Every finding on record at Pine Valley Center For Rehabilitation And Nursing

Based on observation and interview the facility did not ensure that food was stored in accordance with professional standards for food service safety. Specifically, twenty-five (25) food items were not properly identified and dated in the kitchen refrigerators, freezers, and food storage areas.Findings include:The facility policy titled Food Storage last revised May 2025, documented all containers must be legible and accurately labeled and dated. Food must be dated as it is placed on the shelves and left over food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before it is refrigerated. All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates. On 12/15/2025 at 9:40 AM, the initial inspection of the kitchen was conducted with the Food Service Director, and the following were observed:In the Meat Refrigerator: a five (5) lb. container of peeled garlic with no opened date, one (1) tray of cabbage-open to air in a container with no date prepared and no identification label, one (1) tray of chicken legs with no identification label. In the Meat Freezer: one (1) tray of ground chicken with no date prepared and no identification label and one (1) tray of cabbage open to air in a container with no date prepared and no identification label.In the Two Door Cooler: nine (9) cups of salad with no date prepared and no identification label, two (2) trays of juices with no identification label, two (2) opened bags of bread with no opened date, one (1) opened bag of Corn Flakes with no opened date and no identification label and one (1) pound block of butter opened with no opened date. In the Dairy Freezer: one (1) bag of carrots with no opened date, three (3) sandwiches with no identification label and one (1) container of apple sauce with no identification label.During an interview on 12/15/2025 at 10:01 AM, the Food Service Director stated they knew all items needed to be marked with dates opened and an identification of what the item was. They stated all food items that were not labeled correctly were opened or prepared during the weekend.During a follow-up interview on 12/22/2025 at 9:02 AM, the Food Service Director stated when food arrived at the facility, the food was to be properly labeled and dated. If food was removed from the original container, then the food item needed to be properly labeled and dated. They stated If a food item was opened, then the container must be labeled with an open date.10NYCRR 415.14(h)

Based on observation, record review, and interview the facility did not ensure each resident received care, consistent with professional standards of practice, to prevent and/or treat pressure ulcers for three (3) of eight (8) residents (Residents #59, #91 and #100) reviewed for Pressure Ulcers. Specifically, 1) heel offloading was not implemented as per physician order for Resident #59 who was assessed at risk for pressure ulcers 2) heel offloading was not implemented as per comprehensive care plan and physician order for Resident #91 who was assessed at risk for pressure ulcers and 3) heel offloading was not implemented as per physician order for Resident #100 who was assessed at risk for pressure ulcers.The findings include:A policy titled Pressure Ulcer Prevention and Intervention Program, updated 06/2025, documented residents of this facility will have a pressure sore prevention and intervention program to identify risk factors, prevent pressure sore and ulcer formation when avoidable and promote skin integrity, as well as interventions to heal existing pressure sores and ulcers and prevent new sores from developing.1) Resident #59's diagnoses included hypertensive heart disease, unspecified sequelae of cerebral infarction, and spastic hemiplegia affecting the right non -dominant side. The physician order dated 10/01/2022 documented heels offloaded The current care plan titled At Risk for Impairment of Skin Integrity did not include an intervention to address offloading the heels. A quarterly Minimum Data Set (a resident assessment tool) dated 10/21/2025 documented Resident #59 had severe cognitive impairment, did not reject cares, had impairments on both upper and lower extremities, was dependent for all cares and was at risk for pressure ulcers.During observations on 12/15/2025 at 3:38 PM, 12/16/2026 at 10:15 AM, 12/16/2025 at 12:50 PM, 12/17/2025 at 9:29 AM, 12/17/2025 at 12:53 PM, 12/18/2025 at 9:05 AM and 12/19/2025 at 9:56 AM Resident #59 was in bed lying on their back. Resident #59's heels were not offloaded and were resting on the mattress. No pillows were in place to assist with offloading heels. During an interview on 12/18/2025 at 9:20, Certified Nurse Aide #7 stated Resident #59 was dependent with activities of daily living. They stated they were not aware that Resident #59's bilateral heels should be offloaded. They stated Resident 59's heels did not have wounds, therefore did not need to be offloaded. During an interview on 12/18/2025 at 9:45 AM, Registered Nurse Unit Manager #6 stated Resident #59 did not have heel wounds. After checking the electronic medical record, they stated there was a physician order to offload the resident's heels. Registered Nurse Unit Manager #6 stated it was difficult to offload the heels because Resident #59 moved their feet frequently. They stated certified nurse aides and nurses were responsible for ensuring heels were offloaded. They stated they completed spot checks on unit residents to ensure heels were offloaded if ordered by physician. They stated they were not sure if they checked Resident #59 during this week.2) Resident #91's diagnoses included unspecified sequelae of cerebral infarction, anxiety disorder, and unspecified dementia with other behavioral disorder.An annual comprehensive Minimum Data Set (a resident assessment tool) dated 11/24/2025 documented Resident #91 had severe cognitive impairment, no rejection of cares, was dependent for activities of daily living and at