Every finding on record at Orchard Park Rehab & Living Center

Based on record reviews, interviews, and facility policy, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 3 sampled residents reviewed during a complaint investigation (Resident's #1).Findings: Review of facility policy CNA Documentation dated 1/19 states Resident care will be documents in an accurate and efficient manner by CNA's as a means of reviewing resident status and progress toward identified goals The CNA Daily flow sheet will be completed each shift by the CNA assigned to the resident. Using the codes provided on the form, the CNA is to indicate the care provided . Review of Resident #1's admission Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was dependent of facility staff for toileting transfers, hygiene and mobility.Review of Activity of Daily Living (ADL) charting from 4/14/26 through 5/30/36 (47 days) lacked evidence Resident #1 received toileting/hygiene assistance on 4/14/26,4/15/26, 4/17/26, 4/18/26, 4/23/26, 4/25/26, 4/27/26, 4/28/26, 4/29/26, 5/6/26, 5/7/26, 5/15/26, 5/16/26. During the day shift 4/16/26, 4/19/26, 4/20/26, 4/22/26, 4/24/26, 4/29/26, 4/30/36, 5/1/26, 5/2/26, 5/3/26, 5/8/26, 5/9/26, 5/10/26, 5/13/26, 5/17/26, 5/18/26, 5/20/26, 5/21/26, 5/22/26, 5/24/26. During the evening shift 4/16/26, 4/19/26, 4/20/26, 4/21/26, 4/22/26, 4/26/26, 4/29/26, 4/20/26, 5/1/26, 5/3/26, 5/4/26, 5/11/26, 5/12/26, 5/17/26, 5/18/26, 5/19/26, 5/21/26, 5/22/26, 5/25/26, 5/26/26, 5/28/26, or 5/29/26. During the night shift 4/18/26, 4/21/26, 4/26/26, 5/10/26, 5/11/26, 5/12/26, 5/13/26, 5/25/25, and 5/26/26.During an interview on 6/25/26 at 9:06 a.m., Certified Nursing Assistant (CNA#1) stated that they are expected to document on each resident in their assignment every day before the end of shift and if a resident refused, it should also be documented in the Electronic Medical Record (EMR).During an interview on 6/25/26 at 12:31 p.m., the Director of Nursing stated CNA staff should be documenting ADL care before the end of their shift.

Based on observations and interviews the facility failed to ensure a resident was treated with dignity and respect for 1 of 3 residents reviewed during a complaint investigation (Resident #3).Findings: Observation of Resident #3 on 6/25/26 at 9:06 a.m., and 11:31 a.m., a urinary catheter was observed hanging from bedframe visible from door containing a yellow liquid. At this time Resident #3 stated he's/she's had a Foley on and off for a long time. When asked if it concerns him/her that the foley is visible from the door, resident stated wouldn't it concern you? During an observation of Resident #3 with Director of Nursing on 6/25/26 at 9:31 a.m., Director of Nursing confirmed Foley catheter uncovered, observed from door. Confirmed the foley bag should have been covered.

Based on interviews, record reviews, and facility policy, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the problems, interventions, and initial goals needed to provide minimum healthcare information necessary to properly care for 1 of 3 residents reviewed during a complaint investigation (Resident #1).Findings:Review of policy 48 Hour Baseline Care Plan dated 10/18 sates .A baseline care plan will be created within 48 hours of admission ., the Care Plan will contain the following 6 key elements: initial goals based on admission orders, all physician orders, including medications and administration schedule; dietary orders, therapy services to be provided; social service needs' PASRR recommendations (if any).Resident #1 was admitted 4/26 and diagnosis to include atrial fibrillation. Heart failure and morbid obesity, which made him/her dependent on staff to meet his/her ADL needs.Review of Resident #1 active orders revealed order with start date of 4/14/26 for antiplatelet medication Eliquis 5 mg tablet 2 times daily.Review of Resident #1's care plan updated 5/13/26 lacked goals and interventions for the use of anticoagulant medications.Further review of Care plan states ADL: [Resident #1] requires (Specify): extensive/limited/supervision) assistance with self-care secondary to (Specify): __ AEB [Resident #1] inability to perform ADL's independently. GOAL: [Resident #1] will accept/receive assistance to complete daily tasks over the next 90 days. INTERVENTIONS: Mobility: [Specify]: (extensive/limited/supervision) assistance required with mobility: (Specify: Hoyer lift, 2 assist for transfers, etc.). Bathing/Grooming (Specify: extensive/limited/supervision) assistance required with bathing and grooming: (Specify: 1 person assist, 2 person assist, set up etc.). Dressing (Specify: extensive/limited/supervision) assistance required with dressing: (Specify: 1 person assist, 2 person assist, setup, etc.).Further review of Resident #1's care plan lacked goals and interventions in the areas of ADL were completed for this resident.During an interview on 6/25/26 at 12:31 p.m., the Director of Nursing (DON) stated that she completed and updated care plans. At this time DON reviewed Resident #1's care plan and confirmed it lacked goals and interventions for the use of anticoagulants, and ADLs.

