Every finding on record at Ocean Gardens Care Center

Based on observation, record review, and interviews during a survey, the facility failed to ensure that a resident was free from physical abuse. This was evident in one (1) (Resident #1) out of two (2) residents reviewed and sampled for abuse. Specifically, on 04/20/2026 at about 12:45 PM, in the resident's dining room, Resident #1 suddenly grabbed Certified Nursing Assistant #1's left breast when Certified Nursing Assistant #1 was feeding Resident #1. Certified Nursing Assistant #1 reacted to having her breast suddenly grabbed by pushed or slapped Resident #1's hand. Registered Nurse #1 and Certified Nursing Assistants # 2 were in the dining room and provided conflicting statements regarding if Resident #1 was slapped or Resident #1's hand was pushed away. The findings are: The facility's policy titled, Prohibition of Residents abuse/ neglect and Misappropriation of Property dated 02/01/2008 and last revised 05/16/2025, documented: Residents have the right to be free from abuse, neglect, exploitation and misappropriation of property. All alleged violations involving mistreatment of residents, neglect, or abuses including injuries of unknown source must be verbally reported immediately when discovered to the Administrator, Director of Nursing, Director of Social Work, or designee immediately. Resident #1 was admitted to the facility with diagnoses of dementia (damage to the brain that affect daily life), anxiety (the body response to stress), and bipolar disorder (changes in mood,energy, or activity levels). The Minimum Data Set (a resident assessment tool) dated 01/21/2026, documented Resident #1 was severe cognitively impaired. Resident #1 requires assistance with most activities of daily living and was fed by staff. Resident #1's Behavior Care Plan /Activity Reports dated 07/09/2024, documented Resident #1 has a history of grabbing and inappropriate behaviors. Interventions included approach calmly, redirect and stepping away. It also stated Resident #1 remained easily redirected. Review of Registered Nurse Supervisor #1 Progress Note of 04/21/2026 at 07:11 PM, documented Certified Nursing Assistant #1 and Registered Nurse #1 stated Resident #1's hand was redirected and Certified Nursing Assistant 2 stated that no incident occurred. Review of Accident/Incident Report and employee statements dated 04/21/2026, revealed that on 04/20/2026 at about 12:45 PM, when feeding Resident #1 in the dining room, Resident #1 suddenly grabbed Certified Nursing Assistant #1's left breast. Staff statements are contradictory. Certified Nursing Assistant #1 documented that they pushed Resident #1's hand away. Statements from Registered Nurse #1 and Certified Nursing Assistant #2 dated 04/21/20026 stated they witnessed Certified Nursing #1 hit Resident #1. Attempted to interview Resident #1 on 04/30/2026 at 2 PM, Resident #1 just responded they were ok. During an interview on 04/30/2026 at 10:20 AM, Registered Nurse #1 stated that on entering the dining room on 04/20/2026 at lunch time about 12:45 PM they witnessed Resident #1 grab the breast of Nursing Assistant #1 and Nursing Assistant #1 angrily and with one swing knocked Resident #1's hand off their breast. They informed the Certified Nursing Assistant #1 they cannot do that to a resident and informed the Registered Nurse Supervisor #1 who was on the unit. No written statements were requested. During an interview on 04/30/2026 at 12:43 PM, Nursing Assistant #1 demonstrated they placed Resident #1's hand gently down and denied they hit or slapped Resident #1. During an interview on 04/30/2026 at 2:42 PM, the Director of Nursing stated they were informed by the Assistant Director of Nursing/Risk Manager on the morning of 04/21/2026 that there was an incident on 04/20/2026, however, statements received were contradictory. Registered Nurse #1 and Certified Nursing Assistant # 2 were called for interview and an investigation was started, law enforcement, and the New York State Department of Health were informed. No arrests were made. During an interview on 05/01/2026 at 10:43 AM, the Assistant Director of Nursing / Risk Manager stated that close to 3PM on 04/20/2026 Registered Nurse Supervisor #1 informed them of the incident and they requested Nurse Supervisor #1 to obtain statements from the eyewitnesses. The statements and information that were initially received on 04/21/2026 were conflicting and not from the eyewitnesses because they were off duty on 04/21/2026. During an interview on 05/04/2026 at 2:29 PM, the Assistant Administrator stated they were informed of an incident when the issue was mentioned during morning meeting on 04/21/2026. A Certified nursing assistant was grabbed on 04/20/2026. An employee incident report was requested. It was not known at that time that there was an allegation of abuse until after the meeting and the investigation was in progress on 04/21/2026. During a telephone interview on 05/06/2026 at 11:48 AM, Certified Nursing Assistant # 2 stated they witnessed Certified Nursing Assistant #1 hit Resident #1 twice after the Resident #1 grabbed their breast on 04/20/2026. Registered Nurse #1 was coming into the dining room and witnessed the incident and informed Certified Nursing Assistant #1 they cannot do that to a resident. Registered Nurse Supervisor #1 who was in the unit office, was informed of what occurred in the dining room and they were never asked to write any statements on 04/20/2026. During a telephone interview on 5/19/2026 at 12:40 PM, the Administrator stated that initially it was reported in morning meeting (does not remember by whom) that Resident #1 touched a Certified Nursing Assistant #1 and an incident report was done. There were no reports of hitting or slapping to Resident #1. The Administrator stated at least 5 days later they received a call that there was an allegation of Resident #1 being hit or slapped and that the Director of Nursing will investigate and that there are ongoing in-services on resident rights and abuse. These in-services are now weekly in addition to the mandatory in-services. 10 New York Code, Rules, Regulations 415.4(b)

Based on observation, record review, and interviews conducted during survey, the facility failed to ensure that a resident environment remained free of accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This was evident for one (1) out of five (5) residents (Resident #1) reviewed for accidents. Specifically, Resident #1 who requires two (2)-person assists for bed mobility and transfers, was observed on 02/28/2026 at 10:00 AM with a burn to their left thigh, which was later assessed as a second-degree full thickness burn. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy. The findings are:The facility policy titled Accident/Incident Protocols last revision date of 01/2026 states it is the policy of the facility to investigate all accidents and incidents and provide interventions in an effort to prevent reoccurrences, where possible. The Registered Nurse will notify the Administrator and Director of Nursing of any occurrence involving alleged abuse, neglect, or mistreatment immediately. New York State Department of Health, local police department, and next of kin will be notified by Assistant Director of Nursing. Resident #1 was admitted to the facility with diagnoses including dementia, anxiety disorder, and convulsion (a sudden, violent, involuntary contraction or series of contractions) disorder with seizures.The Quarterly Minimum Data Set (a resident assessment tool) dated 02/12/2026 documented Resident #1 had moderately impaired cognition. Section GG documented Resident #1 required total assistance with transfer and toileting needs, partial/moderate assist with roll left and right and sit to lying position (bed mobility). Resident #1 requires a Hoyer lift (a mechanical device designed to safely transfer patients) with two (2) people for transfers. Resident #1 requires substantial/maximal assistance with roll left and right.The Resident Certified Nurse Assistant Documentation Record dated 02/01/2026 - 02/28/2026 documented Resident #1 was a two (2)-person assist for total dependence for toileting, bed mobility and transfers with Hoyer lift.A Nursing Skin Assessment note by Registered Nurse Supervisor #1 dated 02/28/2026 at 12:37 PM documented Resident #1 was observed with erythema (redness) of left upper thigh extending to mid-thigh approximately 15 centimeters by 8 centimeters. The erythema had irregular shape, uneven borders, bright pink to red in color, with blistering in the mid-region. Resident #1 appeared to have been lying with their thigh on the heating vent (this was not witnessed by any staff). Area assessed and treated with Silvadene (antibiotic cream used to treat second- and third-degree burns) and dry clean dressing. Bed repositioned away from heating vent. Medical Doctor #1 and Resident #1's next of kin notified.A Physician's Order dated 02/28/2026 at 1:16 PM documented Silvadene 1% topical cream, daily and as needed to left outer thigh and cover with dry clean dressing.A review of the Facility Incident Report with a completion date of 03/05/2026 revealed during a bed bath, Certified Nurse Assistant #1 discovered a 15 centimeter by 8 centimeter blanchable red area with blister on the left lateral thigh of Resident #1. The investigation determined that due to the resident's poor awareness of bed boundaries and the altering pressure of the air mattress, Resident #1 likely shifted or rolled towards the radiator. The investigation concluded there was no reasonable cause to believe that abuse or neglect occurred. Although abuse and neglect were not substantiated, disciplinary action was taken due to safety lapses. Certified Nurse Assistant #1 (assigned 02/27/2026 during the 6:00 AM - 2:00 PM shift) and Certified Nurse Assistant #2 (assigned 02/28/2026 during the 11:00 PM - 7:00 AM shift) were each suspended for three (3) days. Both certified nurse assistants were subsequently provided in-service education on burn prevention, safe handling, and to ensure that beds are positioned three (3) feet away from radiators. During an interview on 03/10/2026 at 12:28 PM, Certified Nurse Assistant #2, who was assigned to Resident #1 on 02/27/2027 during the night shift (11:00PM-7:00AM), stated they did rounds at 11:00 PM, and hourly rounding at 1:00 AM and 2:00 AM on 02/28/2026. Certified Nurse Assistant #2 stated Resident #1 slept throughout the night and during brief change. Certified Nurse Assistant #2 stated Resident #1's bed was not close to the radiator because they walked around the bed during incontinence care. Certified Nurse Assistant #2 stated Resident #1's legs were exposed during incontinence care at midnight and again at 5:00 AM, and there were no reddened areas on Resident #1's legs and thighs. Certified Nurse Assistant #2 added that Certified Nurse Assistant #3 assisted them with incontinence care. Certified Nurse Assistant #2 stated they did not observe Resident #1's leg on the radiator during their shift. Certified Nurse Assistant #2 stated Resident #1 remained in the same position that they were left in when they were turned/repositioned. Certified Nurse Assistant #2 stated they last saw Resident #1 at 6:30 AM lying on their back in the center of their bed. During an interview on 03/10/2026 at 3:37 PM, Certified Nurse Assistant #3 stated there were two (2) certified nurse assistants working on Resident #1's unit on 02/27/2026 during the night shift (11:00 PM - 7:00 AM). Certified Nurse Assistant #3 stated they were not assigned to Resident #1 and assisted Certified Nurse Assistant #2 to turn Resident #1 at midnight. Certified Nurse Assistant #3 stated they assisted Certified Nurse Assistant #2 with changing Resident #1's incontinence brief. Certified Nurse Assistant #3 stated Resident #1's bed was not close to the radiator because they were able to move around the bed. Certified Nurse Assistant #3 stated they last saw Resident #1 on 02/28/2026 at 6:35 AM lying on their back in the center of their bed.During an interview on 03/10/2026 at 5:44 PM, Certified Nurse Assistant #1, who was assigned to Resident #1 on 02/27/2026 and 02/28/2026 on the 6:00 AM - 2:00 PM shift, stated Resident #1 was wearing a hospital gown and did not have any redness on their thighs on 02/27/2026 when their shift ended. Certified Nurse Assistant #1 stated that on 02/28/2026, they first saw Resident #1 at 6:00 AM during rounding. Certified Nurse Assistant #1 stated Resident #1 was asleep lying on their left side in the center of their bed facing the window. Certified Nurse Assistant #1 stated Resident #1's bed was two (2) feet away from the radiator because they were able to walk around the bed, and they have never observed Resident #1 with their legs resting on the radiator. Certified Nurse Assistant #1 stated that at 8:30 AM, Resident #1 was observed lying on their back in the center of the bed and another certified nurse assistant (unsure of name) assisted them with sitting Resident #1 up in bed and they fed them breakfast. Certified Nurse Assistant #1 stated that at 9:30 AM, during morning care, another certified nurse assistant (unsure of name) assisted them with turning Resident #1 on their right side and that was when they observed the redness on Resident #1's left thigh and they called the nurse. Certified Nurse Assistant #1 stated Resident #1 was unable to move themself after being positioned. Certified Nurse Assistant #1 stated Resident #1 requires a Hoyer lift transfer with two (2) people. During an interview on 03/10/2026 at 4:00 PM, Registered Nurse Supervisor #1 stated when they arrived on the unit, Registered Nurse #2 and Certified Nurse Assistant #1 were in Resident #1's room. Registered Nurse Supervisor #1 stated Resident #1's bed was not next to the radiator because Certified Nurse Assistant #1 was standing between the bed and the radiator. Registered Nurse Supervisor #1 stated Resident #1 was lying on their back in the middle of their bed. Registered Nurse Supervisor #1 stated they asked Resident #1 if they were in pain and Resident #1 shook their head (indicating no). Registered Nurse Supervisor #1 stated Resident #1 did not appear to be uncomfortable and was not guarding the wound during assessment. Registered Nurse Supervisor #1 stated the wound assessment revealed a dark pink rectangular shaped line on the left upper thigh with a small blister in the center of the wound. Registered Nurse Supervisor #1 stated they believed Resident #1 sustained the injury from the radiator as the pattern of the lines on Resident #1's left thigh matched the line patterns on the top of the radiator. Registered Nurse Supervisor #1 stated the wound measured 15 centimeters by 8 centimeters. Registered NurseSupervisor #1 stated the wound had no drainage. During an interview on 03/11/2026 at 1:20 PM, Medical Doctor #1 stated they were notified of the wound and ordered Silvadene cream. Medical Doctor #1 stated they assessed Resident #1's left thigh and that the wound could be a second-degree burn caused from a hot surface such as a radiator and not hot liquid. Medical Doctor #1 stated if Resident #1 sustained the burn from the radiator, it would be avoidable. During an interview on 03/11/2026 at 2:30 PM, the Director of Nursing stated the facility investigation did not reveal how Resident #1 got injured. The Director of Nursing stated an order for every 30-minutes bed positioning observation was put in place and Resident #1's bed was moved three (3) feet away from the radiator. The Director of Nursing stated other interventions for Resident #1 have been put in place status post the incident on 02/28/2026. The Director of Nursing stated their investigation revealed Resident #1 requires partial/moderate assistance with bed mobility and has poor awareness of bed boundaries, combined with the alternating pressure of the air mattress, the resident likely rolled or shifted towards the radiator. 10 New York Codes, Rules, and Regulations 415.12(h)(2)

