licensed Practical Nurse #5's statement documented that on 11/26/2024 they made rounds at 4:30pm and noted Resident #1 was not in their room but did not find it unusual. At 5:00pm Certified Nurse Assistant # 3 told them Resident #1 was not in their room. Licensed Practical Nurse #5 documented they searched the room. During an interview conducted on 12/3/2024 at 1:53pm with the Administrator, they stated they were not in the facility when the incident occurred but was informed by the Director of Nursing. Staff interviews were obtained and reviewed by the Director of Nursing on 11/26/2024.The Administrator stated the cameras in the lobby are not functional. There are no recordings and there is no live feed. The Administrator stated they were not sure if there is a camera in the parking lot or driveway. The Administrator stated that the Regional Nurse submitted the incident report to Department of Health on 11/27/2024 at 1:11 am. During a subsequent interview on 12/3/2024 at 3:43 pm with the Administrator, they stated that the Assistant Administrator supervises the receptionist. The Administrator stated the Director of Nursing reported to them that an officer found a person that fit the description of the resident on the street, and they asked the officer to take them to the train station because they needed to go to the Port Authority Station. The officer escorted the individual to the train station as requested. The Administrator stated the officer described the individual as presenting well and had 2 bags, black coat and had shoes on. The Administrator stated Resident #1 withdrew one hundred dollars from their account on 11/22/2024. The Administrator stated Residents who are at risk for elopement are supervised closely and frequently monitored every 1-3 hours. The Administrator could not provide any documentation for the supervision provided to Resident #1 prior to the incident on 11/26/2024. During a telephone interview on 12/4/2024 at 8:45 am with Certified Nurse Assistant #2, they stated that they worked on the 2nd floor on 11/26/2024 and it was a very busy day giving care, serving trays, collecting trays, feeding residents. Certified Nurse Assistant #2 stated they saw Resident #1 during breakfast time around 8:30am - 9:00am sitting on their bed eating. Resident #1 usually ate in their room for all 3 meals breakfast lunch, and dinner. Certified Nurse Assistant #2 stated they did not see the resident again after 9:00am. Certified Nurse Assistant #2 they did not give Resident #1 a lunch tray and did not pick Resident #1 lunch tray. Certified Nurse Assistant #2 stated that they knew Resident #1was missing in the afternoon approximately 4:00pm-5:00pm pm because they kept passing by the resident's room and did not see the Resident. Certified Nurse Assistant #2 stated they informed Certified Nurse Assistant #3 that Resident#1 was not in their room. Both Certified Nurse Assistant #2 and Certified Nurse Assistant #3 checked the resident's bathroom, alerted the nurse and they began to look for Resident#1 about 5:00pm. The nurse alerted all the Certified Nurse Assistants to check all the rooms. Certified Nurse Assistant #2 stated they checked all floors and could not find Resident #1. During a telephone interview on 12/4/2024 at 9:14 with Certified Nurse Assistant # 3, they stated they worked the 3:00pm - 11:00pm shift on 11/26/2024. Certified Nurse Assistant #3 stated they came in at 3:00pm, made rounds and checked rooms. Certified Nursing Assistant #3 stated they thought Resident #1 went to activity after they checked the residents' room and Resident #1 was not in their room, as Resident #1 goes to the lobby for activity. Certified Nursing Assistant #3 stated they realized at dinner time after 5:00pm pm that Resident #1 was not in their room. Certified Nursing Assistant #3 stated they reported to Licensed Practical Nurse #5 after 5:00pm that Resident #1 was not in their room. They all began to look for Resident #1. During an interview conducted on 12/4/2024 at 9:53 am with Licensed Practical Nurse # 5, they stated they worked on 11/26/2024 when they were asked to come in and cover the shift. Licensed Practical Nurse #5 stated they made rounds about 4:30pm to check on the residents and did not see Resident #1 but it was not unusual for Resident #1 not to be there in their room because sometimes the resident goes downstairs for recreation. Licensed Practical Nurse # 5 stated a little after 5:00pm, Certified Nurse Aide # 3 while passing out the dinner trays reported that Resident #1 was not in their room. Licensed Practical Nurse # 5 stated they asked Certified Nurse Aide #1 and Certified Nurse Aide #2 who worked the day shift where Resident #1 was. Licensed Practical Nurse # 5 stated they all began to search the room for the resident, and they checked the computer to see if the resident went out on pass but there was no note indicating the resident was out on pass. Licensed Practical Nurse # 5 stated the policy of nursing home for missing residents is to start looking for the resident and call the supervisor. Licensed Practical Nurse # 5 stated they went downstairs and found the Director of Nursing who was already aware of the situation. Licensed Practical Nurse # 5 stated they heard Code Gray called but does not remember the exact time it was called. Resident #1 was not found. Resident was monitored during rounds every 3 hours. During an interview on 12/4/2024 at10:36 am, Receptionist # 4 stated that they worked the 8:00am - 4:00pm shift on 11/26/2024. The day shift is always busy. Receptionist # 4 stated they answer the phones open doors, listen to family concerns, complete paperwork for residents out on pass, transfer phone