Based on record reviews, interviews, and facility policy the facility failed to update/implement goals and interventions for use of foley catheter for 1 of 3 care plans reviewed during a complaint investigation (Resident #3).Findings: Review of facility policy Comprehensive Person-Centered Care Planning dated 1/19 states The facility must develop and implement a .care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and [NAME]/psychosocial needs Resident #3 was admitted 11/25. Observations of Resident #3 on 6/25/26 revealed he/she required use of a foley catheter, which was observed hooked to the bedframe and visible from the door. At this time Resident #3 states he/she has had a foley for quite some time. Review of Care plan, updated 6/9/26, lacked evidence that goals and interventions were put into place for the use of a foley catheter. During a review of Resident #3's care plan with Director of Nursing on 6/25/26 at 9:35 a.m. Director of Nursing confirmed above concerns.

Based on record review, interviews, and facility policy, the facility failed to monitor side effects of psychotropic medications for 1 of 3 residents reviewed during a complaint investigation (Resident #1).Findings:Review of facility policy Psychoactive Medication Use Policy dated 9/18 states A psychoactive drug is any medication affecting brain activity associated with mental processes and behavior. These include, but are not limited to, drugs in the following categories: anti-psychotic; anti-depressant, anti-anxiety, hypnotic. Target behavior documentation will be collected and documented on a daily basis; Side effect monitoring and documentation will be collected and documented on a daily basis. Psychoactive medications will only be used in conjunction with the Individual Care Plan . Resident #1 was admitted 4/16 for skilled care services and had diagnoses to include depression, bipolar disorder, and attention deficit hyperactive disorder.Review of Resident #1 clinical record revealed the following:-Order with start date of 4/14/26 for antidepressant Mirtazapine 30 mg tablet, one time daily.-Order with start date of 4/14/26 for antipsychotic Aripiprazole 15mg tablet, one time daily.-Order with start date 4/14/26 for antidepressant Trazodone 100 mg, one time daily. Review of Resident #1's entire clinical record lacked evidence he/she was being monitored for side effects or behaviors for use of these medications.During an interview on 6/25/26 at 10:25 a.m., Licensed Practical Nurse (LPN)#1 stated any resident on a psychotropic medication should be monitored for side effects and behaviors and it would be documented in the Electronic Clinical Record.During a review of Resident #1's clinical record on 6/25/26 at 12:31 p.m., The Director of Nursing stated that the facility should be monitoring for behaviors and side effects of psychotropic medications and at this time confirmed the above findings.

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 3 of 3 Units (Cortland, Northern Spy and [NAME]), the Therapy room, a common area, and the laundry room for 2 of 2 environmental tours (1/20/26 and 1/22/26).Findings: 1. On 1/20/26 at 10:56 a.m., 2 surveyors observed multiple cooking dishes stacked under the therapy room sink next to and below the drainpipe. At this time, in an interview with two surveyors present, a Certified Occupational Therapy Aide (COTA) confirmed the finding. On 1/20/26 at 11:15 a.m., in an interview with a surveyor, the Director of Nursing (DON) confirmed the cupboard contained dishes that were stored and stacked under and near to the therapy room sink drainpipe. 2. On 1/21/26 from 10:35 a.m. to 11:15 a.m., a surveyor conducted an Environmental tour with the Maintenance Director and the Director of Environmental Services in which the following findings were observed: Cortland Unit:- Resident rooms [ROOM NUMBERS] had privacy curtains that were missing hooks, hanging down and in disrepair. - Resident room [ROOM NUMBER] - The bathroom baseboard heater had chipped/missing paint and was rusty creating an uncleanable surface. The bathroom door protective surface was pulled away and coming off the door on the inside and outside of the door and the inside bottom of the door was chipped/gouged exposing unsealed wood. There was a wash basin on the floor the under sink. The toilet water fill line had a rusty escutcheon (the cap that covers the wall opening around the water line entrance). The room baseboard heater had chipped/missing paint and was rusty creating an uncleanable surface. - The hallway floor, at different locations throughout the hallway, had 7 chipped/broken floor tiles. - The Whirlpool room walls with chipped/missing paint and damaged sheetrock creating uncleanable surfaces. The floor linoleum was ripped/missing at the corner of the wall by the toilet and at the sink cabinet. Additionally, the linoleum was ripped/missing around the floor drain and seams in the middle of the floor had split and pulled apart. A ceiling light was rusty and the ceiling grid next to the light was rusty. The whirlpool tub was dirty, stained yellow and cracked throughout the tub. Additionally, the tub's water intake screen and water jets were soiled and stained. Northern Spy: - Resident room [ROOM NUMBER] had privacy curtains that were missing hooks, hanging down and in disrepair. - Resident room [ROOM NUMBER] - The bathroom ceiling tile, around a sprinkler head, was bubbled up and bent out of shape. - The hallway floor, at different locations throughout the hallway, had 32 chipped/broken floor tiles. [NAME] Unit:-6 cracked/broken floor tiles on [NAME] Unit-[NAME] shower room revealed chipped and missing paint on the walls. Common area:- The ceiling, near the nurse's station. had large brown stains on it. - The ramp, going downstairs, had a broken handrail. Laundry room:- The left clothes dryer had Velcro tape holding the bottom lint door on and had tape on the door glass. - A three-shelf laundry cart had ripped and hanging duct tape on the bottom shelf. On 1/21/26 at 11:15 a.m., in an interview with a surveyor, the Maintenance Director and the Director of Environmental Services confirmed the findings.