risk for pressure ulcers. A resident care plan titled Impaired Activities of Daily Living documented turn and position and encourage to elevate heels in bed. A physician order dated 02/10/2025 documented turn and reposition and heels offloaded.During observations on 12/15/2025 at 10:27 AM, 12/16/2025 at 9:58 AM, and 12/17/2025 at 9:45 AM, Resident #91 was in bed with their bilateral heels resting on the mattress. The heels were not offloaded. During an interview on 12/18/2025 at 11:00 AM, Licensed Practical Nurse #9 stated Resident #91's bilateral heels should be offloaded while in bed during the day. They stated certified nurse aides or nurses were responsible for offloading heels and ensuring they were not resting on the mattress. During an interview on 12/18/2025 at 11:32 AM, Registered Nurse Supervisor #4 stated all residents who have an order for heels to be offloaded, should be offloaded. They stated unit nurses/unit manager/supervisor should be supervising certified nurse aides to ensure resident's heels were offloaded. 3) Resident # 100's diagnoses included hemiplegia and hemiparesis, heart failure, and atrial fibrillation. A physician order dated 01/02/2025 documented turn and reposition, heels offloaded, and air mattressThe quarterly Minimum Data Set (a resident assessment tool) dated 10/09/2025 documented Resident #100 had severe cognitive impairment, required substantial/maximal assistance for bed mobility, was dependent for transfers and was at risk for pressure ulcersA resident care plan titled At Risk for Skin Impairment dated 10/23/2025 documented turn and reposition every two (2) hours, weekly skin checks, and protective skin care every shift and as needed. There was no care plan intervention to offload heels as per physician order. During observations on 12/16/2025 at 9:30 AM, 12/16/2025 at 12:37 PM Resident #100 was observed in bed lying on their back. The bilateral bare feet were resting on the mattress and were not offloaded. During an interview on 12/18/2025 at 11:10 AM. Licensed Practical Nurse #9 stated Resident 100's bilateral heels should be offloaded when in bed. During an interview on 12/22/2025 at 3:18 PM, the Director of Nursing stated Resident heels should be offloaded when there was a physician order or care plan intervention. 10NYCRR 415.12(c)(1)

Based on observation, interview, and record review the facility did not ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for four (4) of six (6) residents (Residents #50, #34, #59, and #91) reviewed for Positioning and Mobility. Specifically, 1) the use of carrot splints was not implemented as per physician order and care plan for Resident #50 with contractures (fingers bent into the palms) of both hands, 2) the use of a left- hand roll brace was not implemented as per physician order for Resident #34, and 3) the use of a right resting hand splint was not implemented as per physician order for Resident #59. Additionally, the use of a left-hand carrot was not implemented as per physician order for Resident #91. The findings include: The policy and procedure titled Contracture Management revised 09/21/2025 documented prevent the decrease in range of motion, maintain skin and joint integrity, and optimize functional abilities. Minimize all potential contractures when possible and minimize further loss of range of motion in existing contractures with the use of splints and /or orthotics and/or positioning devices to supports as tolerated. 1). Resident # 50 was admitted with diagnoses including Alzheimer's, dementia, and depression. The quarterly Minimum Data Set (an assessment tool) dated 09/24/2025 documented Resident #50 had severe cognitive impairment. The 06/20/2025 Activities of Daily Living/Mobility care plan documented range of motion to both upper extremities with morning and evening care, and application of splints. The 06/20/2025 occupational therapy evaluation documented Resident #50 had contractures of both hands and recommended bilateral carrot splints to be always worn except during hygiene, skin checks, bathing, and range of motion exercises. The 6/22/2025 physician order documented carrot splints for both hands remove for hygiene, skin checks, bathing, and range of motion exercises. During an observation on 12/15/2025 at 11:17 AM, Resident #50 was sitting in a Geri-chair with contractures to both hands. The carrot splints were resting on the resident's chest and not on their hands. During an observation on 12/16/2025 at 8:06 AM, Resident #50 was sleeping in bed with the left carrot splint off. The carrot splint was resting on the sheets in the resident's bed. During an observation on 12/17/2025 at 8:46 AM, Resident #50 was in bed while Certified Nurse Aide #17 fed them breakfast. Resident 50's hands were contracted. The carrot splints were resting on top of the resident's bedside chest. During an observation on 12/17/2025 at 11:11 AM, Resident #50 was sitting in a Geri-chair with the left-hand clenched and without the use of the carrot splint. During an observation/interview on 12/17/2025 at 1:04 PM, Resident #50 was sitting in a Geri-chair and Certified Nurse Aide #18 assisted them with their lunch. Resident #50 did not have carrot splints in use. During an interview on 12/17/2025 at 1:10 PM, Registered Nurse Manager #6 stated there were no physician orders for the use of carrot splints in the medication and/or treatment administration records and there was no care plan in place for the use of splints. Registered Nurse Manager #6 stated certified nurse aides or nurses were responsible for placing the splints on the residents. During a follow-up observation/interview on 12/17/2025 at 1:17 PM, Certified Nurse Aide #18 logged on to the kiosk, and stated there was documentation that carrot splints were placed on Resident #50 hands. Certified Nurse Aide #18 stated the resident was not wearing the splints, they found them in the resident's Geri-chair. During an interview on 12/17/2025 at 3:51 PM, the Director of Rehabilitation stated that