calls. Receptionist # 4 stated they saw Resident #1 at the lobby around 11:30am sitting waiting for the mail which was their normal routine. Receptionist # 4 stated they saw Resident # 1 handing their mail to the mail man and walk past the desk towards the elevator. Receptionist # 4 stated they are not sure if Resident # 1 went to the bathroom. Receptionist # 4 stated they do not recall the exact time. They left the facility at 4pm and the facility called at 6:00 pm, they were called and asked if they saw Resident #1. During an interview on 12/4/2024 at 12:52pm with Social Worker, they stated Resident #1 never attended any care plan meetings and always declined invitations. There is no plan for discharge for Resident #1. Resident #1 was a Long-Term resident who comes down to the first floor and wait for the mailman. Resident's usual routine is at the lobby between 11:00am -12:00 pm to wait for the mailman. Social worker stated Resident #1 spoke about when they were a ballerina, and the resident seemed content in the facility and never tried to leave or express any desire to leave, was happy and wanted to remain in the facility. During an interview on 12/4/2024 at 4:00pm with the resident's representative, they stated they communicated with Resident #1 only by mail and that they only exchanged letters. They never spoke on the phone. Resident #1 had expressed that the place is like a prison because they are locked up. Resident's representative stated that they told the resident the place is the best place for them because they take good care of them, and it is not a prison. Resident#1's representative stated they never informed the facility about what the resident expressed, because they thought it was private matter between them and their sister. Resident's representative stated on average they get a letter from resident once a month or every other month. Resident's representative stated they got a call from the [NAME] Plains Police Department to inform them that the resident was found in Los Angeles. Resident representative stated that resident used to live in Los Angeles for [AGE] years by themself and then they were evicted and found themselves in New York during wintertime, was screaming out of control and the Police took the resident into the court system. During an interview on 12/4/2024 at 5:18pm with the Director of Nursing, they stated that on 11/26/2024, they saw Resident #1 at 12:15pm or 12:30pm at the lobby by the window facing the parking lot. At 7:00pm [NAME] Plains Police officer came to the facility to collect additional information about the resident and asked for a description which was provided by the Director of Nursing. The Director of Nursing stated that they gave the officer a description of what the resident was wearing which was dark pants/blue or black top and sneakers but did not see the resident with bags. At 10:00 pm the officer returned to the facility to inform the Director of Nursing that Eastchester Police escorted someone who may fit the resident's description to the train station. No specifics were provided. The Director of Nursing stated they called the Administrator when Code Gray was activated a little after 6:00pm. Staff told the receptionist to call the code. The facility protocol for calling a code gray is for staff to speak to the supervisor if resident is not on the unit, or in their room or in rehab. The Supervisor will instruct the receptionist to call the code. The Director of Nursing confirmed that the facility had no knowledge that Resident #1 had left the building. During an interview with the Administrator on 12/5/2024 at 9:24 am, and also at 11:39 am and Administrator stated that the wander guards are checked for Function every night by the Registered Nurse supervisor and documented in the binder. The wander guard location/placement is checked every shift by the unit nurse and documented in the Treatment Administration Record. The Administrator stated the facility is ensuring that all residents are safe by asking them to wear the wander guard. The Administrator stated that all the residents at risk for elopement are wearing wander guards. 10 NYCRR 415.12(h)(1)

Based on record reviews and interviews during an abbreviated survey (NY00362050), the facility did not ensure Certified Nurse Aide performance appraisals were completed at least once every 12 months for 2 of 3 Certified Nurse Aides record reviewed. Specifically, performance appraisals were not documented every 12 months for Certified Nurse Aide #2 and #3. The Findings are: The Facility Policy on Employee Evaluations created 9/2019 documented the job performance of each employee shall be reviewed and evaluated at least annually. A performance evaluation will be completed on each employee at least annually. The completed performance evaluation will be placed in the employee's personnel record. Review of Facility Personnel Records revealed Certified Nurse Aide #2 was hired 7/1/2022. There was no documented evidence of any annual performance evaluation since date of hire. Review of Facility Personnel Records revealed Certified Nurse Aide #3 was hired 6/20/2017 and performance evaluation was conducted 9/5/2018. There was no documented evidence that an annual performance evaluation was completed after 2018. During an interview on 12/4/24 at 11:00am with the Director of Nursing, they stated that performance evaluations are done by the Director of Nursing and Director of Human Resources . They have been in the facility for 2 months and have not completed any performance evaluations for the staff. During an interview on 12/4/24 at 11:26 am with the Director of Human Resources, they stated that annual performance evaluations for employees are completed by Nursing. Human Resource performs a review and notifies the nursing department if evaluations are not completed. The Director of Human Resource reviewed Certified Nurse Aide #2 & 3's employee file in the presence of the surveyor. The Director for Human Resources could not provide documentation for a recent annual performance evaluation for Certified Nurse Aide #2 and #3. The Director for Human Resource stated the annual performance evaluation for Certified Nurse Aide #2 and #3 were not completed according to the facility policy. 10 NYCRR 415.12(h)(1)