Based on record reviews and interviews, the facility failed to ensure a resident's care plan was developed and implemented to reflect the current needs of the resident for 2 of 14 residents reviewed for care planning (Residents #25, #28).Findings:1. Resident #25 was admitted with diagnoses to include presence of cardiac pacemaker.Review of Resident #25's clinical record revealed a provider progress note dated 11/11/25 that indicated, under active diagnoses, the presence of a cardiac pacemaker. Further record review revealed a nursing progress note dated 1/6/26 that states Attempted to do resident's pacemaker check-could not get machine to transfer data to the clinic, called the clinic back and informed them.A review of Resident #25's care plan lacked evidence that goals and interventions were developed and implemented for the pacemaker. On 1/21/26 at 3:05 p.m. during an interview, Registered Nurse (RN) #1 stated that Resident #25 has a pacemaker, and that it is monitored via a wireless device located in his/her room and that the facility receives reports from the cardiology clinic. RN #1 then stated that occasionally cardiology calls the facility and asks the nurse to reset Resident #25's device.On 1/22/26 at 10:18 a.m. during an interview, the surveyor discussed the above finding with the Director of Nursing (DON) and the Quality Improvement Specialist (QIS). At this time, the DON and QIS reviewed Resident #25's care plan and confirmed that it had not been developed or implemented in the area of the pacemaker. 2. Resident #28 has diagnoses to include intestinal obstruction, nausea with vomiting, and multiple abdominal surgeries.Review of Resident #28's clinical record revealed active physician orders for ambulate 4x [four times] daily to promote bowel function and Senna with Docusate Sodium 8.6 mg-50 mg tablet (2) TABLET Oral Two Times Daily Unspecified Intestinal obstruction Further review of Resident #28's clinical record revealed the following progress notes:A nursing progress note dated 12/4/25 that states, Resident c/o [complained of] abd [abdominal] pain, having loose, watery stools and hypoactive bowel sounds. Resident seen by [physician], order given to send to ER [Emergency Room].Resident transported via facility van.A nursing progress note dated 12/11/25 that states, Resident returned to facility at 11:30 via company wc [wheelchair] van, post small bowel obstruction.Abd remains firm and reports some pain.A nursing progress note dated 12/14/25 that states, Resident up to nurses station at 1830 [6:30 p.m.] reporting [his/her] 'belly is hard again' .Resident with distended, firm ABD [abdomen].sharp pain (5/10) comes and goes on top of constant feeling 'uncomfortable' and 'pressure'. Girth measured 114cm at this time., 110cm upon readmission [DATE]. On call contacted.NPO [nothing by mouth] tonight with water only, if resident becomes febrile and /or vomiting occurs, or increase in pain and resident unable to sleep may go to ER for evaluation.A provider History and Physical dated 12/15/25 that states, .Small bowel obstruction .Recurrent issue.was able to be managed conservatively at the hospital.feeling better, but still not at baseline .Facility to schedule GI [gastrointestinal] follow up .Resume bowel program .A review of Resident #28's care plan lacked evidence that goals and interventions were developed and implemented for the GI concerns.On 1/22/26 at 10:20 a.m. during an interview with the DON and QIS, the surveyor discussed the above finding. At this time, the DON reviewed Resident #28's clinical record, including his/her care plan, and confirmed the care plan lacked goals and interventions concerning Resident #28's recurrent GI concerns.

Based on observations, interviews, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to the storage of chemicals being properly secured and failed to ensure that a resident toilet was secured to the floor for 2 of 2 observations for 1 of 3 days of survey (1/20/26).Findings: 1. On 1/20/26 at 10:10 a.m., a surveyor observed in resident room [ROOM NUMBER] bathroom, the toilet was lose and not secured to the floor. On 1/20/26 at 10:20 a.m., in an interview with a surveyor, confirmed with the the Director of Nursing (DON) the toilet was not secure to the floor and an accident hazard. 2. On 1/20/26 at 10:56 a.m., two surveyors observed two - 1.13-ounce containers of Super Sani-Cloth Germicidal wipes, one - 25oz bottle of Rapid Multi-Surface Disinfectant Cleaner, and one - 8oz container of WD40 Multi-Use Product Aerosol stored in an unlocked cabinet with sink in the kitchenette in the therapy room. At this time, in an interview with a surveyor, confirmed with the Certified Occupational Therapy Aide (COTA) that there were chemicals stored in the unlocked cabinet and the sink is for therapy use and residents have access to the sink. The Safety Data Sheet for Super Sani-Cloth Germicidal wipes noted: 4. First-Aid measures:Inhalation - Remove to fresh air. If exposed or concerned: get medical advice/attention.Eye contact - Rinse immediately with plenty of water, also under the eyelids, for at least 15 minutes. Keep eyes wide open while rinsing. Do not rub affected area. Remove contact lenses, if present, after the first 5 minutes, then continue rinsing eye. Get medical attention if irritation develops and persists.Skin contact - Wash off immediately with soap and plenty of water while removing all contaminated clothes and shoes.Ingestion - Do not induce vomiting unless directed to do so by a medical professional. Clean mouth with water and drink plenty of water afterwards. Never give anything by mouth if victim is unconscious or is convulsing. Call a physician. The Safety Data Sheet for Rapid Multi Surface Disinfectant Cleaner noted: 4. First-Aid measures:In case of eye contact: Rinse immediately with plenty of water, also under the eyelids, for at least 15 minutes. Remove contact lenses, if present and easy to do. Continue rinsing. Get medical attention immediately.In case of skin contact: Wash off immediately with plenty of water for at least 15 minutes. Wash clothing before reuse. Thoroughly clean shoes before reuse. Get medical attention immediately.If swallowed: Rinse mouth with water. Do not induce vomiting. Never give anything by mouth to an unconscious person. Get medical attention immediately.If inhaled: Removed to fresh air. Treat symptomatically. Get medical attention. The Safety Data Sheet for WD40 Multi-Use Product Aerosol noted: 4. First-Aid measures:Ingestion (swallowed): Aspiration Hazard. Do not induce vomiting. Call physician, poison Control Center or the WD40 safety hotline immediately.Eye contact: Flush thoroughly with water. Remove contact lenses if present after the first 5 minutes and continue flushing for several more minutes. Get medical attention if irritation persists.Skin contact: Wash with soap and water. If irritation develops and persists, get medical attention.Inhalation (breathing): If irritation is experienced, move to fresh air. Get medical attention if irritation or other symptoms develop and persist.Signs and symptoms of exposure: Harmful or fatal if swallowed. Aspiration of liquid into the lungs during swallowing or vomiting may cause lung damage. May cause eye and respiratory inhalation. Inhalation of mists or vapors may cause drowsiness, dizziness, and other nervous system effects. Skin contact may cause drying of the skin. On 1/20/26 at 11:15 a.m., in an interview with a surveyor, confirmed with the DON that the unlocked therapy room cabinet contained hazardous chemicals that were accessible to residents.