N.Y. Comp. Codes R. & Regs. Tit. 10 SS 713-1.3 - Nursing units(h) Resident bedrooms shall be designed and equipped for adequate nursing care, comfort and privacy of the residents and shall comply with the following:(1) Placement of residents' beds shall be such that a bed may be approached from at least one side and one end. No bed shall be closer than three feet to a window, radiator, or an adjacent bed. Based on interview and record review conducted during an abbreviated survey, it was determined that the facility failed to ensure compliance with the State and Local Laws. Specifically, resident equipment (bed) is not kept at a minimum of 3 feet from the radiator as referenced in N.Y. Comp. Codes R. & Regs. Tit. 10 713-1.3 - Nursing units. This resulted in harm to a single resident.On 3/10/2026 - 3/13/2026 between hours of 9:00 AM - 5:00 PM, an abbreviated survey conducted in response to an incident (2791175) and following observations, interviews and documentation review made:In an interview with Maintenance Director on 3/10/2026 at approximately 10:40 AM, stated bed in the room moved away from the radiator so could not assess the original distance from radiator and immediately all beds in facility were audited and ensured to be at minimum of 3 feet (36 inches) from edge of radiator and rounds are conducted each morning with a measuring tape. A copy of the audit is submitted by the facility and reviewed.Sampled rooms and distance from Radiator to Mattress.626 - 32 (inches)622 - 36529 - 34513 - configured differently534 - 33538 - 33408 - 38433 - 34420 - 37328 - 40335 - 34208 - 38217 - 36230 - 35220 - 40Interview with maintenance staff on 3/13/2026 at approximately 10:30 AM, stated all beds are checked to ensure locking mechanism is enabled and are at proper distance from radiator. Interview with Assistant Administrator on 3/13/2026 at approximately 2:53 PM stated we change the bed frames as needed, and some use air-mattresses and a maintenance log is kept with dept and manuals for older ones are hard to find but for new beds we should have.Additional interview with Assistant Administrator on 3/13/2026, stated facility implemented corrective measures and Policy and Procedures are updated.Following Documents were reviewed by surveyors:Maintenance In-service dated effective 3/2/26.Patient Care Related Electrical Equipment (PCREE) Policy and Procedure for Maintenance effective 2/22/26.Bed Policy and Procedure. Effective 10/97, Revised 3/26.Quality Assurance Audit dated 3/2/26.PCREE Monthly Electrical Equipment Safety Audit Tool. (effective 3/1/26) N.Y. Comp. Codes R. & Regs. Tit. 10 SS 713-1.3 - Nursing units

Based on observation, record review, and interviews during a survey, the facility failed to ensure the Minimum Data Set assessments accurately reflected the resident's status. This was evident in one (1) out of four (4) residents (Resident #1) sampled. Specifically, Resident #1's Comprehensive Care Plan dated 02/03/2026 documented that Resident #1 required two (2) staff to assist them with bed mobility (roll left to right). The Minimum Data Set assessment dated [DATE] did not accurately reflected Resident #1's bed mobility status. The Minimum Data Set inaccurately coded Resident #1 as requiring Partial/Moderate assistance (Helper does less than half the effort).The findings include:The facility's policy titled Resident Assessment with a last reviewed date of 10/25/2025 documented it is the policy of the facility to ensure a comprehensive and accurate assessment of residents. The policy stated the assessment will include direct observations, and communication with the residents, as well as communication with resident and direct care staff on all shifts. Resident #1 was admitted to the facility with diagnoses that included Dementia, Seizure Disorder, and Chronic Obstructive Pulmonary Disease.The Comprehensive Care Plan titled Activity Daily Living Functional Abilities: Mobility & Mobility Devices with effective date 02/03/2026 documented Resident #1 was dependent on bed mobility (roll left to right) and required total assistance of two (2).The Minimum Data Set assessment dated [DATE] documented Resident #1 had moderately impaired cognition. Resident #1 required Partial/Moderate assistance (Helper does less than half the effort) for bed mobility.During an observation on 03/11/2026 at 9:00AM, Resident #1 was observed with two (2) staff members providing total assistance with bed mobility (roll from lying on the back to left and right side on the bed).On 03/10/2026 at 10:00 AM, Registered Nurse #1 was interviewed and stated that Resident #1 required total care with two (2) people for bed mobility and turning and positioning.On 03/10/2026 at 5:44 PM, Certified Nursing Assistance #1 stated during a telephone interview that Resident #1 required total assistance of two (2) people for bed mobility. Certified Nursing Assistant #1 stated that two (2) people have been providing care since Resident #1's readmission.On 03/11/2026 at 10:30 AM, the Director of Rehabilitation was interviewed and stated that the bed mobility section on the Minimum Data Set (GG0130) assessment was done by rehab department. The Director of Rehabilitation stated that Resident #1 was on skilled therapy and required total care with assistance of two (2) people with bed mobility and transfer. The Director of Rehabilitation stated that there was an error in Resident #1's Minimum Data Set assessment dated [DATE] and the code should have been dependent and not partial/moderate. The Director of Rehabilitation stated they will modify the Minimum Data Set assessment.On 03/12/2026 at 2:20 PM, Minimum Data Set Coordinator #1 was interviewed and stated that they collected information from Resident #1's assessments, staff interviews, and review of the medical records to complete the Minimum Data Set assessments. Minimum Data Set Coordinator#1 stated for accuracy, they usually double check through medical records and resident assessments before submitting the Minimum Data Set assessment. Minimum Data Set Coordinator #1 stated they were not aware of the discrepancy in Resident#1's Minimum Data Set assessment dated on 02/12/2026. 10 New York Codes, Rules, and Regulations 415.11(b)