Based on record review and interviews during an abbreviated survey (NY00352478), the facility did not ensure the Minimum Data Set assessment accurately reflected the resident's status for 1 out of 3 residents reviewed for assessments. Specifically, Resident #1's Quarterly Minimum Data Set assessment dated [DATE] coded the resident as dependent for all cares with 2-person assistance. The Quarterly Minimum Data Set, dated dated dated [DATE] coded the resident as dependent but requiring a 1 person assist which is not indicative of dependence for care. In addition, staff interview revealed a discrepancy on Resident #1's required assistance with bed mobility and the Certified Nurse Assistant Task Instructions/Accountability did not accurately reflect required assistance for Resident#1. Findings include: The facility Minimum Data Set 3.0 policy dated 5/2017 documented the Resident Assessment Instrument process and requirement procedure are as follows: the assessment accurately reflects the resident's status, the assessment process includes direct observation, as well as communication with the resident and direct care staff. Resident #1 was initially admitted to the facility on [DATE] and last readmitted on [DATE] with diagnosis including but not limited to Parkinson's disease, Schizophrenia and Dementia. A Quarterly Minimum Data Set, dated dated dated [DATE] documented the resident had impairment on both sides to upper and lower extremities. The resident was dependent for eating, toileting, bed mobility and transfers. No bed rails in use. The Minimum Data Set coding documented dependent for tasks signifies helper does all the effort. Resident does none of the effort to complete the activity or, the assistance of 2 or more helpers is required for the resident to complete the activity. A Quarterly Minimum Data Set, dated dated dated [DATE] documented the resident had impairment of their upper extremity on one side and impairment to both lower extremities. The resident was dependent for bed mobility, toileting, and transfers with 2-person assistance. Review of the Minimum Dat Set dated 11/6/2023, 02/04/2024, 05/06/2024 revealed the resident had impairment to both upper extremities and one lower extremity. The resident was dependent for eating, bed mobility and transfers. Documented no bed rail in use. Review of a nursing quarterly evaluation dated 02/04/2024, 05/06/2024, 08/06/2024 revealed the resident was dependent for bed mobility with 1-person physical assist. The mobility section documented the resident was bedfast and had very limited mobility with changing and controlling body position. Review of a quarterly assessment dated [DATE] documented that for activities of daily living the resident required x 2 staff total dependence, resident does not participate in activity at all for bed mobility. The mobility section documented the resident was dependent for bed mobility with a 1-person physical assist. The skin section documented the resident was completely immobile, does not make even slight changes in body or extremity position without assistance. Review of a quarterly evaluation dated 07/31/2023 documented the resident was completely immobile, does not make even slight changes in body or extremity position without assistance, and required x 2 staff total dependence, resident does not participate in activity at all for bed mobility. The Care Plan and the Certified Nurse Assistant accountability/task instruction did not accurately reflect the required assistance for a resident dependent for all cares as indicated. During an interview on 09/19/2024 at 1:25 PM, Certified Nurse Assistant #2 stated they recall Resident #1 required assist of 1 person for tasks in the computer. Certified Nurse Assistant #2 stated whenever they provided cares to Resident #, they would always get another certified nurse assistant to help them because the resident was heavy. During an interview on 09/19/2024 at 1:49 PM, Certified Nurse Assistant #4 stated they had worked with Resident #1 before and they needed 2 people assist, especially without the side rails. Certified Nurse Assistant #4 stated Resident #1 was stiff, and their leg stuck out and if you are not familiar with them and turn them, they can fall right off the bed. During an interview on 09/19/2024 at 3:38 PM, Certified Nurse Assistant #1 stated they were familiar with Resident #1 and had worked with them before the incident. Certified Nurse Assistant #1 stated that Resident #1 was a 1 person assist for bed mobility and cares. Certified Nurse Assistant #1 stated they feel Resident #1 needed to be cared for by 2 people, and they could have told the nurse or the supervisor, but they did not. During an interview on 09/20/2024 at 1:38 PM, the Physical Therapist stated when they receive a referral from nursing for a long-term resident, they would evaluate the resident and inform nursing of any recommendations and nursing then updates the computer with the recommendations from the rehabilitation department. The Physical Therapist stated to determine if a dependent resident needs a 1 to 2 person assist depends on the therapist's judgement and if