Based on facility policy, observations, record reviews, and interviews, the facility failed to maintain a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 3 of 3 residents reviewed for respiratory care (Residents #1, #27, and #8).Findings 1. On 1/20/26 at 9:15 a.m. and on 1/21/26 at 8:55 a.m., observation of Resident #1's oxygen tubing dated 11/19/25 laying on the floor. On 1/21/26 at 9:10 a.m., In an interview and observation with a surveyor, the Director of Nursing (DON) observed and confirmed the above findings. 2. On 1//20/26 at 9:23 a.m. and on 1/21/26 at 8:58 a.m., observation of Resident #27's unlabeled and unbagged nebulizer tubing and mask on his/her bedside table. On 1/21/26 at 9:10 a.m., In an interview with a surveyor, the DON observed and confirmed the above findings. 3.On 1/20/26 at 11:43 a.m. and on 1/21/26 at 8:23 a.m. observed Resident #8's unbagged nebulizer mask and tubing lying on a shelf in his/her room. On 1/21/26 at 8:23 a.m. in an interview with a surveyor, Licensed Practical Nurse #2 observed and confirmed the nebulizer mask, and tubing was not bagged and should be. Facility Policy titled Oxygen Use and Storage under the section labeled Respiratory Care states; Nasal cannula's will be discarded and changed every 2 weeks.When the nasal cannula is not in use, on both the concentrator and portable tanks, the cannula will be placed in a plastic bag to avoid the risk of it becoming contaminated( i.e., touching the floor, etc ). Nebulizer parts should be rinsed after each use, allowed to air dry then placed in a respiratory set up bag once dried.

Based on observation and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a wall air conditioning unit, floors, and shelving. Further, the facility failed to ensure foods were discarded past their use by date, closed/sealed, and/or labeled and dated. In addition, the facility failed to ensure that plumbing fixtures were properly installed for an ice machine to prevent backflow as required by the Maine State Plumbing Code for 1 of 1 tour for 1 of 3 days of survey (1/20/26).Findings: On 1/20/26 from 8:05 a.m. to 8:35 a.m., a surveyor conducted an initial kitchen tour in which the following findings were observed:- The wall air conditioning unit, by the three-bay pot sink, was dusty/dirty.- There was dirt, trash and food debris on the floor underneath the equipment. - The bottom shelf, of the coffee pot table, had chipped/missing paint creating an uncleanable surface. - The small storage room, by the walk-in refrigerator, had one package of crackers that was not labeled and dated. Also, there was a previously opened package of vanilla shake supplement powder that was open to air and not sealed. - The small storage room, on the left as you enter the kitchen, had a container of thickened cranberry cocktail concentrate with a use by date of 12/11/25.- The drain lines for the ice machine were installed down in the drainpipe located next to the ice machine. The drain lines did not have the 1-inch air gap as required. The facility Food Storage policy/procedure noted: All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. The direct connection of wastewater and potable water was in violation of the 10-114 State of Maine Rules Chapter 226, definition Section A, which defines an Air-Gap Separation - A physical separation between the free-flowing discharge end of a potable water supply pipeline and an open or non-pressure receiving vessel. An air-gap separation shall be at least twice the diameter of the supply pipe measured vertically above the overflow rim of the vessel - in no case less than one-inch (2.54 cm) and the Code of Federal Regulation, Title 21, Part 1250, Section 1250, 30 (d) states all plumbing shall be so designed, installed, and maintained as to prevent contamination of the water supply, food, and food utensils. On 1/20/26 at 9:05 a.m., in an interview with a surveyor, the Administrator discussed and confirmed the findings.