the splints were to be used for severe contractures. The Director of Rehabilitation stated the carrot splints helped to keep the fingers from further flexing and prevented the nails from digging into the resident's palm. 2) Resident # 34's had diagnoses including contracture of the left wrist and spastic hemiplegia. A physician order dated 11/06/2024 documented left-hand roll. Remove for hygiene/skin checks/range of motion. A care plan titled Impaired Activities of Daily Living dated 02/12/2025 documented splint/brace, refer to physician order for details and equipment/devices when out of bed. The Quarterly Minimum Data Set, dated [DATE] documented Resident #34 was cognitively intact, had a left sided contracture, no rejection of cares, and received supervision for activities of daily living. During an observation and interview with Resident #34 on 12/15/2025 at 3:31 PM. Resident # 23 had a left-hand contracture and was without the use of a left-hand roll brace. Resident #34 stated the hand roll brace was present in their drawer. Resident #34 stated they were not aware why staff was not placing the hand roll brace daily. They stated they did not ask staff to apply the hand roll brace when it was not applied. Resident #34 stated they could not apply or remove the hand roll brace independently. During an observation on 12/16/2025 at 9:07 AM, 12/16/2025 at 12:51 PM, 12/17/2025 at 9:30 AM and 12/17/2025 at 12:59 PM Resident #34 was sitting in a wheelchair. A left-hand roll brace was not in place. During an interview with Certified Nurse Aide #7 they stated Resident #34 had a left-hand contracture, but they were not aware if Resident #34 wore a brace. Certified Nurse Aide #7 stated they did not recently place a brace on Resident #34 and did not discuss brace use with the unit nursing staff. During an interview on 12/18/2025 at 9:53 AM, Registered Nurse Unit Manager #6 stated Resident #34 had a physician order for a hand roll device on the left hand and they believed Resident #34 wore the brace all week. Registered Nurse Unit Manager #6 stated they provided spot checks on the unit to ensure residents wore the ordered devices. They stated they were not sure if they provided a spot check for Resident #34. During an interview on 12/22/2025 at 9:12 AM, the Director of Rehabilitation stated Resident #34 had a physician order for a left-hand roll brace to be worn during waking hours and nursing staff was responsible for applying the device daily. The Director of Rehabilitation stated they were not aware why the brace was not in place. They stated if there were concerns regarding a resident not wanting to wear a brace or if a brace was missing, nursing should enter a rehabilitation referral for evaluation. 3) Resident # 59 had diagnoses including unspecified sequelae of cerebral infarction and spastic hemiplegia affecting the right non- dominant side. A physician order dated 10/28/2022 documented right resting hand splint. Remove for sleep, hygiene and range of motion. Check skin every four (4) hours. 8:00 AM on and 8:00 PM off. A care plan titled Contractures updated 2/12/2024 documented refer to physician orders for detail. A quarterly Minimum Data Set (a resident assessment tool) dated 10/21/2025 documented Resident #59 had severe cognitive impairment, did not reject cares, had impairments on both sides upper and lower, and was dependent for all cares and movement. During an observation on 12/15/2025 at 3:38 PM, Resident #59's right-hand was contracted and without the use of a resting hand splint. During an observation on 12/16/2025 at 10:11 AM, 12/16/2025 at 12:48 PM, 12/17/2025 at 9:29 AM, and 12/17/2025 at 12:53 PM Resident #59 was in bed, without the use of a right resting hand splint. During an interview on 12/18/2025 at 9:20 AM, Certified Nurse Aide #7 stated Resident #59 did not have a brace/splint. They stated they did not place a brace on Resident #59 while providing cares. Certified Nurse Aide #7 stated they did not check the electronic medical record to confirm if Resident #59 required a right-hand splint/brace due to not being good with computers. They stated they did not discuss a right-hand splint/brace with unit nursing staff. During an interview and observation on 12/18/2025 at 9:36 AM, Licensed Practical Nurse #5 stated Resident #59 had a right-hand contracture. They stated they were not aware if Resident #59 wore a splint. During an interview on 12/18/2025 at 9:45 AM Registered Nurse Unit Manager #6 stated Resident #59 had a right-hand contracture and wore a splint daily from 8:00 AM to 8:00 PM. They stated they applied the right-hand splint this morning but did not apply the splint earlier in the week. They stated they were not aware if Resident #59 had the right-hand splint on earlier in the week. They stated they were not sure if they completed spot checks on Resident #59 to confirm if the splint was in place. They stated nursing staff were responsible for applying the right-hand splint each morning. During an interview on 12/22/2025 at 9:12 AM, the Director of Rehabilitation stated Resident #59 should have a right-hand splint on during waking hours daily. They stated they did not receive communication from unit staff regarding resident #59 not wearing the brace. 10NYCRR 415.12 (e)(2)