they did an evaluation and they were able to complete the evaluation independently on the unit without the assistance of another staff member or therapist, then the resident may require a 1 person assist. The Physical Therapist stated if they had trouble and needed another therapist or staff member to assist them with the resident's evaluation, then they would recommend a 2 person assist. During an interview on 9/20/2024 at 1:38 PM the Physical Therapist stated when they receive a referral from nursing for a long-term resident, they would evaluate the resident and inform nursing of any recommendations and nursing then updates the computer with the recommendations from the rehabilitation department. The Physical Therapist stated to determine if a dependent resident needs a 1 to 2 person assist depends on the therapist's judgement and if they did an evaluation and they were able to complete the evaluation independently on the unit without the assistance of another staff member or therapist, then the resident may require a 1 person assist. Stated if they had trouble and needed another therapist or staff member to assist them with the resident's evaluation, then they would recommend a 2 person assist. During a telephone interview on 9/20/2024 at 2:09 PM, the Registered Nurse Minimum Data Set Coordinator stated they have been working in the facility for 4 years. The Registered Nurse Minimum Data Set Coordinator stated they sometimes residents' assessments are done in the facility in person, but other times they do not have an assessor, so the bulk of the Minimum Data Set books are done offsite. The Registered Nurse Minimum Data Set coordinator stated they use the assessments completed by the nurses on the unit to complete their Minimum Data Set and if something does not add up in the documentation, they will then go back and check on the information themself. The Registered Nurse Minimum Data Set Coordinator stated they also review the previous books to make sure that nothing has changed from the last assessment. 10 NYCRR 415.11(b)

Based on record review and interview during an abbreviated survey (NY00352478, NY00350699), 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 1 out of 3 residents reviewed for activities of daily living. Specifically, there was no documented evidence that a comprehensive care plan was initiated after the Quarterly Minimum Data Set assessment dated [DATE], that documented that the resident was dependent for all cares. In addition, the care plan did not accurately reflect the required assistance for a resident dependent for all cares on the Certified Nurse Assistant Task Instructions/Accountability. Resident #1 fell out of bed while Certified Assistant #1 was providing cares alone without rails and sustained lacerations to the forehead, and right nares and possible cervical fracture. The findings are: The facility Care Plan Comprehensive policy dated 10/2015 and last revised 10/2019 documented the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Assessments of the resident are ongoing and care plans are revised as information about the residents and resident's condition change, when the resident has been readmitted to the facility from the hospital and at least quarterly with scheduled Minimum Data Sets. Resident #1 was last readmitted to the facility on [DATE] with diagnosis including but not limited to Parkinson's disease, Schizophrenia and Dementia. A Quarterly Minimum Data Set, dated dated dated [DATE] documented the resident had severe cognitive impairment with daily decision making. No behaviors documented. The resident had impairment on both sides to upper and lower extremities. The resident was dependent for eating, toileting, bed mobility and transfers. No bed rails in use. There was no documented evidence that a comprehensive care plan was initiated after the Quarterly Minimum Data Set assessment dated [DATE] that documented that the resident was dependent for all cares. During an interview on 09/19/2024 at 1:25 PM, Certified Nurse Assistant #2 stated they recall Resident #1 required assist of 1 person for tasks in the computer. Certified Nurse Assistant #2 stated whenever they provided cares to Resident #, they would always get another certified nurse assistant to help them because the resident was heavy. During an interview on 09/19/2024 at 1:49 PM, Certified Nurse Assistant #4 stated they had worked with Resident #1 before and they needed 2 people assist, especially without the side rails. Certified Nurse Assistant #4 stated Resident #1 was stiff, and their leg stuck out and if you are not familiar with them and turn them, they can fall right off the bed. During an interview on 09/19/2024 at 3:38 PM, Certified Nurse Assistant #1 stated they were familiar with Resident #1 and had worked with them before the incident. Certified Nurse Assistant #1 stated that Resident #1 was a 1 person assist for bed mobility and cares. Certified Nurse Assistant #1 stated they feel Resident #1 needed to be cared for by 2 people, and they could have told the nurse or the supervisor, but they did not. During a telephone interview on 9/20/2024 at 2:09 PM, the Registered Nurse Minimum Data Set Coordinator stated they have been working in the facility for 4 years now. The Registered Nurse Minimum Data Set Coordinator stated they sometimes do assess the residents in the facility in person, but at this time they do not have an assessor, so the bulk of the Minimum Data Set books are done offsite. The Registered Nurse Minimum Data Set coordinator stated they use the assessments completed by the nurses on the unit to complete their Minimum Data Set and if something does not add up in the documentation they will then go