Based on employee record reviews, interviews, and the Facility Assessment, the facility failed to develop, implement, and maintain an effective in-service training program by failing to ensure that a Certified Nursing Assistant (CNA) received the required dementia management training for 5 out of 5 randomly sampled CNA files (CNA #1, CNA #2, CNA #3, CNA #4, and CNA #5).Findings:A review of the Comprehensive Facility Assessment, updated August 2025, indicates the facility is licensed for 38 beds and under Section 2.4, that the facility commonly provides care to individuals with Alzheimer's Disease and Non-Alzheimer's Dementia and that the Number/Average or Range of Residents with Dementia is 12. Section 3.1 Resident support/care needs states, Specific Care or Practices.care of someone with cognitive impairment.On 1/22/26, five randomly sampled employee files were reviewed and revealed the following:1. CNA #1 was hired on 1/7/25. The employee file lacked evidence of dementia training.2. CNA #2 was hired on 1/14/25. The employee file lacked evidence of dementia training.3. CNA #3 was hired on 12/12/25. The employee file lacked evidence of dementia training.5. CNA #4 was hired on 7/23/25. The employee file lacked evidence of dementia training.6. CNA #5 was hired as contracted staff with an initial start date of 3/29/25, and a most recently renewed contract start date of 12/9/25. The employee file lacked evidence of dementia training.On 1/22/26 at 11:59 a.m., during an interview in the presence of 2 surveyors, the Business Office Manager confirmed that the above CNAs have not received dementia training. At this time, the Business Office Manager provided a copy of the facility's Mandatory Education Calendar, which indicates staff is not scheduled to receive Dementia Management training until August 2026.

Based on record review and interview, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each Minimum Data Set (MDS) assessment for 1 of 14 residents reviewed for care planning (Resident #28).Finding:Review of Resident #28's clinical record revealed an MDS Quarterly Assessment was completed on 12/17/25. Further review of Resident #28's clinical record lacked evidence that an IDT meeting was held within 7 days following the assessment.On 1/22/26 at 12:04 p.m., the above finding was discussed during an interview with the Social Services Director (LSW). At this time, the LSW stated that Resident #28's IDT meeting was held on 12/19/25. The surveyor requested evidence of the meeting, and the LSW stated she was off at the time and would request the meeting notes from the Director of Nursing (DNS). On 1/22/26 at 12:35 p.m. during a follow-up interview in the presence of 4 surveyors, the LSW confirmed that the facility did not have the meeting notes or evidence that an IDT meeting was held for the 12/17/25 assessment.

Based on record reviews and interviews, the facility failed to issue a written transfer/discharge notice and a bed hold notice to include cost of care to the legal representative for 2 of 4 sampled residents reviewed for transfer to an acute care hospital (Residents #4, #28).Findings:1. Resident #4 was admitted to the facility in January 2024.A review of Resident #4's clinical record indicated he/she was transported to an acute care hospital on [DATE]. Further review of the clinical record lacked evidence that Resident #4 and his/her representative received a written transfer/discharge notice and a written bed hold notice for the above date.2. Resident #28 was admitted to the facility in October 2022.A review of Resident #28's clinical record indicated he/she was transported to an acute care hospital on 4/2/25. Further review of the clinical record revealed the following nursing progress notes, indicating Resident #28 was again transported to an acute care hospital on 4/4/25 and was subsequently admitted : A nursing progress note dated 4/4/25 that states, Spoke with [Gastroenterologist] in regards to last ED [Emergency Department] visit.Was advised that resident return to ED for another evaluation.Resident is going to ED at [alternate ED] .transported by facility staff.A nursing progress note dated 4/4/25 that states, .left a voicemail that we received a call from [Gastroenterologist] and they wanted [Resident #28] back in the ED. As a team we decided to bring [him/her] to [alternate ED] as resident was just in [original ED] and they did not help [him/her].A nursing progress note dated 4/4/25 that states, Resident admitted to [acute care hospital] with Dx [diagnosis] of intestinal blockage.Additional record review indicated Resident #28 was transported to an acute care hospital on [DATE] and was subsequently admitted .Resident #28's clinical record lacked evidence that R2's representative received a written transfer/discharge notice and a written bed hold notice for the above dates.On 1/22/26 at 11:15 a.m. a surveyor discussed the above findings during an interview with the Licensed Social Worker (LSW). At this time, the LSW confirmed that she does not have evidence that the facility provided a written transfer notice and a written bed hold notice for Resident #4's transfer on 10/19/25 and Resident #28's transfers on 4/2/25, 4/4/25, and 12/4/25. The LSW then stated that Resident #28's transfer to the Emergency Department on 4/4/25 was a scheduled appointment, so the facility was not required to provide a transfer notice or a bed hold notice.

Based on observation and interview, the facility failed to post nurse staffing information on a daily basis for 1 of 3 days of survey (1/20/26).Finding:On 1/20/26 at 8:00 a.m., upon entering the facility, 4 surveyors observed the posted nurse staffing sheet dated 1/14/26, 6 days prior.On 1/22/26 at 8:22 a.m., the above finding was discussed with the Administrator. At this time, the Administrator stated that the Scheduler or the clinical team is responsible for posting the nurse staffing daily.On 1/22/26 at 9:47 a.m., during an interview, the Scheduler stated that since she started in August, she posts the nurse staffing information each weekday and that nursing posts the staffing on weekends. At this time, the surveyor discussed the above observation, and the scheduler stated that it was overlooked for those 6 days.