Number of residents sampled:Number of residents cited:Based on observation, record review, and interviews, the facility failed to ensure that necessary housekeeping and maintenance services were provided to maintain a safe, clean, comfortable and homelike environment for residents. This was evident for four (4) (3rd Floor, 4th floor, 5th floor, and 6th floor) of five (5) resident units observed. Specifically, an accumulation of dust, dirt, and stains were noted on bedside tables, intravenous poles, feeding pumps, oxygen concentrators and suction machines, torn arm rests and soiled wheelchairs were observed in resident rooms, and rust stains were observed in resident shower rooms. The findings include: The facility policy titled Environmental Policy and Procedure, Subject: Safe, Clean, Comfortable and Home-Like Environment documented that housekeeping and maintenance services are provided to maintain a safe, clean comfortable homelike environment in such a manner to acknowledge and respect resident rights to the extent possible. During observation of the 5th and 6th floor of the facility, from 01/05/2026 at 10:08 AM to 01/12/2026 at 11:13 AM, the bathroom floors in rooms 501, 505, 506, 507 and 513 were observed with black dirt in between the tiles. In the 6th floor resident's day room, 3 red chairs were ripped, and six shared tables had stripped paint on the top of the tables. The following was observed on the 4th Floor, a). In room [ROOM NUMBER], brown stains were on the floor, brown-colored rust on the bathroom door frame, the soap dispenser unit was missing off the wall, there were white cracked tiles and black/brownish stains on the floor near the sink. b). In room [ROOM NUMBER], the bedside table tray had brown colored wood exposed around the edges. c). In room [ROOM NUMBER], there was a hole in the bathroom door. The following were observed from 01/05/2026 through 01/12/2026: 1). In the 3rd floor Dining Room a. Three (3) over bed tray tables in disrepair exposing inner corking along edges. b. Six (6) of six (6) window curtains in disrepair, hanging off the intended hooks. c. Four (4) yellow wooden frame vinyl chairs soiled and accumulation of dirt and debris to wooden frame area. d. Two (2) soiled and dusty oxygen concentrator underneath the dining room table. e. One (1) chair with torn seat cushion. f. Three (3) radiators rusty with accumulation of dirt and debris. 2). In room [ROOM NUMBER]-A: a. The over bed tray table in disrepair exposed corking all along the edges. b. Window curtains were off the intended hooks. c. A soiled wheelchair. 3). In room [ROOM NUMBER]-B: a. A recliner chair was layered with yellowish stains, and an accumulation of dirt and debris alongside the panels. The front wheel was entangled in a clear plastic bag. 4.) In room [ROOM NUMBER]-A: a. A wheelchair with soiled seat cushion and accumulation of dust and dirt to wheel spokes. 5.) In Resident Bath/Shower Room across room [ROOM NUMBER]: a. Bubbled over ceiling located over the toilet seat. b. Two (2) of two (2) curtains with torn and frayed. c. One (1) of two (2) curtains with diminished width, not covering wall to wall corners. d. Blue panel covered with rust stains. e. Rusty call bell panel 6.) In room [ROOM NUMBER]-A: a. A rusty metal bed frame. b. Loose closet doorknob. c. Heavily worn, wooden bedside dresser table. 5.) On the 5th floor: a. In room [ROOM NUMBER] an oxygen concentrator was layered with accumulation of dust dirt and debris. b. The Intravenous pole was encrusted with a brownish substance. c. The front of the feeding pump with brownish streaks, dirt and dust. d. A torn floor mat e. A recliner chair seat padding with multiple whitish stains, dirt and debris. 6.) In room [ROOM NUMBER]-A: a. A dusty oxygen concentrator. b. A dusty nebulizer located on bedside table. c. A rusty radiator On 01/12/2026 at 8:29 AM, Licensed Practical Nurse #1 stated the evening housekeeper is responsible for cleaning the wheelchairs. Licensed Practical Nurse #1 also stated the nurses should be wiping down any spills from feeding formulas on the pump including the intravenous poles when in use. Licensed Practical Nurse #1 further stated the Maintenance department cleans and changes the filters to the oxygen concentrators, and the nurses should also be wiping down the front of concentrators when in use. On 01/12/2026 at 8:39 AM, Registered Nurse #2 stated the nurse is responsible for wiping down the intravenous poles and feeding pumps, and a full cleaning will be done by the housekeeping department. Registered Nurse #2 also stated staff are to notify housekeeping with any urgent needs. Registered Nurse #2 further stated the night shift housekeeper will remove the wheelchairs that are placed outside the resident's rooms for cleaning. On 01/12/2026 at 8:48 AM, Housekeeper #1 stated they are responsible for maintaining a clean resident room, including room furniture and bathrooms. Housekeeper #1 also stated the nurses are responsible for cleaning the oxygen concentrators, intravenous poles, and all resident equipment in current use. On 01/12/2026 at 7:51 AM, the Director of Housekeeping Services was interviewed and stated cleaning of the intravenous poles is the responsibility of the housekeeping staff and they are to wipe down the bottom of the poles when in use. The Director of Housekeeping Services also stated the nursing department is to inform the housekeeping department of any housekeeping issues that need immediate attention. The Director of Housekeeping Services further stated the daily wheelchair schedule is posted on each floor for the nurse staff know and for wheelchairs to be removed and placed outside room doors, for the night shift staff. On 01/12/2026 at 11:16 AM, a follow-up interview was conducted with the Director of Housekeeping Services who stated their primary responsibility towards our residents, not excluding staff or visitors, is to ensure and maintain a safe, clean and sanitary environment to the best of our ability. The Director of Housekeeping Services also stated they conduct daily rounds on each floor to ensure housekeeping staff are performing their assigned duties and maintaining a clean environment, and they check resident rooms and observe walls for stains or bodily fluids, windows for dust. The corridors and dining room areas are also looked at for cleanliness and safety. The residents' bathrooms are included in my rounding activities. The Director of Housekeeping Services further stated there is a plan to replace the window curtains with shades. The Director of Housekeeping Services stated they review the wheelchair log sheet the night before to know which wheelchairs or recliner chairs have been cleaned. There is one (1) night shift staff from 11:00 PM to 7:00 AM assigned for the cleaning of the wheelchairs in addition to handling, storing and replacing linen, and there are approximately eight (8) to thirteen (13) wheelchairs to wash during one (1) night. The Director of Housekeeping Services also stated they do not clean the feeding pump, the nebulizers or oxygen concentrators when in use, but when not in use, the concentrators and intravenous poles are taken to the central supply area for cleaning and storage. The Director of Housekeeping Services further stated the bed frames are cleaned about two (2) or three (3) times a year and when needed, and many are old and rusty, and the privacy curtains are changed as needed. The Director of Housekeeping Services stated the nurse station area is cleaned daily, however, to avoid any type of disconnection, staff will not remove any items such as the computer or mouse. The Director of Housekeeping Services also stated there is a housekeeper and a maid on each unit, and some challenges include resident behaviors and refusal to have their chairs taken away. The Wheelchair Cleaning Log sheet dated 12/18/2025 to 01/07/2026 was reviewed and contained no documented evidence of the above identified wheelchairs listed on the Wheelchair Cleaning Log sheet. On 01/12/2026 at 12:30 PM, the Director of Maintenance stated they are responsible for ensuring that Life Safety Protocols are maintained, including servicing, repairing and replacing resident equipment to meet their needs and comfort level and functionality. The Director of Maintenance also stated they maintain the functionality of the air conditioners and radiators, including changing the filter of the concentrators monthly. The Director of Maintenance further stated they expect staff to create a work ticket if there is a need for a repair or replacement of equipment, and they have staff assigned to perform daily checks of the maintenance logbook located on each unit. Based on urgency, issues will be addressed. The Director of Maintenance stated they make daily rounds and look for potential safety concerns, and they plan to replace the nurse station countertops. On 01/12/2026 at 12:49 PM, the Administrator stated unannounced, sporadic environmental rounds are conducted weekly to ensure a safe and clean environment for residents, staff and visitors. We check for cleanliness, elimination of dust, working and clean equipment, clean furniture and in good repair. Monthly audits are scheduled for all department heads to make rounds. The environmental audit rounds are made in pairs of two (2) and round one floor per day. If there are issues identified during the rounding, each department is responsible for addressing their findings. We discuss any concerns during our daily morning meetings. The Administrator also stated there is a checklist that is completed during the environmental audits, however resident equipment is not listed on the audit tool. The Administrator further stated they approved several purchases for furniture and maintenance staff is responsible for making the switch. The Administrator stated the nurses are responsible for cleaning the top half of the intravenous poles and the bottom half is done by the housekeeping department. Nurses are responsible for maintaining the cleanliness of the oxygen concentrators when in use. The Administrator also stated they have extra chairs in the Main Dining that can be used to replace worn out chairs, and if beds are in poor condition, they should be swapped out and replaced with a new one. The Administrator further stated they rely on staff and meet with my staff to discuss the outcome or other areas of concern during the quarterly quality assurance meetings. 10 NYCRR 415.5(h)(2)

Number of residents sampled:Number of residents cited: Based on observation, interviews and record review, the facility failed to ensure infection control practices and procedures were maintained. This was evident for one (1) of five (5) units (Unit 3). Specifically, shared activity items including but not limited to, plastic building blocks, plastic crayon baskets, incomplete plastic egg toy were observed with brownish stains and an accumulation of dirt and debris. Based on observation, interviews and record review, the facility failed to ensure infection control practices and procedures were maintained. This was evident for one (1) of five (5) units (Unit 3). Specifically, shared activity items including but not limited to, plastic building blocks, plastic crayon baskets, incomplete plastic egg toy were observed with brownish stains and an accumulation of dirt and debris. The findings include but are not limited to: The facility policy titled 'Infection Control Policy: Multipurpose Equipment Cleaning', dated 07/2025 documented it was to maintain the health, safety and wellbeing of our residents by preventing the spread of infection. Equipment: Activity Shared Equipment: Procedure: All multipurpose equipment must be cleaned and disinfected between resident use. From 01/05/2026 through 01/12/2026, in the Dining Room Area an incomplete plastic egg game which contained four (4) plastic eggs was observed were soiled with thick brownish stains during an activity. The game cover was layered with dirt and debris. In addition, a blue plastic building toy were soiled with brownish dark stains, and plastic crayon baskets and bowl were heavily soiled with debris and dirt. During an interview on 01/12/2026 at 8:19 AM, Recreation Staff #1 stated games are wiped down with germicidal wipes to prevent the spread of infection after each use. Recreation Staff #1 also stated disinfecting is done after activities and before activities take place. On 01/12/2026 at 8:19 AM, the State Surveyor and Recreation Staff #1 observed the activity toys on the 3rd floor together. The activity toys were observed in the same identified condition as observed on previous days of the survey. Recreation Staff #1 stated the activity toys had not been wiped or disinfected, and that a better job could be done.On 01/12/2026 at 8:19 AM, cleaning wipes were observed inside the activity cabinet.Durin an interview on 01/12/2026 at 9:08 AM, the Director of Recreation stated disinfecting all shared activity games is important to prevent the spread of infection. the Director of Recreation also stated all shared games and toys are to be disinfected before and after use, and the recreation staff are in-serviced to reinforce this policy. The Director of Recreation further stated they make rounds at different times of the day to ensure activities are taking place, and staff are following our policy on infection control.On 01/12/2026 at 10:11 AM, the Director of Nursing who is also the Infection Control Preventionist stated all departments are in serviced and educated on infection control practices and competencies are conducted to ensure proficiency. The Director of Nursing also items or equipment shared by residents is to be disinfected after resident use to prevent the spread of infection. On 01/12/2026 at 10:25 AM, Nurse Educator #2 was interviewed and stated staff are in serviced on the importance of infection control practices to prevent the transmission of pathogens and bacteria, and education is continuous and ongoing. Nurse Educator #2 also stated equipment shared by residents includes but is not limited to, building blocks, puzzles, games and toys. 10 NYCRR 415.19 (b)(4)

Number of residents sampled:Number of residents cited:Based on observations and interviews, the facility did not ensure the physical environment was kept safe, sanitary, functional, and comfortable for residents, staff and the public. Specifically, the outer panels and top end corners of the nurse station was in disrepair, chairs in the nursing station were soiled and had torn bilateral arm rests. In addition, both elevators had graffiti on the walls. This was evident on four (4) of five (5) units (4th floor, 5th floor, 6th floor, and 3rd floor,). 1). During observation from 01/05/2026 to 01/12/2026 between 09:00 AM and 1:00 PM on Unit 4, the following were observed: a). The nursing station room was observed to have two (2) black chairs that were dusty and dirty and one (1) black chair had a large rip exposing brown colored padding. Staff applied plastic covers over the chairs before sitting on them. b). Pieces of the white colored wall next to the handwashing sink was peeling off. c). A black and brown colored substance was observed on the floor under the sink. d). Staff lockers were in disrepair and had a brown colored substance on them. e). On 01/09/2026 at 09:19 AM, the staff bathroom had brown colored stains around the door frame. The lock on the bathroom door was stained a brown color. The hot water faucet was leaking. On 01/08/2026 at 2:00 PM, Registered Nurse #4, who is also the Nursing Supervisor for Unit 4, was interviewed and stated they requested new chairs a few weeks ago and no new chairs have been brought to the 4th floor. On 01/08/2026 at 2:02 PM, Registered Nurse #5 was interviewed and was reluctant to speak to the surveyor and stated Unit 4 does need new chairs. 2). During observation of the environment on the 5th and 6th floor of the facility from 01/05/2026 at 10:08 AM to 01/12/2026 at 11:13 AM, the 5th floor nursing station was observed with 1 ripped chair. The 6th floor nursing station was observed with 2 ripped chairs at the desk. A gray cement patch was observed on the floor at the 6th floor nursing station entrance door. The 6th floor male and female bathroom in the hallway was observed with a large amount of black dirt in between the floor tiles. On 1/12/2026 at 1:30 PM, Maintenance Worker #1was interviewed and stated they agree furniture in the day room and the nursing station need to be replaced. Maintenance Worker #1 further stated they would talk to their supervisor about the condition of all chairs and the gray cement patch on the unit. The following were observed from 01/05/2026 through 01/12/2026: 3. 3rd floor Nurse Station: a). The front bottom corner panel of the nursing station was in disrepair and protruding. The top corner ends were frayed exposing inner wood. The countertop was layered with old and dirty tape. b). One (1) black swivel chair had torn bilateral foam arm rests, the seat cushion was heavily soiled, and the wheels were entangled with garbage and debris. On 01/12/2026 at 11:16 AM, the Director of Housekeeping Services was interviewed and stated environmental cleaning is performed at the nursing station, and they clean around the countertop and do not clean around the computer area, and wire connections to avoid any wire disconnection issues. On 01/12/2026 at 12:30 PM, the Director of Maintenance stated that they are responsible for ensuring that Life Safety Protocols are maintained, including servicing, repairing and replacing resident equipment to meet their needs and comfort level and functionality. The Director of Maintenance also stated the facility plans to replace the nursing station countertops. The Director of Maintenance further stated tray tables, and some chairs had been ordered but could not specify where these items had been placed. 10 NYCRR 415.29