back and check on the information themself. The Registered Nurse Minimum Data Set Coordinator stated they also review the previous books to make sure that nothing has changed from the last assessment. During an interview on 9/20/2024 at 2:30 PM, the Medical Director stated Resident #1 was a one person assist and they were care planned for that. The Medical Director stated the facility followed protocol, there was no change in Resident #1's need for care. The Medical Director stated Resident #1 had not experienced any falls and nothing had changed in the resident's physicality or contractures for the plan of care to be changed. The Medical Director stated the staff in the facility felt it was appropriate for the resident to have a 1 person assist for cares. During an interview on 9/20/2024 at 3:32 PM, the Director of Nursing stated residents should be evaluated by the rehabilitation department to determine if they are a 1 person or 2 person assist and the resident's Kardex is updated to ensure that everyone is aware of how to care for the resident. The Director of Nursing stated if there is a change in a resident's status, the staff should inform the nurse so the resident can be reevaluated. During an interview on 9/20/2024 at 4:03 PM, the Administrator stated they found out the resident had a fall from the Director of Nursing, and the case was clinically reviewed in morning report on 08/21/2024. The Administrator stated they asked if the incident resulted from a break in the care plan, because if this was a break in the care plan then they need to report the incident to the State. The Director of Nursing informed the Administrator that there was no need for an immediate report because there was no breech in the care plan. The Administrator stated they reviewed their processes and there was no break in the process. The Administrator stated that staff should tell the nurse or the nurse manager if there is a change in the resident's status, so that the resident can be reviewed by the interdisciplinary team and an order can be obtained for the rehabilitation department to evaluate them. The Administrator stated once the status of the resident is determined to need an update or a change, then the unit manager or head nurse would then update the task in the system. The Administrator stated the rehabilitation department would determine if the resident were a 1 person or a 2 person assist with cares. The Administrator stated the nurse manager updates the care plans. 10 NYCRR 415.11(c)(1)

Based on record review and interview during an abbreviated survey ( NY00350699), the facility did not ensure that a comprehensive person-centered care plan was reviewed and revised for 1 out of 3 residents (Resident #2) reviewed for care planning. Specifically, Resident #2 had a self-reported fall on 7/24/2024 and their actual fall care plan was not updated to reflect it. Findings include: The facility Care Plan Comprehensive policy dated 10/2015 and last revised 10/2019 documented the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Assessments of the resident are ongoing and care plans are revised as information about the residents and resident's condition change, when the resident has been readmitted to the facility from the hospital and at least quarterly with scheduled Minimum Data Sets. Resident #2 initially admitted to the facility on [DATE] and last readmitted on [DATE] with diagnosis including but not limited to Metabolic Encephalopathy, Hemiplegia affecting Left Dominant Side and Dysphagia Oropharyngeal Phase. A Quarterly Minimum Data Set, dated dated dated [DATE] documented the resident was rarely/never understood and had severe cognitive impairment with daily decision making. No behaviors documented. The resident had impairment on both sides of their lower extremities. The resident was dependent for toileting and required maximal assistance with bed mobility and transferring was not attempted. The resident was always incontinent of urine and bowel. No documented swallowing disorders and had a feeding tube. No restraints or alarms in use. Review of an accident/incident report dated 07/24/2024 at 2:00 AM documented Resident #2 reported they fell . The resident was found in left lateral position close to the side table. The bed was in the lowest position, left and right-side rails were down, and floor mat in place. The resident had a bump with redness to the back of their head. Actions documented assessment/documentation, call bell within reach with instructions, care plan updated, diagnostic studies, fall assessment completed, first aid initiated, floor mat, low bed, neuro checks initiated, pain assessment, refer to therapy and skin assessment completed. Resident #2 was transferred to the hospital for evaluation and their wife was at the bedside. Further review of the at risk for fall/ actual fall care plan revealed it was not updated to reflect the fall that occurred on 07/24/2024. During an interview on 09/20/2024 at 4:03 PM, the Administrator stated the nurse manager updates the care plans for the residents on the unit. During a telephone interview on 10/1/2024 at 12:50 PM, the Registered Nurse Unit Manager 4th floor stated they were covering Resident #2's unit in July of 2024. Registered Nurse Unit Manager 4th floor stated they were told by staff that Resident #2's wife reported the resident had fallen out of bed at approximately 2:00 AM. Registered Nurse Unit Manager 4th floor stated they were informed about the incident late the next day and they did their initial assessment and reported the fall to the Director of Nursing. Registered Nurse Unit Manager 4th floor stated they would be the one responsible for updating the care plan for Resident #2's fall and that they did not document in the fall plan exactly, but they did do the enabler section. 10 NYCRR 415.11 (c)(2)(i-iii)