Based on observation and interview, the facility failed to insure all single resident rooms measured at least 100 square feet for 2 of 6 single resident rooms (#116 and #118).Findings: On 1/20/26 at 8:30 a.m., two surveyors observed rooms [ROOM NUMBERS] with a resident occupying each room. 1. A review of the Orchard Park Resident List (Census) indicated Resident #2 was residing in room [ROOM NUMBER], a single resident room. On 1/20/26 at 9:30 a.m., facility documentation noted that room [ROOM NUMBER] measured 93 square feet. At this time, a surveyor measured the room and measured 93 square feet. A surveyor requested documentation showing the facility had a variance for room [ROOM NUMBER]. 2. A review of the Orchard Park Resident List (Census) indicated Resident #2 was residing in room [ROOM NUMBER], a single resident room. On 1/20/26 at 9:30 a.m., facility documentation noted that room [ROOM NUMBER] measured 93 square feet. At this time, a surveyor measured the room and measured 93 square feet. A surveyor requested documentation showing the facility had a variance for room [ROOM NUMBER]. On 1/20/26 at 9:40 a.m., The surveyor observed the facility license and there was no waiver stated on the facility license. On 1/21/26 at 9:50 a.m., in an interview with a surveyor, the Administrator confirmed that the facility did not have variances for Resident Room # 116 and Resident room [ROOM NUMBER] for not having the required space of 100 square feet for a single resident room.

Based on record review, interview and review of the facility's internal investigation, the facility failed to ensure that 1 of 1 resident reviewed for dignity was provided care in a manner that maintained and respected his/her dignity. (Resident #1) The Division of Licensing and Certification received the facility reported incident regarding Resident #1 related to mistreatment on 8/4/25.Review of the facilities 5-day follow-up investigation dated 8/7/25 indicated that 8/4/25, Resident #1 was observed seated in a wheelchair wearing johnny pants that had been applied backwards, with the ties positioned in the back and secured in a double knot. The resident was also seated on a sheet that had been tied in front of him/her around the waist and secured in a double knot. On 8/27/25 at approximately 2:18 p.m., during a telephone interview with a surveyor, Certified Nurse's Assistant #6, (CNA) confirmed these actions, stating that he had tied a sheet around Resident #1's waist and secured it in a double knot as he/she was sitting in his/her wheelchair and applied johnny pants backwards, with the ties positioned in the back and secured in a double knot to deter Resident #1 from accessing his/her brief because he was unable to locate a belt. CNA #6 further explained that Resident #1 was noted to shred and remove her brief. CNA #6 confirmed these interventions were not included in Resident 1's plan of care and acknowledged that he had previously received training on abuse, neglect, restraints and resident rights. CNA #6 further stated he did not recognize his actions of applying the johnny pants backwards with the ties positioned in the back in a double knot and secured in a double knot as inappropriate and that this intervention had been explained to him during orientation to prevent the resident from shredding and removing his/her brief. The facilities investigation concluded that CNA #6's actions were considered abuse and use of a restraint even though there were no malicious intent. The facilities internal investigation through interviews and written statements determined that the residents' rights were violated when he/she was inappropriately tied with a sheet in a double knot and johnny pants were put backwards and secured with a double knot which restrained his/her ability to access his/her brief. All of which constituted resident abuse. CNA #6's contract was terminated immediately. The facility also immediately educated all staff on abuse, neglect, restraint, use, dignity and respect. On 8/26/25 at 1:00 p.m., during an exit interview with the Director of Nursing, (DON) the above findings were discussed, including concerns related to dignity, respect, abuse and restraint. The Director of Nursing acknowledged the findings and confirmed understanding of the cited concerns.

Based on record review, interviews and review of the facility's Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property policy, the facility failed to ensure that 1 of 1 resident reviewed was free from abuse when the resident was found with a sheet double knotted in front of her waist and a pair of johnny pants applied backwards with the ties double knotted behind him/her. (Resident #1) The Division of Licensing and Certification received the facility reported incident regarding Resident #1 related to mistreatment on 8/4/25.The facilities policy, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property indicates: It is the policy of this facility that each resident will be free from abuse. Abused can include verbal, mental, sexual or physical abuse, misappropriation of resident property and exploitation, corporal punishment, or involuntary seclusion. The resident will also be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the residents' medical symptoms. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. A. Abuse is defined as 483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm pain or mental anguish. Abuse also includes deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being, physical harm, pain or mental anguish. It includes verbal abuse. sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately not that the individual must have intended to inflict injury or harm. The facility policy further indicates the following: E. Convenience is defined as the result of any action that has the effect of altering a resident's behavior such that the resident requires a lesser amount of effort or care and is not in the resident's best interest. H. Freedom of movement means any change in place or position for the body or any part of the body that the person is physically able to control. N. Manual method means to hold or limit a resident's voluntary movement by using body contact as method of physical restraint. T. Physical restraint is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: Is attached or adjacent to the residence body, cannot be removed easily by the resident and restricts the resident's freedom of movement or normal access to his or her body. U. Removes easily means the manual method, physical or mechanical device, equipment or material can be removed intentionally by the resident in the same manner as it was applied.Review of the facilities 5-day follow-up investigation dated 8/7/25 indicated that 8/4/25, Resident #1 was observed seated in a wheelchair wearing johnny pants that had been applied backwards, with the ties positioned in the back and secured in a double knot. The resident was also seated on a sheet that had been tied in front of him/her around the waist and secured in a double knot. On 8/27/25 at approximately 2:18 p.m., during a telephone interview with a surveyor, Certified Nurse's Assistant #6, (CNA) confirmed these actions, stating that he had tied a sheet around Resident #1's waist and secured it in a double knot as he/she was sitting in his/her wheelchair and applied johnny pants backwards, with the ties positioned in the back and secured in a double knot to deter Resident #1 from accessing his/her brief because he was unable to locate a belt. CNA #6 further explained that Resident #1 was noted to shred and remove her brief. CNA #6 confirmed these interventions were not included in Resident 1's plan of care and acknowledged that he had previously received training on abuse, neglect, restraints and resident rights. CNA #6 further stated he did not recognize his actions of applying the johnny pants backwards with the ties positioned in the back in a double knot and secured in a double knot as inappropriate and that this intervention had been explained to him during orientation to prevent the resident from shredding and removing his/her brief. The facilities investigation concluded that CNA #6's actions were considered abuse and use of a restraint even though there were no malicious intent. The facilities internal investigation through interviews and written statements determined that the residents' rights were violated when he/she was inappropriately tied with a sheet in a double knot and johnny pants were put backwards and secured with a double knot which restrained his/her ability to access his/her brief. All of which constituted resident abuse. CNA #6's contract was terminated immediately. The facility also immediately educated all staff on abuse, neglect, restraint, use, dignity and respect. On 8/26/25 at 1:00 p.m., during an exit interview with the Director of Nursing, (DON) the above findings were discussed, including concerns related to dignity, respect, abuse and restraint. The Director of Nursing acknowledged the findings and confirmed understanding of the cited concerns.