Based on observation, record review, and interviews during the abbreviated survey (607137), the facility did ensure it maintained an effective pest control program to keep the facility free from pests. This was evident on one (1) of sis (6) floors (Floor 1). Specifically, large and small live roaches were observed crawling from under the pushcart in the Recreation staff room on the 1st floor. The findings are:The facility Housekeeping policy titled 'Pest Control' revised 04/2025 documented it is the policy of this facility to have extermination services to control or abort any potential for an infestation. On 01/08/2026 at 1:45 PM while doing an interview with the Director of Social Services in the Recreation staff room, multiple large and small brown colored roaches were observed crawling from under the cart.The Ozane Pest Control Management Service Report documented the following services: On 08/01/2024 the facility was treated for insects and rodents with chemicals.On 08/06/2024 the facility was treated for insects and rodents with chemicals on Unit 2.On 08/13/2024 the facility was treated for insects, ants, and rodents with chemicals on Unit 4 and Unit 2.On 08/15/2024 the facility was treated for insects and rodents with chemicals in the kitchen and complaints.On 08/22/2024 the facility was treated for insects and rodents with chemicals in the kitchen, inspection and complaints.On 08/29/2024 the facility was treated for insects with chemicals for inspection and complaints. There was no evidence an effective pest control program was maintained to prevent the spread of roach infestation in the facility. On 01/08/2026 at 10:00 AM, the Housekeeping Director was interviewed and stated the Pest Control Company comes in once a week to treat for any pests, and they are doing the best that they can. On 01/08/2026 at 2:00 PM, Registered Nurse #4, who is also the Nursing Supervisor for Unit 4, was interviewed and declined to speak about any sightings of any insects or rodents on the unit. On 01/08/2026 at 2:05 PM, Housekeeper #2 was interviewed and stated that they cover Unit 4, and they do not have any issues with the environment and that they have not seen any roaches. 10 NYCRR 415.29(j)(5)

Based on record observation, record review and interviews conducted during the Recertification and Abbreviated Survey (Complaint #607115 and #2630760), the facility failed to ensure the resident and/or the resident's representative was immediately informed of an accident which resulted in an injury and/or hospitalization. This was evident for two (2) of two (2) residents (Resident #139 & Resident #242) reviewed for Notification of Change out of 38 total sampled residents. Specifically, 1). On 03/25/2024 at 09:30 PM, Resident #139 was found sitting on the floor with a laceration to the left eyebrow that required hospitalization. There was no documented evidence Resident #139's designated representative and/or next of kin was notified of the change in their condition, and 2). On 12/03/2025 at 03:09 PM, Resident #242 was noted with a skin opening to the left dorsal foot. There was no documented evidence Resident #242 designated representative and/or next of kin was notified of the change in their condition. The facility's policy titled 'Notification of Changes', last reviewed 12/2025, documented it is the policy of the facility to immediately inform the resident; consult the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is an accident or incident involving the resident, upon significant change in status or condition, or regarding changes in resident's rights. 1. Resident #139 was admitted to the facility with diagnoses that included Schizophrenia, Anxiety, and Dementia. The Quarterly Minimum Data Set, dated [DATE] revealed Resident #139 was severely cognitively impaired. Family provided source of information. The Accident/Incident Report dated 03/25/2024 at 09:30 PM, documented Resident #139 was seen sitting on their wheelchair with laceration on their left eyebrow. The report also documented 'Family notified: No. No Next of Kin.' The Nursing progress note dated 03/25/2024 at 10:46 PM revealed Resident #139 was sitting on floor in their room described as an unwitnessed fall with laceration to their left eyebrow. Designated Representative Notified: No next of kin. Review of Resident139's Face sheet documented next of kin contact information listed. There was no documented evidence the facility attempted to call the designated representative. On 01/08/2026 at 09:45 AM, an interview was conducted with the Director of Nursing who stated they have looked into all of the documentation and could not find any documentation of where the next of kin was notified of the fall and the hospitalization that occurred on 03/25/2024. The Director of Nursing also stated staff is supposed to look into the chart to see if the resident has a next of kin and they are to call the next of kin to notify the next of kin of any changes. The Director of Nursing further stated the Registered Nurse Supervisor on duty that day, who no longer works at the facility, did not look or attempt to call the family and the sibling is very involved and is the next of kin. The Director of Nursing stated the staff did not follow facility protocol because there was a next of kin in the chart and on the resident's face sheet. 2.Resident #242 was admitted with diagnoses that included Non-Alzheimer's Dementia, Parkinson's Disease, and Cerebrovascular Disease. The Annual Minimum Data Set assessment for Resident #242 dated 10/17/2025 documented Resident #242 had sort and long-term memory and severely impaired cognitive skills for decision-making. The Nursing progress notes dated 12/03/2025 at 03:09 PM, documented Resident #242 was noted with a skin opening to the left dorsal foot. The primary Medical Doctor was informed, and a telephone order was given for Bacitracin treatment daily. Resident #242 is pending a venous doppler secondary to swelling prior to the opening. The Nursing progress notes dated 12/03/2025 at 04:35 PM, documented called residents next of kin to update about skin opening on residents' foot. Will re-attempt at a later time. There was no documented evidence Resident #242's representative was notified of the change in resident's condition. On 01/12/2026 at 10:59 AM, Registered Nurse Supervisor #2 stated they wrote the note on 12/03/2025 at 4:35PM in Resident #242's medical record. Registered Nurse Supervisor #2 also stated that while they wrote in the note on 12/03/2025 that they would attempt to call the resident's sibling later they do not recall if they called the sibling. Registered Nurse Supervisor #2 further stated they were then out sick and not in the facility for at least a month after writing this note. Registered Nurse Supervisor #2 stated they are not sure if anyone else called the sibling and did not state if this was endorsed to staff on the oncoming shift. On 01/12/2026 at 1:54 PM, the Director of Nursing stated the next of kin notification is done by either Nursing or Social Work. The Director of Nursing also stated Registered Nurse Supervisor #2 reached out to the family but did not speak to the family member, and it is the facility policy not to leave a voice mail. The Director of Nursing further stated the Registered Nurse Supervisor #2 did not leave a voicemail, and while they documented in the note, they would follow-up, they did not and failed to communicate this to other staff so it could be followed up on. The Director of Nursing stated there is an end of shift report and Registered Nurse Supervisor #2 should have communicated they were no able to reach the next of kin and that this needed to be followed up on. 10 NYCRR 415.3(f)(2)(ii)(c)