Based on observation, Interview, and record review the facility did not ensure they developed and/or implemented a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's needs for one (1) of five (5) residents (Resident #13) reviewed for Environment. Specifically, a care plan was not developed and/or implemented to address Resident #13's known hoarding behavior.The findings include:Resident #13 had diagnoses of chronic kidney disease and malignant neoplasm of the cervix.The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #13 was cognitively intact and did not display any inappropriate behavior.The Comprehensive Care Plan related to behavior initiated 10/15/2025 documented Resident #13 had episodes of refusing to go for dialysis treatment.There was no documented evidence a behavior care plan was developed to address Resident #13's hoarding behavior.On 12/16/2025 at 11:57 AM and 12/18/2025 at 3:45 PM, Resident #13's room was observed with six large clear plastic bags containing an assortment of clothing. The plastic bags were arranged on the periphery of Resident #13's rooms and were piled on top of each other on chairs blocking access to the sink, bathroom, and windows in the resident's room. There were several large plastic storage bins on two wire shelves against the wall on the far side of room from the doorway. Resident #13 was interviewed during the observation and stated they were unable to put their clothing away and organize their belongings. Resident #13 stated staff used to help them to go through their belongings. They stated they did not trust staff to put it away for them. On 12/19/2025 at 11:27 AM, the Case Manager was interviewed and stated Resident #13 had hoarding tendencies and did not allow anyone to touch the clothing in their room. Staff have attempted to clean out Resident #13's room. The former Director of Nursing had a set schedule and would regularly work with Resident #13 to remove extraneous items to prevent overcrowding in the room. They stated no other staff member has been assigned since the Director of Nursing left and there was no set schedule to help Resident #13 clean out their room. The Case Manager reviewed Resident #13's medical record and stated there was no care plan to address Resident #13's hoarding behavior and there was no system in place to prevent Resident #13's hoarding behaviors from increasing. On 12/22/2025 at 1:38 PM, the Director of Nursing was interviewed and stated it was tricky to address Resident #13's hoarding behavior and try to organize or discard extraneous items in their room. They stated Resident #13 did have a noncompliance care plan in place. If there was anything unsafe, the Director of Nursing stated staff would remove it from Resident #13's room. 10 NYCRR 415.12

Based on interviews and record review the facility did not ensure the residents' Minimum Data Set assessments were completed not less frequently than once every three (3) months for one (1) of two (2) residents (Resident #44) reviewed for Resident Assessment. Specifically, a quarterly Minimum Data Set assessment was not completed three (3) months after the completion of the 06/28/2025 annual Minimum Data Set for Resident #44.The findings includeAn undated facility policy titled Comprehensive Assessment documented the Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments at least quarterly.Resident #44's diagnoses included obstructive uropathy, unstageable pressure ulcer of sacral region and adult failure to thrive. An annual Minimum Data Set (a resident assessment tool) dated 06/28/2025 documented Resident #44 had severe cognitive impairment, was dependent for activities of daily living, and had one pressure ulcer. There was no documented evidence of a September/October 2025 quarterly Minimum Data Set.During an interview on 12/19/2025 at 11:14 AM Minimum Data Set Coordinator #3 stated Resident #44 had an annual comprehensive Minimum Data Set completed on 06/28/2025 and a quarterly Minimum Data Set should have been completed in September or October 2025. NY CRR 415.11(a)(4)

Based on observation and interview the facility did not ensure drugs and biologicals were maintained in accordance with currently accepted professional standards for storage. Specifically, the Three East High Side medication cart was found unattended in the unit corridor near the nursing station unlocked with one (1) drawer left open.The findings are:The policy titled Medication Storage dated May 2025, documented nursing staff shall be responsible for maintaining medication storage, and compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals shall be locked when not in use.During an observation on 12/18/2025 at 4:00 PM, the Three East High Side medication cart was found unattended in the unit corridor near the nursing station unlocked with one (1) drawer left open. The medication carts assigned nurse, Licensed Practical Nurse #20 was not near the cart, not within eyesight of the cart and was in the unit's medication room behind a closed door. During an interview on 12/18/2025 at 4:09 PM, Licensed Practical Nurse #20 stated they knew the cart was supposed to be locked to prevent any resident or other nurse from having access to the medications.10 NYCRR 415.18

Based on observation, interview, and record review the facility did not ensure the resident plan of care was reviewed and revised for one (1) of three (3) residents (Resident #13) reviewed for Rehabilitation Services. Specifically, Resident #13 had a care plan intervention for bilateral siderail enablers and was observed without enablers in place. Resident #13 had diagnoses of chronic kidney disease and malignant neoplasm of the cervix.The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #13 was cognitively intact and was independent in rolling to the left and right in bed.The Comprehensive Care Plan related to activities of daily living performance and physical mobility dated 08/28/2025 and last reviewed 09/10/2025 documented Resident #13 used top bilateral bed rails for rolling to the left and right in bed, bed mobility, and transfers from bed. The Comprehensive Care Plan related to impaired mobility dated 08/28/2025 documented Resident #13 was provided with bilateral 1/2 siderails to promote and assist with bed mobility. Nursing Bed Rail/Grab Bar assessment dated [DATE] documented Resident #13 needed a bedrail to increase independence with bed mobility and transfers in and out of bed.The Physician Order an order for Resident #13 to have siderails was initiated 08/27/2025 and discontinued on 12/10/2025.On 12/16/2025 at 11:57 AM, Resident #13 was interviewed and stated they used to have siderails on their bed to move more easily in bed. Resident #13 stated their siderails were removed