Based on record review, interview, facility's internal investigation and Restraint Policy, the facility failed to ensure that 1 of 1 resident was free from the use of restraints. (Resident #1 The Division of Licensing and Certification received the facility reported incident regarding Resident #1 related to mistreatment on 8/4/25.Review of the facilities 5-day follow-up investigation dated 8/7/25 indicated that 8/4/25, Resident #1 was observed seated in a wheelchair wearing johnny pants that had been applied backwards, with the ties positioned in the back and secured in a double knot. The resident was also seated on a sheet that had been tied in front of him/her around the waist and secured in a double knot. The facilities restraint use policy indicates: The facility must ensure the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and are not required to treat the residents' medical symptoms. II. Procedure Examples of facility practices and meeting the definition of a physical restraint include but are not limited to: C. Tucking in a sheet tightly so the resident cannot get out of bed or fastening fabric or clothing, so a resident's freedom of movement is restricted. On 8/27/25 at approximately 2:18 p.m., during a telephone interview with a surveyor, Certified Nurse's Assistant #6, (CNA) confirmed these actions, stating that he had tied a sheet around Resident #1's waist and secured it in a double knot as he/she was sitting in his/her wheelchair and applied johnny pants backwards, with the ties positioned in the back and secured in a double knot to deter Resident #1 from accessing his/her brief because he was unable to locate a belt. CNA #6 further explained that Resident #1 was noted to shred and remove her brief. CNA #6 confirmed these interventions were not included in Resident 1's plan of care and acknowledged that he had previously received training on abuse, neglect, restraints and resident rights. CNA #6 further stated he did not recognize his actions of applying the johnny pants backwards with the ties positioned in the back in a double knot and secured in a double knot as inappropriate and that this intervention had been explained to him during orientation to prevent the resident from shredding and removing his/her brief. The facilities investigation concluded that CNA #6's actions were considered abuse and use of a restraint even though there were no malicious intent. The facilities internal investigation through interviews and written statements determined that the residents' rights were violated when he/she was inappropriately tied with a sheet in a double knot and johnny pants were put backwards and secured with a double knot which restrained his/her ability to access his/her brief. All of which constituted resident abuse. CNA #6's contract was terminated immediately. The facility also immediately educated all staff on abuse, neglect, restraint, use, dignity and respect. On 8/26/25 at 1:00 p.m., during an exit interview with the Director of Nursing, (DON) the above findings were discussed, including concerns related to dignity, respect, abuse and restraint. The Director of Nursing acknowledged the findings and confirmed understanding of the cited concerns.

Based on review of the facility's Infection Control Immunizations - Influenza, Pneumococcal, COVID and Employee Immunization/Vaccination Requirements policy and procedures and interviews the facility failed to develop and implement policy and procedure to ensure all staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine or information on obtaining COVID-19 vaccine. This has the potential to effect all employees. Findings: Review of the Infection Control Immunizations - Influenza, Pneumococcal, COVID policy, last revised on 12/24, and the Employee Immunization/Vaccination Requirements policy, last revised on 9/5/23 failed to include procedures relating to staff education regarding the benefits and potential risks associated with COVID-19 vaccine or information on obtaining COVID-19 vaccine. 1. On 12/10/24 at 2:38 p.m., during an interview, the Infection Preventionist confirmed that staff are not provided education regarding the benefits and potential risks associated with COVID-19 vaccine, stating, No, I haven't since last year, In addition, she confirmed that there is no information relating to COVID-19 in the new employee packet. 51331 2. On 12/11/24 at 7:50 a.m., during an interview with the Maintenance Director, he states that he has not recieved education on the COVID Spikevax within the past year. 3. On 12/11/24 at 7:55 a.m., during an interview with the Licensed Pratical Nurse, who states she has not received education on the COVID spikevax within the past year. 4. On 12/11/24 at 8:00 a.m., during an interview with the facilities [NAME] Clerk, she discussd that she has never received education on the COVID spikevax.