Number of residents sampled:1Number of residents cited:1 Based on observations, interviews, and record review, the facility failed to ensure that a resident remained free of physical restraints. This was evidenced for one (1) (Resident #9) of one (1) resident reviewed for Physical Restraints out of 38 total sampled residents. Specifically, on 01/07/2026, 01/08/26, and 01/09/2026, Resident #9 was observed seated in a wheelchair in the 3rd floor dining room, with a table in front of them and their back against the wall, and 2 chairs on either side of resident, preventing Resident #9 from moving around. The findings are: The facility's policy titled 'Restraints', last revised 10/2025 documented the facility will strive for a restraint free environment, in order that the dignity, independence, physical and psychological functioning of the residents will not be compromised. Resident #9 was admitted to the facility with diagnoses that include Aphasia, Non-Alzheimer's Dementia, Parkinson's, and Seizure Disorder.The Annual Minimum Data Set, dated [DATE], documented Resident #9 had moderately impaired cognitive skills for decision-making, had no behaviors, used a wheelchair, walker. The Minimum Data Set also documented Resident #9 was frequently incontinent of bowel and bladder and required moderate assistance for bed mobility, chair and toilet transfers and maximal assistance for eating.On 01/07/2026 at 9:48 AM, Resident #9 was observed in the dining room, engaged in activities. From 9:48 AM to 11:30 AM, Resident #9 was observed sitting in a wheelchair in the dining room, with a table in front of them and their wheelchair back against the wall, with 2 chairs on either side of resident restricting Resident#9's movement to that area.On 01/08/2026 from 11:04 AM to 12:36 PM, Resident #9 was observed sitting in a wheelchair in the dining room, with a table in front of them and their wheelchair back against the wall, with 2 chairs on either side of resident preventing Resident #9 from moving from the area.On 01/09/2026 at 9:36 AM, Resident #9 was observed in the dining room, engaged in activities, with a table in front of them and their back against the wall, and 2 chairs on either side of resident limiting their movement to that area. On 01/12/2026 at 1:07 PM, Resident #9 was observed in the dining room, sitting in a wheelchair, with a table in front of them and their wheelchair's back against the wall, and another resident on the on the left side of them. Registered Nurse Supervisor attempted to have Resident #9 stand however Resident #9 was unable to follow their directions at this time and was not physically capable of moving the table. The Comprehensive Care Plan Titled Cognition, created 5/21/25, documented behavior-yelling/screaming, resistive to care, abusive language, non-compliance with care. Goals include that Resident #9 will maintain/minimize decline in cognitive capacity as evidenced by staff assessment, documentation and/or resident interview x 90 days, review date 2/9/26. Interventions include continue to provide simple choices. The Comprehensive Care Plan titled Behavioral Symptoms, created 5/21/25, Resident's identified symptoms impact on others that it significantly interferes with the resident's care, with the resident's participation in activities or social interactions and can put others at significant risk for physical injury. Goals include Resident#9 will have improved behavior of the above as evidenced by observation and documentation in medical chart x 90 days, review date 2/18/26. Interventions include provide support and develop a rapport with resident so that a trusting relationship can develop. The Comprehensive Care Plan titled Resident alternate choice, behavior symptoms , created 6/2/21, refusal to wear shoes and socks, prefers to wear boxers in the hallway, refusal to wear compression stockings/TED stockings, prefers to eat outside his room/in the hallway, and put self on floor, despite encouragement and counseling about the risk, related to resident's value belief system, Other delusions. Goals include Resident will understand risks/complications related to refusals x 90 days, 1/26/26. Interventions include identify care preferences, recognize right to choose.A Nursing Progress note dated 12/4/25 documented description of fall/occurrence, that at 5:15 PM, Resident #9 was observed by staff attempting to get up from their wheelchair, attempted to walk then fell facing forward, bracing themselves with hands and catching self along tables. Resident #9 was observed in a seated position on floor upon writer's prompt arrival, assisted back to wheelchair. Closely monitored by staff afterward.A Nursing progress note dated 12/4/25 documented during lunch time Resident #9 kept attempting to ambulate on their own. Nurse tried redirecting Resident #9 and directing them back to chair. While assisting Resident #9 back to chair, Resident #9 swung and hit nurse in the throat. Nurse Practitioner attempted to have Resident #9 sent to hospital, however resident refused. Will continue to monitor. A Social Worker note dated 12/8/25 documented on 12/5/25, as noted resident was observed in the dayroom standing up from the wheelchair and attempting to ambulate without assistance. Resident #9 refused redirection from staff and became physically aggressive, scratching a Certified Nursing Assistant on the right arm. Resident #9 was then assisted in lowering themselves to the ground to keep resident from possibly injury. Resident #9 is alert; however, staff continue to anticipate and address all needs. Due to their severe cognitive impairment, social worker was unable to provide effective education, offered emotional support to the Resident #9.A nurse's note dated 12/15/25 documented Resident #9 had a behavioral episode in day room yelling gibberish and attempting to stand and hit staff. Resident #9 was able to be calmed and redirected. However, later was still getting out of wheelchair and walking unit with unsteady gait yelling gibberish again. Resident #9 was followed and safety maintained by two staff.There was no documented evidence or care plans that reveals Resident #9 had a preference or behaviors to sit in the designated area in the dining room. On 01/08/2026 at 11:11 AM, Certified Nursing Assistant #1 was interviewed and stated they are assigned to Resident #9 who needs moderate assistance for eating, walking, and transfer, and is on a toilet schedule. Certified Nursing Assistant #1 also stated that Resident #9 has behaviors, has temper tantrums, would constantly get up, and can get aggressive at times for no reason, and can hit someone. Certified Nursing Assistant #1 further stated they would talk to Resident #9 in a normal tone, Resident #9 can understand both Creole and Spanish, and can speak English. Certified Nursing Assistant #1 stated that they do not do 30-minute monitoring for Resident #9 who stays in the dining room and is taken out to be toileted. On 01/09/2026 at 11:04 AM, Recreation Aide #1 was interviewed and stated they are assigned on Unit 3, and most of the time they are on the unit from 8:45 AM to 11:50 AM every day. Recreation Aide #1 also stated they do activities with all of the residents and Resident #9 likes some of the activities. Recreation Aide #1 further stated Resident #9 is a fall risk, so they are a little safer over there, behind the table, and they participate in activities from that spot. On 01/09/2026 at 11:10 AM, Nurse Manager #2 was interviewed and stated they try to redirect Resident #9, and sometimes Resident #9 would escalate and be aggressive, and sometimes they would calm down. Nurse Manager #2 also stated Resident #9 has spontaneous actions, and Resident #9 wants to sit behind the table against the wall, as that is their favorite spot and that if they put Resident #9 elsewhere, they would make a fuss. Nurse Manager #2 further stated Resident #9 can have outbursts and sometimes may lash out. Nurse Manager #2 also stated Resident #9 can get out of wheelchair and walk around. On 01/12/2026 at 11:44 AM, the Director of Nursing was interviewed and stated they were not aware if Resident #9 had a specific location they preferred to sit in the dining room. The Director of Nursing also stated usually they would put the residents who need close supervision to sit close to the staff as they sit in the dining room. The Director of Nursing further stated Resident #9 does have a history of falls and is monitored in the dining room. The Director of Nursing stated they did not consider the table placement a restraint as Resident #9 is able to get out anytime, and even when there are other residents sitting on either side of the Resident #9, the other residents are able to move to and allow Resident #9 out. 10 NYCRR 415.4(a) (2-7)

Number of residents sampled: 5Number of residents cited: 2 Based on record review and interviews during the Recertification and Complaint (#2630760 and #607117), the facility failed to ensure all alleged violations involving abuse, neglect, or mistreatment including injuries of unknown origin are reported immediately, but not later than two (2) hours after the allegation is made to the State Survey Agency. This was evident for two (2) of five (5) residents reviewed for Abuse (Resident #126 & Resident #242) out of 38 total sampled residents. Specifically, 1.) On 4/12/2024 at 7:00 AM Resident #126 was observed with facial discoloration/redness to right and left eye and surrounding skin and redness/mild swelling to forehead and eyelids. Resident #126 was unable to explain the injury and the Administrator was first made aware of the incident at 9:00 AM. The injury of unknown source was not reported to the New York State Department of Health until 04/12/2024 at 1:57 PM, and 2.) On 11/21/2025 at 6:00 AM, Resident #242 was observed sitting in a wheelchair in another resident's room and was observed with a left eyebrow laceration measuring 2 centimeters which was bleeding. Resident #242 was transferred to the hospital and returned with Steri-Strips to left eyebrow. Facility concluded resident #242 likely resident had hit/bumped their head on a hard surface which caused the injury to their left eyebrow and did not report the injury of unknown source to the New York State Department of Health. The findings are: The facility's policy titled 'Prohibition of Resident Abuse, Neglect and Misappropriation of Property' with a revised date of 05/06/2025 documented all alleged violations involving serious injuries of unknown source must be reported and investigated immediately and findings of such investigations must be reported to the New York State Department of Health within two (2) hours as well as other required agencies that is law Enforcement. The policy further documented the facility will follow the New York State Department reporting mandates. 1.) Resident #126 was admitted to the facility with diagnoses that included Cellulitis, Sepsis, and Dementia. The Annual Minimum Data Set assessment dated [DATE] documented Resident #126 had moderately impaired cognitive skills. The assessment further documented Resident #126 needed supervision for eating, oral hygiene, and personal hygiene, and moderate assistance for toileting. A facility's Accident/Incident Report documented on 04/12/2024 at 7:05 AM, Resident #126 was observed sitting in a wheelchair in the hallway with discoloration to face, redness to right forehead, right cheek, and ecchymosis to right lower eyelids. The Accident/Incident report also documented Resident #126 was unable to give a statement due to cognitive impairment, and employee statements did not indicate there was a witness to Resident #126's injury. The Nursing progress note dated 04/12/2024 documented Resident #126 was observed with facial discoloration, right and left eyes surrounding skin redness. Mild swelling to forehead and eyelid. Resident was unable to explain what happened due to language barrier and cognition impairment. Primary physician and family informed. As per record review, the facility Incident Report submission was submitted to the New York State Department of Health on 04/12/2024 at 1:57 PM. As per the report this was an injury of unknown source and staff made aware at 7:00 AM, and the Administrator was made aware at 9:00 AM, however the incident was not submitted until 4/12/2024 at 1:57 PM. On 1/12/2026 at 10:48 AM, the Assistant Director of Nursing was interviewed and stated that the incident was reported to the New York State Department of Health and provided no explanation as to why it was reported late. 2. Resident #242 was admitted with diagnoses that included Non-Alzheimer's Dementia, Parkinson's Disease, and Cerebrovascular Disease. The Annual Minimum Data Set assessment for Resident #242 dated 10/17/2025 documented Resident #242 had sort and long-term memory and severely impaired cognitive skills for decision-making. The facility Incident Report dated 11/21/2025 documented Resident #242 was observed sitting in wheelchair in another resident's room with blood dripping from the left side of their face. Location of occurrence unknown. 911 was called and Resident #242 was transferred to the hospital for evaluation. Resident #242 was unable to state what occurred due to severely impaired cognition. The assigned Certified Nursing Assistant reported they observed Resident #242 walking in the hallway at 5:30 AM. The facility investigation contained no conclusion as to what occurred. The Nursing progress notes dated 11/22/2025 at 06:35 AM, documented Resident #242 returned from the hospital related to a fall evaluation. Steri strip to left eyebrow laceration, with swelling present. There was no documented evidence Resident #242's injury of unknown origin with laceration to left eyebrow was reported to the New York State Department of Health. On 01/12/2026 at 1:52 PM, the Director of Nursing stated if this incident falls under the rules for the Department of Health reporting, then it should be reported. The Director of Nursing also stated management meets every Friday and in morning report they discuss all accident and incidents. The Director of Nursing also stated the initial documentation on this incident was a fall, but after reviewing this incident they do see how it can be presented as an injury of unknown origin as Resident #242 was unable to verbalize what happened. The Director of Nursing further stated it was not reported to the Department of Health because it was reported as a fall. On 01/12/2026 at 10:19 AM, Assistant Director of Nursing #1 stated they are responsible for reporting accident/incidents for the facility. Assistant Director of Nursing #1 also stated this incident should have been reported as an injury of unknown origin, because there was no clear evidence Resident #242 fell. Assistant Director of Nursing #1 further they did not recall any discussion about reporting this incident. 415.4 (b)(2)