and they did not know the reason.On 12/19/2025 at 12:50 PM, the Director of Rehabilitation was interviewed and stated the latest rehabilitation evaluation determined Resident #13 should have bilateral bedrail enablers in bed for mobility. The Director of Rehabilitation stated nursing was also responsible for conducting a safety assessment of Resident #13 to determine whether bedrails were appropriate. The Director of Rehabilitation checked the medical record and stated the last nursing assessment for bedrails was in 09/2025 and documented Resident #13 should have siderails. The Director of Rehabilitation stated they did not know why Resident #13's bedrails were removed and would need to communicate with the Nursing Department.On 12/22/2025 at 11:09 AM, Licensed Practical Nurse #11 was interviewed and stated they were responsible for updating resident care plans and Resident #13's care plan intervention for bedrails may not have been updated to reflect the resident's most recent bed mobility status.On 12/22/2025 at 1:38 PM, the Director of Nursing was interviewed and stated Resident #13 previously used bedrails for bed mobility but no longer was safe using them and the order for bedrails was discontinued. 10 NYCRR 415.11(c)(2)(i-iii)

Based on record review and interview conducted during the recertification survey from 12/15/2025 to 12/22/2024, the facility did not ensure that Minimum Data Set 3.0 Assessments accurately reflected the residents' status for one (1) of seven (7) residents reviewed for Accidents. Specifically, the Minimum Data Set 3.0 annual comprehensive assessment did not identify Resident #9 as an active smoker.The findings included:An undated facility policy titled Comprehensive Assessment documented information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning. Resident #9's diagnoses included nicotine dependence, unspecified paraplegia and bipolar disorder. The Resident Smoking Contract was signed and dated on 12/05/2024.The care plan updated 08/24/2025 documented monitor compliance with smoking contract, resident would be directed to designated smoking area and smoking screen to determine safety.The Annual Comprehensive Minimum Data Set (a resident assessment tool) dated 10/22/2025 documented Resident #9 was cognitively intact. The Minimum Data Set was not coded to indicate Resident #9 was an active smoker at the time of assessment.During an interview on 12/15/2025 at 12:10 PM Resident #9 stated they were an active smoker and had signed a smoking contract with the facilityDuring an interview and observation on 12/19/2025 at 11:06 AM, Minimum Data Set Coordinator #3 stated they completed the annual comprehensive Minimum Data Set assessment on 10/22/2025. They stated Resident #9 was coded as a non-smoker. They stated this was an oversight and Resident #9 should have been coded as a smoker. They stated they would modify the assessment.10NYCRR 415.11(c)(1)

Based on interview and record review conducted during the abbreviated survey (2626453), the facility did not ensure all alleged violations of abuse were reported immediately, but not later than two (2) hours to the New York State Department of Health for one (1) of three (3) residents reviewed for abuse (Resident #1). Specifically, on 9/23/2025 at approximately 2:00 PM Resident #1's family member reported that Resident #1 alleged sexual abuse, and the allegation was not reported to the New York State Department of Health until 9/24/2025 at 11:18 AM. The 10/10/2024 facility policy titled Abuse Prevention Policy and Procedure, documented it is the responsibility of all facility employees, consultants, visitors, family members and physicians to immediately report any incident or suspected incident of resident abuse, neglect, mistreatment, exploitation, misappropriation of resident property or any resident injury of unknown origin. All alleged violations involving abuse neglect exploitation or mistreatment including injuries of unknown origin and misappropriation of resident property must be reported immediately but no later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury to the administrator of the facility and to the New York State Department of Health. Resident #1 had diagnoses which included anxiety disorder, depression, and hypertension.The 7/15/25 Minimum Data Set Comprehensive admission Assessment documented the resident had intact cognition and physical and behavioral symptoms directed toward others which significantly intruded on the privacy or activity of others and put the resident at significant risk for physical illness or injury and significantly interfered with the resident's care. The resident required substantial assistance with showers/bathing.The 9/23/25 facility Incident Report documented that on 9/23/2025 at 2:00 PM, Resident #1's family member reported that Resident #1 made an allegation of sexual abuse. The Webform Submission Nursing Home Facility Incident Report documented the allegation of sexual abuse was submitted to the New York State Department of Health on 9/24/2025 at 11:18 AM. On 10/06/2025 at 10:34 AM during an interview, the Director of Nursing stated that on 9/23/2025 around 2:00 PM, the Director of Activities reported that Resident #1's family member reported Resident #1's allegation of sexual abuse. The Director of Nursing stated they did not report the allegation to the New York State Department of Health until 9/24/2025 at 11:18 AM because the allegation was vague and confusing, and the resident had a history of accusations, and the facility completed an internal investigation within two (2) hours and concluded that abuse did not occur. On 10/6/2025 at 2:10 PM during an interview, the facility Administrator stated they are aware that allegations of abuse should be reported within two (2) hours, however if the allegation is confusing or if the resident is confused, they want to do an internal investigation first to assure the allegation needs to be reported to the New York State Department of Health, and if they believe abuse may have occurred they would report within two (2) hours. 10 NYCRR 415.4(b)(2)