Based on observations and interviews, the facility failed to adequately maintain maintenance and housekeeping services necessary to maintain the facility in good repair and sanitary conditions for 3 of 3 units (Northern Spy, Cortland and [NAME]) and the laundry room for 1 of 1 environmental tour (12/11/24). Findings: 1. On 11/19/24, from 10:05 a.m. to 10:30 a.m., an environmental tour was conducted with the Administrator, the Maintenance Director and the Housekeeping Account Manager, in which the following findings were observed: - The shower room across her nursing station had a missing ceiling tile and a broken shelf which was missing laminate on the edge exposing bare wood. - -The whirlpool room had ripped/torn flooring at the corners of the sink cabinet and had a large split-apart seam in the middle of the floor which was full of dirt. The bottom edge of the sink cabinet was broke and missing laminate. The walls had chipped/missing paint and holes in them. - Resident room [ROOM NUMBER] - On 12/09/24 at 9:54 a.m., a surveyor tested the hot water and found it to be cool to the touch and at 86 degrees Fahrenheit (F). The surveyor let the water run until 10:00 a.m. and the water was still cool to the touch On 12/9/24 at 10:49 a.m., in an interview, the Maintenance Director stated that the furnace was acting up after being looked at a while ago. He stated that the water temperature fluctuates hot to cold. It never goes above 120 (F). - Resident room [ROOM NUMBER]- The baseboard heater had chipped/missing paint, was broken apart lying on the floor and in disrepair. The bathroom floor was soiled with dirt and the caulking around the base of the toilet was dirty. - Resident room [ROOM NUMBER] - The baseboard heater had chipped/missing paint and was rusting. The bathroom floor dirty around the edges. The caulking around the base of the toilet was dirty. The cold water faucet was broken and ran all the time. The toilet fill water line escutcheon was rusty. - Resident room [ROOM NUMBER] - The room walls were marked/marred with black marks. The baseboard heater was broken apart and rusty. - Resident room [ROOM NUMBER] - On 12/09/24 at 9:52 a.m., a surveyor tested the hot water. After running for 5 minutes the water was not over 100 (F). The baseboard heater in room had chipped/missing paint and was rusty. - Resident room [ROOM NUMBER] - Resident #16 Broda chair was dirty with dried foods. The baseboard heater was broken apart and had chipped/missing paint. The bathroom door had chipped/missing laminate on the bottom left corner creating an uncleanable surface. - Resident room [ROOM NUMBER] - The room walls were marked/marred with black marks and had chipped/missing paint exposing sheetrock and a metal corner. The paint was missing from above the baseboard heater exposing sheetrock and the heater was broken exposing fins and pipes. The bathroom had a dusty/dirty fan on the floor. - There was a broken hallway ceiling tile outside of resident room [ROOM NUMBER]. - Resident room [ROOM NUMBER] - The room walls were marked/marred with black marks and there was unpainted spackle behind and around the book shelf. There was missing paint above baseboard heater exposing sheetrock. - Resident room [ROOM NUMBER]- The bathroom baseboard heater had chipped/missing paint and was rusty. The room baseboard heater was broken, lying on the floor and in disrepair. - Therapy/Rehab Room - The floor is heavily soiled with dirt. - The Northern Spy Unit hallway floor had 35 cracked/broken floor tiles. - The laundry room wall air conditioning unit was dusty/dirty. 2 of the 3 dryers were not operational. #1 has been inoperable for 2 years and #3 broke down a week ago with no timeframe on getting it fixed. On 12/10/24 at 1:19 p.m., observation of laundry rooms with the Housekeeping Account Manager. Dryer #3 has sign do not use and the Housekeeping Account Manager stated laundry sometimes needs to be prioritized due to having one dryer. She stated Dryer #3 has been out of order since about last Friday. On 12/10/24 at 1:28 p.m., in an interview with the Maintenance Director, he stated Dryer #1 has been out of order for over 2 years. Dryer #3 drum is slightly off balance due to a bearing. He had a company come out for a quote but is now having [NAME] equipment come to take a look for a second opinion. A surveyor requested the initial quote and no quote was made available the surveyor. On 11/19/24 at 10:30 a.m., in an interview, the Administrator, the Maintenance Director and the Housekeeping Account Manager confirmed the findings. 51331 2. On 12/9/24 at 9:54 a.m. and on 12/10/24 at 10:12 a.m., observation of a strong smelling urine odor coming from Resident #21's room. On 12/10/24 at 10:20 a.m., during an interview, the above information was confirmed with the Director of Nursing (DON). The DON states that Resident #21's foley bag is frequently not screwed on all the way causing it leaks on the floor. The DON believes that the urine has absorbed into the flooring. When follow up question about what they are doing to counteract the odor, the DON states that housekeeping is cleaning the room daily but it is not helping. 3. On 12/9/24 at 9:45 a.m. and on12/10/24 at 10:12 a.m., observation of 2 wash basins on the bathroom floor, under the sink. On 12/10/24 at 10:27 a.m., the above information was confirmed with the DON.