Based on record review and interview during an abbreviated survey (NY00352478, NY00350699), the facility did not ensure the resident environment remained as free of accident hazards as is possible; and that each resident received adequate supervision and assistance to prevent accidents for 1 out of 3 residents reviewed for accidents. Specifically, on 8/21/2024, Resident #1 who had been identified as totally dependent with cares (helper completes all activities for the resident, resident does not use any of their own strength for any part of the activity), fell off the bed when Certified Nursing Assistant #1 was providing care by themself. Resident #1 sustained an unstable cervical spine C4-C5 fracture and possible left femoral neck fracture with deep forehead lacerations 4.5cm long and 0.1cm depth across forehead, swollen upper lip and gums and right nares. Resident #1's care plan documented resident required 1 person assist. Resident was transferred to the hospital for further medical evaluation. Findings include: The facility Safety and Supervision policy dated 11/2017 and last revised 02/01/2024 documented facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual risk factors. The facility-oriented approach included identifying residents risk factors based on environmental hazards, developing action plans and interventions that are resident specific, supervision or assistive device use and temporary or permanent modification of the environment. The facility Minimum Data Set 3.0 policy dated 5/2017 documented the Resident Assessment Instrument process and requirement procedure are as follows: the assessment accurately reflects the resident's status, the assessment process includes direct observation, as well as communication with the resident and direct care staff. Resident #1 was initially admitted to the facility on [DATE] and last readmitted on [DATE] with diagnosis including but not limited to Parkinson's disease, Schizophrenia and Dementia. A Quarterly Minimum Data Set, dated dated dated [DATE] documented the resident had severe cognitive impairment with daily decision making. No behaviors documented. The resident had impairment on both sides to upper and lower extremities. The resident was dependent for eating, toileting, bed mobility and transfers. No bed rails were in use. Review of the incident report dated 8/21/2024 documented Resident #1 fell off the bed while a staff member turned them over. The Incident Report documented no signs of pain observed, but Resident #1 sustained a cut to their forehead which seems painful. There were no preventive measures in place. The resident sustained 2 lacerations, one to their forehead and under their right nares. The investigative report conclusion documented Resident #1 is a one person assist with bed mobility. Return demonstration performed by Certified Nurse Assistant #1 with no negative findings. The resident had a severe contracture of their right leg; outward flexed from the hip, turning inward from the knee and the foot flexed pointing upward. The resident was also laying on an alternating air mattress. The resident will be re-evaluated by rehabilitation for bed mobility status and contracture maintenance upon return to the facility. This isolated incident, no abuse, mistreatment, neglect identified. Plan of care was followed. Review of Resident #1's hospital discharge summary dated 8/28/2024 documented Resident #1 was admitted for a fall off their bed while they were receiving care at the facility. The Discharge summary documented the presenting history as, Resident #1 showed an unstable cervical spine C4-C5 fracture and possible left femoral neck fracture. The resident is immobile and a functional quadriplegic and documented the principal diagnosis as neck fracture, cervical transverse process fracture. Review of a quarterly evaluation dated 02/17/2023, 05/17/2023 and 07/31/2023 documented the resident was completely immobile, does not make any slight changes in body or extremity position without assistance, and required x 2 staff total dependence, resident does not participate in activity at all for bed mobility. During an interview on 09/19/2024 at 1:30 PM, Licensed Practical Nurse #1 stated they have been working in the facility since 2017. Licensed Practical Nurse #1 stated they were Resident #1's primary nurse on 08/21/2024. Licensed Practical Nurse #1 stated Certified Nurse Assistant #1 came and told them that Resident #1 fell off the bed. Licensed Practical Nurse #1 stated they saw Resident #1 on the floor, the nursing supervisor assessed the resident, and they called 911. Licensed Practical Nurse #1 stated they applied a cold compress to Resident #1's forehead and their nose because they were bleeding then applied a dressing to the areas. Licensed Practical Nurse #1 stated Resident #1 was on the floor on their left side. Licensed Practical Nurse #1 stated there were no side rails on Resident #1's bed and that side rails are not used in the facility. Licensed Practical Nurse #1 stated Resident #1 was a 1 person assist with cares, but Resident #1 could not assist with their transferring or turning in bed. During an interview on 09/19/2024 at 1:25 PM, Certified Nurse Assistant #2 stated they recall Resident #1 required assist of 1 person for tasks in the computer. Certified Nurse Assistant #2 stated whenever they provided cares to Resident #, they would always get another certified nurse assistant to help them because the resident was heavy. During an interview on 09/19/2024 at 1:49 PM, Certified Nurse Assistant #4 stated