Based on observation, record review, and interviews conducted during an Abbreviated Survey (NY00343684 and NY00337964), the facility did not ensure that the alleged violations involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property were reported immediately, but not later that two (2) hours after the allegation is made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involved abuse to the administrator of the facility and to other officials (including to the State Agency).This was evident for six (6) out of six (6) residents (Resident #2, #3, #4, # 5, #6 and Resident #7) sampled. Specifically, on 04/18/2024 at 5:50 AM, License Practical Nurse #2 saw Resident #3 wandered into Resident #2's room and sat on the bed. Resident #2 kicked and pulled Resident #3's arm to get Resident #3 out of the room. The facility reported the incident to New York State Department of Health on 04/19/2024 at 7:20 PM. On 05/09/2024 at approximately 6:40 AM, License Practical Nurse #2 as entered a room, Resident #4 was lying on their bed with private area exposed and Resident #2 was standing at Resident #4's bedside with their pants down and private area exposed. The facility reported the incident to New York State Department of Health on 05/09/2024 at 12:19 PM. On 05/28/2024 at 10:00 AM, Resident #7 told Licensed Practical Nurse #1 that Housekeeper #1 took their fifty dollars. The facility did not report the alleged misappropriation of property to local law enforcement. On 06/20/2024 at 10:55 PM, Resident #3 wandered into Resident #5's room and was found on the floor. Resident #3's cognition was severely impaired and therefore, they could not explain what had happened. Resident #5 stated they pushed Resident #3. The facility reported the incident to New York State Department of Health on 06/21/2024 at 4:02 PM. On 09/07/2024 at 9:45 PM, Resident #3 wandered into Resident #6's room and hit Resident #6's hands and shoulder when Resident #6 asked Resident #3 to stop going through their drawers. The facility reported the incident to New York State Department of Health on 09/08/2024 at 6:50 PM. The findings are: The facility's Policy and Procedure titled Prevention of Resident Abuse/Neglect and Misappropriation of Property dated on 06/20/2024, documented that all alleged violations involving mistreatment of residents, neglect, or abuses, including injuries of unknown source are reported when discovered to the Administrator, Director of Nursing, Director of Social Work and/or their designees. Facility will follow the NYSDOH Reporting mandates. When the results of the investigation are substantiated, a report is also made to the State Certification agency (New York State Department of Health) and to all other agencies as required, and according to the New York State Department of Health reporting requirements. Resident #2 was admitted to the facility with diagnosis including bipolar disorder (mental disorder), and Depression. The Minimum Data Set, dated dated dated [DATE], documented Resident #2 had intact cognition. Resident #3 was admitted to the facility with diagnosis including Schizophrenia (a mental health condition that affect how people think, feel, and behave), and Non-Alzheimer's Dementia. The Minimum Data Set, dated dated dated [DATE], documented Resident #3 had severely impaired cognition. The facility's investigation dated 04/18/2024 at 5:50 AM, documented License Practical Nurse # 2 responded to Resident #2 shouting at Resident #3 to get out of a room that did not belong to either resident. Licensed Practical Nurse #2 observed Resident #2 kick and pull Resident #3's arm in attempt to get them out. Licensed Practical Nurse #2 intervened and redirected Resident #2 to their room. The facility conclude that the incident was unavoidable and there may be reasonable cause to believe abuse occurred. Resident #4 was admitted to the facility with diagnosis including Depression and Schizophrenia. The Minimum Data Set, dated dated dated [DATE] documented Resident #4 had severely impaired cognition. The Resident Accident/Incident Report dated 05/09/2024 at 6:35 AM, documented Licensed Practical Nurse # 2 observed Resident #2 making frequent stops in front of other resident's room. Licensed Practical Nurse #2 went to check on Resident #2's whereabouts and observed them in Resident #4's room standing at their bedside with perineal (private parts) exposed. Resident #4 was on their bed with private area also exposed. Resident #2 was redirected and was later sent to the hospital for further evaluation. Resident #4 reported Resident #2 did not do anything to them and refused to be transferred to the hospital for evaluation. The facility concluded abuse did not occur, care plans and interventions were implemented. Resident #5 was admitted to the facility with diagnosis including Hypertension and Diabetes (High blood sugar). The Minimum Data Set, dated dated dated [DATE], documented Resident #5 had moderately impaired cognition. The Resident Accident/Incident Report dated 06/20/2024 at 10:55 PM, documented Resident #3 wandered into Resident #5's room and was standing over Resident #5 while they were sleeping. The facility's investigation revealed Resident #5 became upset when they woke up and saw Resident #3 standing over them and reacted. The facility concluded there may be reasonable cause to believe alleged resident abuse, mistreatment or neglect occurred, care plans and interventions were implemented. Resident #6 was admitted to the facility with diagnosis including Diabetes (sugar in the blood), and Dementia. The Minimum Data Set, dated dated dated [DATE], documented Resident #6 had intact cognition. The Resident Accident/Incident Report dated 09/07/2024 documented at 9:45 PM, Resident #3 wandered into Resident #6's room and began opening Resident #6's drawers. Resident #3 hit Resident #6 after Resident #6 told them to stop. The facility concluded there may be reasonable cause to believe alleged resident abuse, mistreatment or neglect occurred and implemented care plans with interventions. Resident #7 was admitted to the facility with diagnoses including Alzheimer's Disease, Bipolar Disease, and Schizophrenia. The Minimum Data Set, dated dated dated [DATE], documented that Resident #7 had short term and long-term memory problems with moderately poor decision making, and disorganized thinking. The Resident Accident/Incident Report dated 05/30/2024, documented Resident #7 stated on 05/28/2024 at 10:00 AM, Housekeeper #1 took their money. The facility's initial investigation dated 06/01/2024, documented there may be reasonable cause to believe alleged resident abuse, mistreatment or neglect has occurred and Housekeeper #1 was removed from Resident #7's floor. The facility's final investigation dated 06/03/2024, documented the facility's findings were inconclusive, and it was undetermined whether there was reasonable cause to believe that abuse, neglect, or mistreatment occurred. Resident #7 was reimbursed, and Housekeeper #1 was reassigned to a different unit. There was no documented evidence that the New York City Law Enforcement was informed. During an interview on 3/20/2025 at 5:00 PM, the Director of Nursing stated that if the facility investigation determined there was reasonable cause to believe misappropriation of property, the police should have been called. A follow up interview conducted on 04/17/2025 at 11:56 AM, Director of Nursing stated any allegation of abuse must be reported to them immediately and should be reported to the Department of Health within 2 hours. During a telephone interview on 04/02/2025 at 9:17 AM, the Assistant Director of Nursing stated they are responsible for reporting all incidents to the New York State Department of Health. They stated they cannot recall when they were made aware of the incidents, but any allegation of abuse should be reported within 2 hours if there was injury and 24 hours if there wasn't injury. 10 NYCRR 415.4(b)(2)

Based on observation, record review, and interviews conducted during an abbreviated survey (NY00323497), the facility failed to protect a resident's right to be free from physical abuse by a nursing home staff. This was evident in one (1) out of three (3) residents (Resident #1) sampled for abuse. Specifically, on 09/07/2023 at approximately 2:15 PM the Occupational Therapist reported to the Director of Nursing that Resident #1 was observed in the dining room with a black eye. Resident #1 reported that they were punched in the eye by a crazy lady and identified Registered Charge Nurse #1 as the person who punched them in the eye on 09/06/2023 during the evening shift. Registered Charge Nurse #1 did not immediately assess Resident #1 after being told Resident was observed with discoloration to their eye. The findings include: The facility's policy and procedure on Prohibition of Residents Abuse, Neglect and Misappropriation of Property dated 03/19/2025 documented the facility residents have the right to be free from Abuse, Neglect, Exploitation and misappropriation of property. Resident #1 was admitted to the facility with diagnoses of Adjustment disorder, Major Depressive Disorder, and Dementia (loss of memory). The Minimum Data Set (an assessment tool) dated 07/03/2023 documented Resident #1 had intact cognition. An Abuse Care Plan dated 07/05/2023 documented interventions to provide a safe and calm environment, and reduced agitation. Provide comfort, reassurance, and keep the resident safe by removing them from being annoyed by other residents. A Nurse Progress note dated 09/07/2023 at 5:29 PM by Licensed Practical Nurse #1 documented Resident #1 was observed with discoloration to their right periorbital. An assessment was done by Registered Nurse and the Emergency Medical Technician. There were no complaints of pain. Resident #1 stated they were struck, resulting in injury. A Summary of Investigation dated 09/07/2023 at 2:15 PM documented they received a call from Occupational Therapist #1 at about 2:15 PM stating Resident #1 was observed with a black eye in the dining room. The Director of Nursing was notified and immediately responded. Resident #1 was observed with a purple bruise to the right lower eye lid. Assigned Certified Nursing Assistant #1 reported that Registered Charge Nurse #1 saw Resident #1 with the purple bruise to their right lower eyelid. Registered Charge Nurse #1 did not assess Resident #1, and did not notify the Nursing Supervisor and Medical Doctor of the potential abuse. Resident #1 was interview and reported that they were punched in the eye by a crazy lady identified as Registered Charge Nurse #1. Registered Charge Nurse #1 was interview and stated on 09/06/2023 at 6:50 PM Resident #1 slapped them on the left side of their face because they were redirecting them from entering the dining room. The dining room was mopped, and the door was closed to allow the floors to be dried. The Medical Doctor was notified and ordered an x-ray of facial bones. The x-ray results dated 09/10/2023 showed no acute fractures. An Optometry examination dated 10/09/2023 documented no changes. 911 was called and responded. Resident #1 and Registered Charge Nurse #1 was interviewed, and no charges were file. The facility concluded that there may be reasonable cause to believe alleged resident abuse, mistreatment or neglect had occurred. A Physician Progress note dated 09/08/2023 at 8:18 AM documented status post-accident and incident possible altercation with another resident (as per pt) - unwitnessed right eye periorbital ecchymoses. Noted to be mild and in resolving stage. Resident #1 was not in any distress and mental status stable at baseline. There was no complaint of pain. Right periorbital ecchymoses, appears to be not of acute nature. A Radiology Report dated 09/10/2023 documented multiple views of the facial bones demonstrate no acute fractures. The orbital rims are intact. Occupational Therapist #1 is no longer employed at the facility but wrote a statement to the facility dated 09/07/2023 stating at approximately 11: 00 AM to Noon they observed Resident #1 walking out of the elevator with a black eye. This was immediately reported to Registered Charge Nurse #1. During an interview on 03/19/2025 at 11:15 AM Resident #1 stated that a lady punched them in their eye some time ago. Resident #1 stated they slapped a lady (unable to recall identity, and the lady then punched them in their eye. Resident #1 stated they are unable to recall the time of the incident. During an interview on 03/19/2025 at 2:22 PM Registered Charge Nurse #1 stated they worked on 09/06/2023 during the day shift from 7:00 AM - 3:00 PM and did not see any discoloration on Resident #1's face. Registered Charge Nurse #1 stated they also worked late on 09/06/2023 and was leaving the unit at approximately 6:50 PM via the stairwell when they observed Resident #1 opening the dining room door to enter inside. Registered Charge Nurse #1 stated they instructed Resident #1 not to enter the dining room because the floor was wet, and Resident #1 slapped them on the left side of their face. Registered Charge Nurse #1 stated Resident #1 began to curse at them stating they had no right to stop them. Registered Charge Nurse #1 stated they screamed out for help and the evening shift medication nurse (Licensed Practical Nurse #1) came over and escorted Resident #1 away. Registered Charge Nurse #1 stated they were late leaving work and did not initiate an incident report, however, they saw the Assistant Director of Nurse in the lobby and reported the incident to them. Registered Charge Nurse #1 stated they did not see any redness or discoloration on Resident #1's face when they arrived at work on 09/27/2023 and conducted rounds during the morning shift. Registered Charge Nurse #1 stated at approximately 11:00 AM - 12:00 PM on 09/27/2023, Occupational Therapist #1 informed them Resident #1 had redness and discoloration on their face. Registered Charge Nurse #1 stated they did not assessed Resident #1, and did not get close to the Resident because the Resident slapped them the prior evening. Registered Charge Nurse #1 stated they did not report the discoloration to neither the Nursing Supervisor nor the Medical Doctor. Registered Charge Nurse #1 stated Occupational Therapist #1 took Resident #1 off the floor to the Director of Nursing office. Registered Charge Nurse #1 stated the Police Officers interviewed them, and they explained the slapped from the previous evening and showed the Officers the swelling on the left side of their face. Registered Charge Nurse #1 stated the Police Officers left and did not file a report. Registered Charge Nurse #1 stated they did not punch or hit Resident #1 in their face. During an interview on 04/04/2025 at 1:00 PM, Licensed Practical Nurse #1 stated they worked as the medication nurse on 09/06/2023 from 3:00 PM - 11:00 PM. Licensed Practical Nurse #1 stated at approximately 6:30 PM - 7:00 PM while they were administering medication, they heard loud voices (Resident #1 and Registered Charge Nurse #1) talking and went to see what was happening. Licensed Practical Nurse #1 stated they did not observe any physical contact between Resident #1 and Registered Charge Nurse #1; however, Registered Charge Nurse #1 informed them Resident #1 slapped them. Licensed Practical Nurse #1 stated they escorted Resident #1 away and Registered Charge Nurse #1 went down the stairs. Licensed Practical Nurse #1 stated they did not see any discoloration on Resident #1's face at time. During an interview on 03/21/2025 at 12:27 PM Certified Nursing Assistant #1 stated they worked on the unit on 09/07/2023 and was assigned to the dining room during the 7:00 AM - 3:00 PM shift. Certified Nursing Assistant #1 stated at approximately 7:20 AM on 09/07/2023 while they were serving breakfast, they observed discoloration and redness to Resident #1's right lower eye lid. Certified Nursing Assistant #1 stated they did not report the discoloration to the nurse because Registered Charge Nurse #1 and the other Certified Nursing Assistants (does not recall their names) were in the dining room serving break while discussing the discoloration on Resident #1's face. The other Certified Nursing Assistants stated it was the first time they saw the discoloration. Certified Nursing Assistant #1 stated Registered Charge Nurse #1 was in the dining room but did not mention anything about the altercation between them and Resident #1 the previous evening. Certified Nursing Assistant #1 stated they received in-service on reporting any skin changes in resident's condition prior to the incident and post incident. During an interview on 04/04/2025 at 10:00AM, Licensed Practical Nurse #2 stated that they worked on the unit as the medication nurse on 09/07/2023 on the 7:00AM - 3:00 PM shift. Licensed Practical Nurse # 2 stated between 7:15 AM - 7:30 AM they covered the dining room for breakfast. Licensed Practical Nurse # 2 stated Resident #1 was not in the dining room therefore, they asked Certified Nursing Assistant #2 to get Resident #1 from their room. Licensed Practical Nurse # 2 stated when Resident #1 arrived in the dining they observed Resident #1 with discoloration/redness to the eye. Licensed Practical Nurse #2 stated the staff members stated this was the first time they saw the discoloration. Licensed Practical Nurse #2 stated Registered Charge Nurse #1 had just arrived on the unit and was walking to their office when they informed them about Resident #1's eye. Licensed Practical Nurse # 2 stated Resident #1 was sitting in the dining room and Registered Charge Nurse #1 looked at Resident #1 and stated they must create an incident report. Licensed Practical Nurse #2 stated Registered Charge Nurse #1 never mention being slapped by Resident #1 the prior evening. Licensed Practical Nurse #2 stated a rehab staff took Resident #1 off the unit. During an interview on 03/19/2025 at 2:30 PM, the Director of Nursing stated on 09/07/2023 at approximately 2:15 PM they were informed by Occupational Therapist #1 that Resident #1 was in the main dining room downstair with a black eye. The Director of Nursing stated they immediately went to Resident #1 and escorted the Resident back to their room to be interviewed and assessed. The Director of Nursing stated Resident #1 reported that they were punched in the eye by a crazy lady. The Director of Nursing stated Resident #1 was able to describe the staff but did not know the staff by name. The Director of Nursing stated they made rounds with Resident #1 on the unit and Resident #1 was able to identify Registered Charge Nurse #1 as the person who punched them in the eye. The Director of Nursing stated they immediately removed Registered Charge Nurse #1 from the unit and called 911. The Director of Nursing stated the Medical Doctor was notified and ordered a facial x-ray. The Director of Nursing stated the Assistant Director of Nursing and them investigated the alleged incident, and the team concluded that Registered Charge Nurse #1 punched Resident #1 in the face. The Director of Nursing stated Resident #1 was consistent with their account of the incident, and information never changes. The Director of Nursing stated Resident #1 was interview by the Attorney General and Resident #1 was consistent. The facility concluded that there may be reasonable cause to believe alleged resident abuse, mistreatment or neglect had occurred. The Director of Nursing stated Registered Charge Nurse #1 no longer works at the facility. A follow up telephone interview was conducted with the Director of Nursing on 04/04/2025 at 10:15AM. The Director of Nursing stated Resident #1 was sitting in the main dining room downstair on the first floor when Occupational Therapist #1 observed Resident #1 with the black eye and reported it to them. The Director of Nursing stated staff members on the unit had already seen the discoloration and notified Registered Charge Nurse #1. The Director of Nursing stated Registered Charge Nurse #1 was informed and knew about the discoloration and never took any steps to assessing or reporting to the administration team. During an interview on 03/21/2025 at 11:30 AM the Assistant Director of Nursing stated Resident #1 was assessed and was observed with a black eye. There were no other bruises. The Assistant Director of Nursing stated Registered Charge Nurse #1 never informed them of any altercation between them and Resident #1 on 09/06/2023 prior to them leaving the facility. The Assistant Director of Nursing stated they do not recall seeing Registered Charge Nurse #1 prior to them leaving the facility on the evening of 09/06/2023. The Assistant Director of Nursing stated that no one observed the discoloration prior to 09/07/2023 during the morning shift and there were no witnesses. However, Resident #1 was consistent and did not change their story. 10 NYCRR 415.4(b)(1)(i)