Based on observation, record review and staff interviews conducted during an abbreviated (NY00351353, NY00361070) survey the facility did not ensure infection control practices to prevent the development and transmission of communicable disease and infection were maintained for 2(Resident #1, Resident #6) of 3 residents reviewed. Specifically,1) Resident #1 was on enhanced precautions, Certified Nursing Assistant #7 and Licensed Practical Nurse #9 were not wearing gowns when they transferred Resident #1 from the bed-chair via Hoyer-lift and Licensed Practical Nurse #9 was not wearing a gown when they stopped Resident #1's G-Tube feeding, clamped the tubing and closed the feeding tube cap. Additionally, during a review of videos Certified Nursing Assistant #1 and #4 and Resident Assistant #2 and #3 were not wearing a gown while assisting Resident # 1 with a bed bath, changing clothes and emptying Resident #1's Foley catheter. 2) for Resident # 6 on enhanced barrier precautions Certified Nursing Assistant #6 and #8 and Resident Assistant # 15 were observed not wearing a gown while transferring Resident # 6 via Hoyer-lift. The Findings are: The undated Infection Prevention and Control Policy documented provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections to the extent possible. The policy documented the use of (personal protective equipment) beyond situations in which exposure to blood and body fluids is anticipated, refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multi-Drug resistant Organisms to staff hands and clothing. 1)Resident #1 was readmitted with diagnoses including Cerebral Vascular Accident, Hemiplegia, and impairment to both upper and lower extremities. The 3/1/24 Physician Order documented enhanced barrier precautions: Other: Wound, G-Tube, Foley. The 8/27/24 Care Plan titled Enhanced Precaution due to Tube Feeding documented continue with enhanced precautions. The 9/8/24 Quarterly Minimum Data Set, (an assessment tool) documented Resident # 1 had severely impaired cognition, was dependent on staff for all activities of daily living, had a Foley catheter, a stage IV wound on their sacrum and had a feeding tube. During observation on 11/25/24 at 9:25am and 9:30am Certified Nursing Assistant #7 and Licensed Practical Nurse #9 were not wearing gowns while using a Hoyer lift to transfer Resident #1 from their bed to the chair. During observation on 11/25/24 at 12:35pm Licensed Practical Nurse #9 was not wearing a gown when they stopped Resident #1's G-Tube feeding, clamped the tubing and closed the feeding tube cap. During interview on 11/27/24 at 10:21am Licensed Practical Nurse #9 stated a gown was not needed when transferring Resident #1 from the bed to chair via Hoyer-lift. Licensed Practical Nurse #9 stated when reading the precaution sign on the resident door, they made a mistake by not wearing a gown when transferring Resident #1. Review of 11/25/24 video review provided by the facility revealed the following: Video #1 dated 10/31/24 time stamped 8:03:04 Certified Nursing Assistant #1 removed Resident #1's gown and provided a bed bath. Certified Nursing Assistant #1 wiped Resident #1's face, Certified Nursing Assistant #1 was not wearing a gown while providing cares which included leaning over the resident. Video #2 was undated/timed, Certified Nursing Assistant #1 pulled up Resident #1 in the bed and their clothing and arms touched Resident #1's body. Certified Nursing Assistant #1 pulled Resident #1's upper body/head to adjust the resident in the bed. Certified Nursing Assistant #1 was not wearing a gown. Video # 3 dated 11/04/24 08:07:58 Certified Nursing Assistant #1 and Resident Assistant #2 were in Resident #1's room. Resident#1 was lying in bed wearing an incontinent brief and both staff were working together to dress Resident #1. Certified Nursing Assistant #1 emptied Resident #1's Foley catheter. Certified Nursing Assistant #1 and Resident Assistant #2 were not wearing gowns. Staff clothing touched the resident on multiple occasions. Unable to contact Certified Nursing Assistant #1/Resident Assistant # 2 despite repeated attempts. During interview on 11/27/24 at 2:37pm Certified Nursing Assistant # 7 stated they had a gown on when they were washing Resident # 1 but had taken the gown off because they were not aware they needed a gown when transferring a resident via Hoyer-lift. 2) Resident #6 was admitted with diagnoses including but not limited to Peripheral Vascular Disease, Obstructive Uropathy, and Neurological-Paraplegia. The 10/30/24 Comprehensive Minimum Data Set Assessment documented Resident #6 was cognitively intact and had a urinary catheter. The 1/2/24 Physician Order documented enhanced barrier precaution: wound, foley. During observation on 11/25/24 at 12:44pm Resident #6's door had an enhanced barrier precautions sign. Resident Assistant #15, Certified Nursing Assistant #6 and #8 transferred Resident #6 from the bed to chair. None of the staff were wearing a gown. 10 NYCRR # 415.19