they had worked with Resident #1 before and they needed 2 people assist, especially without the side rails. Certified Nurse Assistant #4 stated Resident #1 was stiff, and their leg stuck out and if you are not familiar with them and turn them, they can fall right off the bed. During an interview on 09/19/2024 at 3:38 PM, Certified Nurse Assistant #1 stated they have been working in the facility for 5 months. Certified Nurse Assistant #1 stated they were the certified nurse assistant assigned to Resident #1 on 08/21/2024 on the 11 PM to 7 AM shift. They went into Resident #1's room at 6:00 AM to provide care. They turned Resident #1 to the left side towards the door. Certified Nurse Assistant #1 stated one of the resident's feet is contracted and turned upward, so when their foot hit the mattress, their entire body went over the edge of the bed. Certified Nurse Assistant #1 stated they tried to grab Resident #1 and could not catch them, and they fell on their face to the floor. Certified Nurse Assistant #1 stated Resident #1 did not have a side rail in place to the bed and they feel Resident #1 needed to be cared for by 2 people, however they did not inform the nurse or the supervisor. Certified Nurse Assistant #1 stated they did not ask for assistance from the other staff because the other staff were busy doing their own residents cares. During an interview on 09/20/2024 at 12:55 PM, the Registered Nurse Unit Manager of the 4th floor stated the resident could not hold onto the siderails with their hands. Registered Nurse Unit Manager of the 4th floor stated they answered the question wrong. Registered Nurse Unit Manager of the 4th floor stated based on the CMS guidelines and the audit that they completed the resident still would not have been a candidate for the siderails. Registered Nurse Unit Manager of the 4th floor stated according to the guidelines the side rails were more of a safety hazard if the resident's arm would have gotten caught in the rail they would not have been able to remove it. During an interview on 09/20/2024 at 2:30 PM, the Medical Director stated Resident #1 was a one person assist and they were care planned for this. The Medical Director stated the facility followed protocol and there was no change in Resident #1's need for care. The Medical Director stated Resident #1 had not experienced any falls and nothing had changed in the resident's physicality or contractures for the plan of care to be changed. The Medical Director stated the staff in the facility felt it was appropriate for the resident to have a 1 person assist for cares. During a telephone interview on 09/26/2024 at 1:03 PM, Registered Nurse Supervisor #1 stated they have been working in the facility since March 2021. Registered Nurse Supervisor #1 stated they were the night shift supervisor on duty on 08/21/2024 and at 6:00 AM Licensed Practical Nurse #1 called and told them that Resident #1 was on the floor. Registered Nurse Supervisor #1 stated they went to the unit and saw Resident #1 on the floor, laying between the 2 beds. Registered Nurse Supervisor #1 stated Resident #1 was laying on their right side almost face down and they could not see their face, so they approached them and bent down to touch them and turn the resident slightly so they could see their face. Registered Nurse Supervisor #1 stated when they moved Resident #1 over, they saw a small pool of blood on the floor and the resident had a little bit of blood on their forehead and their nose. Registered Nurse Supervisor #1 stated Licensed Practical Nurse #1 and Certified Nurse Assistant #1 were in the room with them, and they told them to call 911, because this was a major fall with injury. Registered Nurse Supervisor #1 stated they became anxious and upset because Resident #1 cannot walk or move, so they could not understand how this fall happened. During an interview on 09/20/2024 at 4:03 PM, the Administrator stated that staff should tell the nurse or the nurse manager if there is a change in the resident's status, so that the resident can be reviewed by the interdisciplinary team and an order can be obtained for the rehabilitation department to evaluate them. The Administrator stated once the status of the resident is determined to need an update or a change, then the unit manager or head nurse would then update the task in the system. The Administrator stated the rehabilitation department would determine if the resident were a 1 person or a 2 person assist with cares. The Administrator stated Resident #1 as per the CMS guideline was not appropriate for side rails and that this was discussed in an interdisciplinary team meeting as well. The Administrator stated their policy is based on the state regulations and the side rail assessments are completed quarterly. 10 NYCRR 415.12(h)(1)

Based on observation and interview conducted during the Recertification Survey from 11/27/23 to 12/5/23, the facility did not ensure housekeeping and maintenance services were provided to maintain a clean, comfortable, and homelike environment on 3 of 6 units. Specifically, observations included loose toilet seat/commode, spackled walls in halls and rooms in need of paint, broken handrails fixed with tape, walls adorned with various sections displaying black streaks and chipped paint, a hole in a wall, and the pungent smell of urine in multiple rooms. Findings include: 1) Unit 2: During an observation on 11/27/23 at 11:25 AM, on 11/28/2023 at 9:41 AM and 3:00 PM, and on 11/30/2023 at 9:05 AM, Rooms #201 and #218 had an unpleasant smell and the bedsheets were soiled with urine. During an interview on 11/30/23 at 10:05 AM, the Licensed Practical Nurse Unit Manager (LPNUM) #1 stated, there were a lot