Based on observation, interviews, and record review conducted during the Recertification survey from 9/20/2023 to 9/27/2023, the facility did not ensure residents' right to send and receive mail. This was evident for 9 of 9 attendees (Resident #39, #151, #100, #181, #83, #185, #67, #96, and #147) of the Resident Council meeting conducted on 9/21/2023. Specifically, the facility did not have a system in place to ensure that residents could receive and send mail on Saturdays. The findings are: The facility's policy titled Resident Packages/Mail dated 5/2023 documented the facility to deliver packages/mail to residents who receive packages/mail from family or other resources offered from the community. Packages/mail received over the weekend and holidays will remain in the mail room until Monday. On 09/21/23 at 10:56 AM, Resident Council Meeting was held with Resident #39, #151, #100, #181, #83, #185, #67, #96, and #147 in attendance. All 9 attendees stated they do not get mail delivered to them on Saturdays and are unable to send mail on Saturdays. On 09/25/23 at 11:42 AM interview with Director of Social work #22, when it comes to the mail, it is delivered Monday to Friday to the front desk, it gets delivered to the Administrative Assistant or purchasing person if it is anything to do with money. Social Service office gets the mail and delivers it to the residents and gets permission to open the mail by the resident, if clothing, housekeeping picks up the clothing, prints the labels, and takes it to the laundry room to be labeled. Mail that is delivered on the weekends gets put inside the mail room by security and waits until Monday for distribution. No mail or packages is distributed on Saturdays, Sundays, or holidays, because social services are not here. The residents must wait until Monday to get the mail. Checks/money goes to the finance department and gets deposited into the resident account. On 09/25/23 at 11:57 AM Interview with Administrative Assistant #11 stated that the administrative assist role with the mail is to get the mail from the front desk, sorts out the mail in the mail room and puts the mail in the appropriate bins, such as social service and/or finance, depending on the type of mail/packages that comes in. Not sure if the mail is delivered on the weekends, only responsibility is to sort the mail and put it in the mailboxes. On 09/25/23 at 12:01 PM interview with Director of Nursing #2, reports that the mail is given out through the social work department and activities department. I am not familiar with the mail policy. 415.3(e)(2)(ii)

Based on record review and staff interview conducted during the Recertification/Complaint survey, the facility did not ensure that the resident and their representatives were provided with a written summary of the baseline care plan (BCP). This was evident for 3 (Residents #85, #164, and #176) of 38 total sampled residents. Specifically, 1) Resident #85 was not provided with a copy of their BCP, 2) Resident #164 was not provided with a copy of their BCP, and 3) Resident #176 was not provided with a copy of their BCP. The findings are: The facility policy titled BCP/Care Plan Summary dated 09/25/2023 documented the facility promotes the resident's right to be informed of the initial plan for the delivery of care and services and to receive a written summary of the baseline care plan. 1) Resident #85 was admitted to the facility 06/01/2023 with diagnoses of coronary artery disease (CAD) and Parkinson's Disease. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #85 had moderate cognitive impairment and did not participate in the assessment. On 09/20/23 at 10:01 AM, Resident #85 was interviewed and stated they have resided in the facility for approximately 3 months and has not been invited to a CCP meeting and was not given a written copy of their BCP. The BCP Summary for Resident #85 was initiated 06/01/2023 and completed 06/02/2023. There was no documented evidence Resident #85, or their designated representative were provided with a copy of the BCP. 2) Resident #164 was admitted to the facility 08/03/2023 with diagnoses of arthritis and depression. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #164 was moderately cognitively impaired, participated in the assessment, and had no family or significant other. On 09/20/23 at 09:40 AM, Resident #164 was interviewed and stated they have been in the facility a month and have not been given a copy of their BCP. The BCP for Resident #164 was initiated 08/03/2023 and completed 08/04/2023. There was no documented evidence Resident #164 was provided with a copy of the BCP. 3) Resident #176 was admitted to the facility 02/01/2023 with diagnoses of Hypertension and Respiratory Failure. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #176 was cognitively intact and participated in the assessment. On 09/20/23 at 10:17 AM, Resident #176 was interviewed and stated they were never invited to discuss their plan of care and do not recall receiving a written copy of their BCP. The BCP for Resident #176 was initiated on 02/01/2023 and completed 04/04/2023. There was no documented evidence Resident #176 received a copy of their BCP. On 09/25/23 at 10:23 AM, an interview was conducted with Registered Nurse (RN) #1 who stated the BCP is completed within 48 hours of a resident's admission to the facility and residents are not given copy of their BCP summary. RN #1 stated they have been working with the facility for less than a year and was not aware residents should be provided with a copy of their BCP. On 09/25/23 at 10:45 AM, an interview was conducted with the Social Worker Director (SWD) who stated the interdisciplinary team members complete the BCP and discuss the BCP with the resident. A copy of the BCP is not provided to the residents or their representatives. On 09/25/23 at 11:38 AM, the Director of Nursing (DON) was interviewed and stated they are not aware whether a copy of the BCP is being given to residents and their representatives consistently. 415.11 (c)

Based on observations, record review, and interviews conducted during the Recertification survey from 09/20/23 to 09/27/23, the facility did not ensure that it was free of medication error rate of 5% or greater. This was evident for 2 of 35 medications observed during medication administration. Specifically, medications were not administered as ordered by the physician: 1) Metformin 500mg 1 tablet was administered instead of 2 tablets(1000mg), and 2) Amlodipine 5mg 1 tablet was administered instead of 2 tablets(10mg) to Resident #134, leading to a medication error rate of 5.69%. The findings are: The facility's policy titled Medication Administration Guidelines dated 1/4/23 documented that medications should be administered as ordered by the Physician. Resident #134 was admitted to the facility with diagnoses that included Diabetes Mellitus and Hypertension. The current Physician's order (PO) as of 9/22/2023 documented Resident #134 receive Metformin 500mg 2 tablets = 1000mg by mouth twice a day at 9am and 5pm. The PO documented Amlodipine 5mg give 2 tablets = 10 mg by mouth once daily at 9am. On 09/22/23 at 10:51 AM, during a medication administration observation conducted on Unit 5, the Registered Nurse (RN) #7 administered Metformin 500mg 1 tablet instead of 2 tablets (1000 mg) and Amlodipine 5mg 1 tablet instead of 2 tablets (10mg) to Resident #134. RN#7 signed the Medication Administration Record confirming 2 tablets (1000 mg) of Metformin and 2 tablets (10mg) of Amlodipine were administered. On 09/22/23 at 12:16 PM, RN #7 was interviewed and stated that it was their 1st time administering the medications to Resident #134. They just read the top of the blister pack and did not realize that it was not the whole order with the dosage. It is different from the hospital where RN #7 stated they are used to working. On 09/26/23 at 04:01 PM, the Director of Nursing (DON) was interviewed and stated that RNs that come from the staffing agency come with experience. The supervisors monitor the new hires since they do not have a buddy system. The expectation is that the RNs are experienced in the facility setting. RN Supervisors spot check the nurses during medication administration. The DON stated that they did not know if a competency was performed for medication administration with RN #7. 415.12(m)(1)