Based on staff interviews and review of facility documentation conducted during an abbreviated (NY00361070, NY00351353) survey, it was determined that the facility did not ensure that a performance review of every nurse aide was completed at least once every 12 months, and that each nurse aide, based on the outcome of the performance reviews, received no less than twelve hours of in-service education per year. This was evident for 2 of 2 Certified Nursing Assistants (nurse aides) reviewed for completion of performance review and in-service education. Specifically, the facility did not ensure that Certified Nursing Assistant #1 & Certified Nursing Assistant #4 had a performance review at least once every 12 months and based on their individual performance review receive no less than twelve hours of in-service education per year. Findings Surveyor requested the facility administrator to provide the 2 Certified Nursing Assistant files including their performance reviews and their in-service education. Review of the documents revealed the following: Certified Nursing Assistant #1 had an orientation checklist dated 10/8/2014. Certified Nursing Assistant #1 had a record indicating that there was a history of verbal counseling's that occurred in the year 2024, one dated May 7th, 2024, for failure to document, one dated September 3rd for improper break time and one dated October 7th for failure to document PO intake for 7 days. In Certified Nursing Assistant #1's employment file there are 2 performance evaluations, the last one is dated May 4th, 2021. There are 9 in-services listed as having been attended by Certified Nursing Assistant #1 and no indication that these in-services would be equal to the required 12 hours of in-service education that is required. Certified Nursing Assistant #4 had a hire date of January 29th 2015. There is no orientation checklist. There are 3 warning notices in their file, 2 that occurred in 2017, it does not indicate that they were verbal. One was for a failure to keep bed linen clean, and the other was for a failure to notify a nurse of a resident need situation. In 2018 Certified Nursing Assistant #4 has a warning notice dated May 18th, that stated leave resident unattended in a bathroom, resident found sitting on the floor. The only performance review on file is dated July 6th 2017, and there are only 3 in-services shown in the file one is on abuse dated January 14th 2015, another one is July 2024 for change in condition and one in August 2014 for fall prevention. 10NYCRR 415.26

Based on interviews, observations and record review conducted during an abbreviated (NY00361070) survey, the facility did not report incidents of staff to resident abuse to local law enforcement. This was evident for 1 (Resident #1) of 3 residents reviewed for abuse. Specifically, Certified Nursing Assistant #1, Certified Nursing Assistant #4, Resident Assistant #2, and Resident Assistant #3 are seen in video footage using more force than necessary to provide care to Resident #1, and those incidents were not reported to local law enforcement. As evidenced by: The facility Policy for abuse has no date, as well as no indication of ever having any updates or reviews it is also noted to not be on any official letterhead. The Policy is written as follows, The Purpose of the Abuse Prevention Program is to ensure a safe, respectful, and dignified environment for all residents. The Policy defines abuse and lists various types of abuse, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish. There is also a definition for mistreatment the inappropriate treatment or exploitation of a resident. The Policy also documents The Elder Justice Act, which requires reporting of any reasonable suspicion of a crime under Section 1150B of the Social Security Act, as established by the Patient Protection and Affordable Care Act, (~6703 (b)(3). This requires certain individuals in long-term care facilities to report a reasonable suspicion of a crime committed against a resident. For New York State, these reports must be made to the NYSDOH and at least one local law enforcement agency of jurisdiction. Resident #1 was readmitted [DATE] with diagnoses which included Cerebral Vascular Accident, Hemiplegia, and impairment to both upper and lower extremities. Resident #1 had severe impaired cognition and was dependent for all cares. The quarterly minimum data set, an assessment tool, dated 9/8/24 documented that Resident #1 had short term and long-term memory problems, and was severely impaired in cognitive skills for decision making. Resident #1 was assessed to have no behaviors. Resident # 1 had impairment on both upper & lower extremities and was dependent on staff for eating, and dependent for all activities of daily living. Resident #1 was indicated to be a high-risk victim of abuse per the care plan titled Potential Victim of abuse, dated 9/10/24. The care plan has a goal listed that Resident #1 will be protected from being a victim of abuse thru the next review period. On 11/19/24 at 2:46pm The Potential to be victim of abuse care plan was updated and indicated that Resident #1 was a score level 10, indicating high risk. The risk factors that are marked off are: lacks basic self-protection skills, is unable to communicate needs effectively, is vulnerable due to cognitive disabilities, is vulnerable due to physical disabilities. In an interview on 11/26/24 at 11:16am with the Director of Nursing they stated that on 11/19/24 it was brought to their attention by Certified Nursing Assistant #1, that Resident Assistant #2, Resident Assistant # 3 and Certified Nursing Assistant #4 had abused Resident #1. Director of Nursing stated that the evidence provided was videos that the family had from a camera they had placed in Resident #1's room. Director of Nursing stated the family showed the videos to them which they watched on 11/19/24. Immediately after viewing the videos the Director of Nursing suspended the staff pending investigation, and when they determined that abuse had occurred, they terminated the four staff identified in the videos. The Director of Nursing stated that on the day of the incident they made it clear to the family that it was their right to call 911. The Director of Nursing stated that they needed to report the incident to Department of Health. The Director of Nursing stated that the facility did not call law enforcement as they thought it was a family thing to do. The Director of Nursing stated they left the decision to call law enforcement up to the family. The facility's internal investigative report documents that the facility contacted the Department of Health on 11/19/24 at 2:31pm and that the facility did not contact any other agency. The report does indicate that the NYS Attorney General's office contacted the facility on 11/20/24 at 3:15pm. During an interview on 11/26/24 at 12:07pm with the Administrator