of residents who required a hoyer lift to get out of bed and it took time to clean their beds. LPNUM #1 stated the CNAs get the residents ready for breakfast by getting them out of bed first then later go to the room to change the bed sheets. During an interview on 12/4/23 at 9:35 AM, Certified Nurse Aide (CNA) #14 stated that the smell in room [ROOM NUMBER] has been brought to the attention of the unit manager but nothing has been done yet. CNA #14 stated that one of the residents in room [ROOM NUMBER] doesn't like to get out of bed and doesn't want to take a shower. CNA #14 stated the other resident has a sore on both legs and that smells most of the time. It has been brought to the attention of the unit manager but do not know what they are doing about it. During an interview on 12/4/23 at 12:45 PM, the Director of Housekeeping stated they were informed on Friday 12/01/2023 about the smell in Rooms #201 and #218. They stated in the past, they have been cleaning and deodorizing other rooms with smells. 47626 2) Unit 3: During an observation conducted on 11/30/23 at 12:28 PM, the 3rd floor hallway was observed with multiple areas of unpainted spackle. Rooms #336 and #337 were observed with spackled walls needing paint. A broken hand rail fixed with tape was observed outside room [ROOM NUMBER]. During an interview on 12/04/23 at 12:58 PM, the Maintenance Director stated there was a log book on every unit, and the log books were checked daily, but concerns were mostly communicated verbally. The Maintenance Director stated they did not currently have a schedule for maintenance for the unit. The Maintenance Director stated when they did their rounds, they fixed issues as they saw them. The Maintenance Director stated they were aware of Unit 3 having many rooms requiring painting, but had not gotten to them yet. During an interview on 12/04/23 at 3:22 PM, the Administrator stated they had 3 ways to communicate with maintenance; the Maintenance Director attended morning report, there were books on every unit, and they utilized google documents. The Administrator stated the Maintenance Director was responsible for fixing issues in the building. 48848 3) Unit 4: During observations on 11/27/23 from 10:54 AM to 12:15 PM, the following was observed: - room [ROOM NUMBER], wall behind headboard of resident's bed had a hole extending approximate 1 foot length by approximately 3 inches in width at widest point; this area was partially covered by a large square piece of wood or particle board. - room [ROOM NUMBER] D, and room [ROOM NUMBER], multiple areas on walls with spackling and blacks streaks and marks; there were also bare walls without decorations or pictures. - The last room in the corridor, on the right side, heading away from nurse's station, did not have a room number plaque outside the resident room identifying the room number and did not have the name of resident residing in this room. A resident was present in room at the time of the observation. Review of the Equipment Repair Log, located on 4th floor in the Nurses' station, revealed a notation on 5/16/23 of crack on wall in room [ROOM NUMBER] W and documented as Done without a date of completion. A second entry for room [ROOM NUMBER] dated 11/29, no year listed, documented Patch hole in wall, and done for date of repair. During an interview on 12/04/23 at 11:00 AM, the Director of Maintenance stated the facility recently renovated the corridor and the dining room on the 4th floor and they were beginning to work on the resident rooms. The Director stated they were not aware of the hole in room [ROOM NUMBER] W but did note the hole during his daily rounds and instructed his team to repair the wall. An interview conducted 12/04/23 at 11:22 AM with LPN #7 revealed that any repairs needed on 4th floor were written in the Equipment Repair Log or called into the maintenance department. 41666 4) Resident #111 had diagnoses of Type II Diabetes Mellitus, depression and bilateral below the knee amputations. The re-admission Minimum data set (MDS) dated [DATE] documented the resident was cognitively intact and required supervision for toilet transfer. The resident was continent of bladder and bowel. Observations were conducted on 11/28/23 at 10:54 AM and on 11/29/23 at 09:18 AM of the raised toilet seat in the resident's bathroom. The seat was easily moved side to side with minimal effort. Duct tape was observed securing the top seat to the raised portion of the seat. The seat was not firm against the porcelain fixture. The facility policy dated 2/1/23 documents: The facility staff are required to follow established energy control procedures to ensure that operable and/or malfunctioning equipment/machinery is shut down and inoperable until maintenance or repair work is completed. During an interview with Resident #111 on 11/28/23 at 10:54 AM they stated they use the bathroom mostly for bowel movements and was able to pull themselves over to the toilet seat with use of the rail on the wall. The resident stated when they pulled toward the seat the resident's weight moved the seat because it was not secured to the toilet. Resident #111 stated they told the nursing staff and the maintenance staff it needed to be fixed. The resident stated no one fixed it so they used duct tape in an attempt to secure the seat but it remained loose and was an accident hazard. During an interview on 11/29/23 at 11:35 AM, the Director of Maintenance stated they could not remember when they first heard of the broken toilet seat but thought it was a week ago. They looked at the toilet seat and determined it was broken and needed parts. They did not inform nursing or the resident not to use the toilet. 10NYCRR 415.3