Based on observation, record review, and interviews conducted during the recertification survey of 9/20/23 through 9/27/23, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was evident during Kitchen observation. Specifically, 1) open produce was stored without a date in the freezer, boxes were stored directly on the freezer floor, and the mixer was observed soiled with grease and grime; and 2) the refrigerator temperature was observed above 41 degrees Fahrenheit (F). The findings are: An undated policy titled Receiving and Storage and Issuing documented food items are stored on shelves at least 6 inches above the floor and 18 inches below the ceiling. All perishable food items are stored in either refrigerators or freezers maintained at a temperature of 41 degrees Fahrenheit (F) or below, and 0 degrees F or below. No food items will ever be stored on refrigerator or freezer floor. 1) On 9/20/23 at 9:29 AM, the Food Service Director (FSD) and Food Service Supervisor (FSS) were present when the kitchen freezer was observed with a box of diced red peppers on the floor. There were multiple other boxes stacked on top of the box of peppers. The freezer also contained an undated open bag of sweet potato fries and an undated bag of sliced zucchini. The walk-in produce refrigerator had 2 undated open and cut heads of lettuce. The 3-door salad/dessert refrigerator contained undated sliced American cheese partially wrapped. The pot rack was observed with shelves that were black with built-up dirt that was able to be felt and be rubbed off. The walk-in dairy refrigerator had shelves with built-up grime, dirt, and grease. The mixing machine was observed with a grease and dirt at hook area and on the base of the unit. At 9:31 am on 9/20/23, the FSD was interviewed and stated the storeroom aide. was responsible for cleaning and managing the refrigerators. Dietary Aide (DA) #2 was present at that time, was interviewed, and stated that they are not the regular storeroom aide. DA #2 stated that refrigeration storage should not be packed too high, and nothing should on the floor. DA #2 further stated that they had gotten a freezer delivery that day and that they found the freezer the way it is with boxes stacked high. At 9:38 am on 9/26/23, the FSS was interviewed and stated the storeroom worker is responsible for the upkeep of the freezer. The original storeroom person was off and DA #2 was filling in for the day. It was a delivery day and food is not usually stored on the floor of the freezer. The pot washer is responsible for the cleanliness of the shelves. The shelves are also part of special cleaning 2 times a week. The FSS stated the mixer is cleaned after every use. 2) On 9/22/23 at 12:05 PM, the temperature of the walk-in refrigerator was observed at 70 F. At the time, the Food Service Director (FSD) was interviewed and stated they were not aware the refrigerator was not working and within acceptable temperature range of 41 F or below. On 9/26/23 at 10:07 AM, an interview was conducted with the FSD who stated the maintenance department was called to service the refrigerator that was at 70 F. Another air curtain was also placed in front of the refrigerator door to prevent cold air from escaping and warm air from going into the refrigerator. 415.14(h)

Based on observations, record review, and interviews conducted during the Recertification survey from 09/20/23 to 09/27/23, the facility did not ensure infection control practices and procedures were maintained. This was evident for 6 (Resident #171, #21, #38, 134, #191 and #173) of 38 total sampled residents. Specifically, Registered Nurse (RN) #7 was observed using the same Blood Pressure (BP) cuff with Resident #171, #21, #38, and #134 without cleaning and disinfecting the BP cuff in between each resident, and RN #3 was observed using the same the Blood sugar/glucose machine (Glucometer) with Resident #191 and #173 without cleaning and disinfecting the Glucometer in between each resident. The findings are: The facility policy titled Multipurpose equipment cleaning, revised 08/2023, documented that all multipurpose equipment must be cleaned and disinfected between resident use, with germicidal/microbial disinfectant disposable wipe. The equipment includes the BP cuff and the Glucometer. On 09/22/23 at 09:54 AM, RN#7 was observed in the dining room with the BP machine. RN #7 did not sanitize the BP cuff prior to placing the BP cuff on Resident #171's right arm. RN#7 finished taking Resident #171's BP. RN #7 did not sanitize the BP cuff or machine. RN #7 then rolled the BP machine next to Resident #21. RN #7 did not sanitize the BP cuff or machine and placed the BP cuff on Resident #21's left arm. RN#7 then placed the same BP cuff on Resident #38 arm without sanitizing the BP cuff or machine prior to placing the BP cuff on Resident #38's arm. RN #7 then went into Resident #134's room with the BP machine and did not sanitize the BP machine and placed the BP cuff onto Resident's #134 arm. RN#7 then rolled the BP machine into the hallway next to the cart without sanitizing the BP cuff. On 09/22/23 at 11:52 AM, RN# 3 was observed removing the Glucometer from inside the medication cart. RN#3 took the Glucometer into Resident #191's room. RN#3 did not sanitize the Glucometer prior to taking it in Resident#191's room. RN #3 then used the Glucometer on Resident #191. RN #3 then took the Glucometer out of Resident#191's room, discarded the strip, and placed the Glucometer on top of the medication cart. RN #3 did not sanitize the Glucometer and used the same Glucometer by placing a clean strip and using it to read Resident #173 blood sugar in the hallway in front of Resident #191's room. On 09/22/23 at 12:16 PM, RN #7 was interviewed and stated that they know that they are supposed to clean the BP cuff after each resident use with anti-bacterial wipes, and that they did not do that today. RN #7 stated that they know that the BP cuff and the machine should be cleaned before and after each resident use. On 09/22/23 at 12:33 PM, RN #3 was interviewed, and stated Glucometer needs to be cleaned before and between each resident use. RN #3 stated they did not clean the Glucometer between Resident #191 and Resident #173. RN #3 stated that they know that they are supposed to clean it for Infection Control purposes, but they forgot. On 09/22/23, at 02:34 PM, RN #2 was interviewed and stated that the Nurses were taught that in between usage, the equipment is to be cleaned with the germicidal wipes, which are kept in the medication cart. RN #2 stated that this information is given to the nurses as part of their orientation. On 09/26/23 at 04:01 PM, the Director of Nursing (DON) was interviewed and stated the BP cuff and Glucometer machines are to be cleaned between use with each resident. All nurses are supposed to be trained on cleaning the equipment. 415.19 (b)(4)

Based on observation, record review, and interview during the recertification and complaint survey from 9/20/2023 to 9/27/2023, the facility did not ensure that the Minimum Data Set 3.0 (MDS) assessment accurately reflected a resident's status. This was evident for 1 of 38 sampled residents (Residents # 32). Specifically, the MDS assessment for Resident # 32 did not reflect Tracheostomy care. The findings are: The facility's policy titled Resident Assessment revised 9/2023 documented the Registered Nurse (RN) conducts or coordinates each assessment with the appropriate participation of health professionals. The policy further states the assessment accurately reflects the resident's status and provide mandated information on each resident's condition. The RN coordinator signs and certifies assessment completion, while everyone who completes a portion of the assessment certifies the accuracy of the assessment. Resident # 32 was admitted to the facility with diagnoses that included Tracheostomy status, Schizophrenia, Asthma, Pulmonary embolism. The Minimum Data Set 3.0 (MDS) assessments dated 03/14/2023 for annual assessment and MDS dated [DATE] for admission assessment documented Resident # 32 had modified cognitive skills for daily decision making and required supervision and encouragement to complete activities of daily living. The assessment for MDS dated [DATE] and 6/15/2023 did not document Resident #32 received tracheostomy care. On 9/21/2023 at 11:39 AM, Resident # 32 was observed in the room [ROOM NUMBER] in bed with tracheostomy, breathing unlabored. Able to respond to simple question by nodding head. Review of Treatment Administration Record (TAR) dated 6/9/2023, 6/10/2023, 6/12/2023, 6/13/2023, 6/16/ 2023, 6/19/2023, 6/21/2023, 6/22/2023, 6/23/2023 documented tracheostomy care were done to Resident # 32. A Medical Doctor (MD) order on admitted d 2/17/2023 and renewed 6/8/2023 documented Resident # 32 was to be observe for signs and symptoms of tracheostomy dislodgement and infection on site and refer accordingly. A comprehensive care plan (CCP) titled Alteration in Respiratory Status effective 6/9/2023 with latest update on 9/7/2023 documented goal was resident will be free of respiratory distress x 90 days. Interventions were Tracheostomy care as per MD order, Suctioning machine at bedside, tracheostomy set at bedside, encourage deep breathing. On 09/27/2023 at 10:22 AM MDS Coordinator (MDSC) was interviewed and stated they overlooked and missed to document in the MDS Section O, Tracheostomy care. MDSC further stated going forward they will check the accuracy of the MDS entries and to make sure to document what the resident has. On 09/27/2023 at 12:54 PM, the Director of Nursing (DON) was interviewed and stated they were not aware tracheostomy care was not entered on the resident #32 MDS however they have a consultant that audits all entries in the MDS and will continue the service of the consultant to help them out with areas that the staff missed to document. 415.11

Based on observation, interview, and record review conducted during the Recertification survey from 9/20/2023 to 9/27/2023, the facility did not develop and implement a comprehensive person-centered care plan (CCP) for a resident. This was evident for 1 (Resident #194) of 38 total sampled residents. Specifically, a CCP related to pain was not developed for Resident #194. The findings are: The facility policy titled CCP dated 12/2022 documented the CCP will be initiated, and appropriate care plans will be in place when there is a change in resident condition. All other episodic care plans will be reviewed as needed to ensure goals and interventions will produce positive resident outcomes. Interdisciplinary development of care plan that will improve the resident's functional abilities and addresses their questions and concerns. Resident # 194 had diagnoses of Unspecified Pain and Schizophrenia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #194 had mild cognitive impairment. On 9/21/2023 at 11:50 AM, Resident #194 was interviewed and stated they had a toothache and mouth pain that is not well-controlled with pain medications. Physician order dated 01/13/2023 and 02/23/2023 documented to give Resident #194 Tylenol 325 mg 2 tablets 2 times a day as needed for central pain syndrome. There was no documented evidence a CCP related to pain management was developed and implemented for Resident #194. On 9/27/2023 at 11:11 AM, Licensed Practical Nurse (LPN) # 1 was interviewed and stated Resident #194 expresses mouth pain. LPN # 1 assesses the resident's pain by asking where the pain is, assessing the area, and reporting to the Registered Nurse (RN) and Medical Doctor. The LPN #1 used a numeric pain scale from 1-10 to assess a resident's level of pain. LPN #1 further stated the Registered Nurse (RN) initiates and updates care plan. On 9/27/2023 at 11:24 AM, RN # 2 was interviewed and stated they are new and Resident #194 has not complained of pain. RN #2 read in the progress notes that Resident #194 had mouth pain and RN #2 should have developed a CCP related to pain for Resident #194. This was overlooked. On 9/27/2023 at 12:57 PM, the Director of Nursing (DON) was interviewed and stated Resident #194 was receiving Tylenol for mouth pain. The DON was not aware that a CCP for pain was not initiated. 415.11(c)(1)