they stated that they did not call the police or anyone else because the family was adamant that no one else be notified. On 11/25/24 Surveyors reviewed the footage of videos provided by the facility and observed the following: Video #1 dated 10/31/24 at time stamp 8:03:04 : Certified Nursing Assistant #1 and Resident Assistant #3 are seen on video in Resident #1's room to provide care. Certified Nursing Assistant #1 is seen removing Resident #1's gown forcefully. Certified Nursing Assistant #1 is seen wiping Resident #1's face in a rough manner. Video #2 has no date and no time stamp. Certified Nursing Assistant #1 and Certified Nursing Assistant #4 are in Resident #1's room. Resident #1 is seen lying in bed fully dressed. Certified Nursing Assistant #1 wearing no personal protective gown, is seen attempting to reposition Resident #1 in the bed. Certified Nursing Assistant #1 is seen pulling and tugging on Resident #1's upper body/head in a forceful manner to adjust Resident #1 in the bed. Video # 3 dated 11/04/24 at time stamp 08:07:58 : Certified Nursing Assistant #1 and Resident Assistant #2 are seen in Resident #1's room. Resident #1 is seen lying in bed wearing only incontinent brief. Resident Assistant #2 uses their right hand and pushes/smooshes Resident #1 on the left side of their face, then smacks Resident #1's left forearm and then flicks Resident #1's forehead, Certified Nursing Assistant #1 is not seen on the video during this time. 10NYCRR 415.4

Based on record reviews, interviews, and observations conducted during an abbreviated (NY00361070, NY00351353) survey, the facility did not ensure that a resident was free from abuse. This was evident for 1 (Resident #1) of 3 residents sampled for abuse. Specifically, Certified Nursing Assistant #1, Certified Nursing Assistant #4, Resident Assistant #2 and Resident Assistant #3 are seen in video footage using more force than necessary to provide care to Resident #1. As evidenced by: The facility policy for abuse has no date created no indication of ever having been reviewed/revised, and it is not printed on official letterhead. The Policy documents, The Purpose of the Abuse Prevention Program is to ensure a safe, respectful, and dignified environment for all residents. The Policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish. Resident #1 was readmitted [DATE] with diagnoses which included Cerebral vascular accident, Hemiplegia, and impairment to both upper and lower extremities. Resident #1 had severe impaired cognition and was dependent for all cares. The quarterly minimum data set, an assessment tool, dated 9/8/24 documented that Resident #1 had short term and long-term memory problems, and was severely impaired in cognitive skills for decision making. Resident #1 was assessed to have no behaviors. Resident #1 had impairment on both upper & lower extremities and was dependent on staff for eating, and dependent for all activities of daily living. Resident #1 was indicated to be a high-risk victim of abuse per the care plan titled Potential Victim of abuse, dated 9/10/24. The care plan has a goal listed that Resident #1 will be protected from being a victim of abuse though the next review period. On 11/19/24 at 2:46pm The Potential to be Victim of Abuse care plan was updated and indicated that Resident #1 was a score level 10, indicating high risk. The risk factors that are marked off are: lacks basic self-protection skills, is unable to communicate needs effectively, is vulnerable due to cognitive disabilities, and is vulnerable due to physical disabilities. On an interview on 11/26/24 at 11:16am with the Director of Nursing they stated that on 11/19/24 it was brought to their attention by Certified Nursing Assistant #1, that Resident Assistant #2, Resident Assistant # 3 and Certified Nursing Assistant #4 had abused Resident #1. Director of Nursing stated that the evidence provided was videos that the family had from a camera they had placed in Resident #1's room. Director of Nursing stated the family showed the videos to them which they watched on 11/19/24. Immediately after viewing the videos the Director of Nursing suspended the staff pending investigation, and when they determined that abuse had occurred, they terminated the four staff identified in the videos. On 11/25/24 Surveyors reviewed the footage of videos provided by the facility and observed the following: Video #1 dated 10/31/24 at time stamp 8:03:04: Certified Nursing Assistant #1 and Resident Assistant #3 are seen on video in Resident #1's room to provide care. Certified Nursing Assistant #1 is seen removing Resident #1's gown forcefully. Certified Nursing Assistant #1 is seen wiping Resident #1's face in a rough manner. Video #2 has no date and no time stamp: Certified Nursing Assistant #1 and Certified Nursing Assistant #4 are in Resident #1's room. Resident #1 is seen lying in bed fully dressed. Certified Nursing Assistant #1 wearing no personal protective gown, is seen attempting to reposition Resident #1 in the bed. Certified Nursing Assistant #1 is seen pulling and tugging on Resident #1's upper body/head in a forceful manner to adjust Resident #1 in the bed. Video # 3 dated 11/04/24 at time stamp 08:07:58: Certified Nursing Assistant #1 and Resident Assistant #2 are seen in the Resident #1's room. Resident #1 is seen lying in bed wearing only incontinent brief. Resident Assistant #2 uses their right hand and pushes/smooshes Resident #1 on the left side of their face, then smacks Resident #1's left forearm and then flicks Resident #1's forehead, Certified Nursing Assistant #1 is not seen on the video during this time. 10NYCRR 415.4(b)(1)(i)

Based on observation, record review and interview during the recertification survey (7/10/23-7/14/23), the facility did not ensure that staff maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, 1) During a meal observation two certified nurse aides (CNA) buttered toast using their bare hands before handing the toast to Residents #124 and #26. 2) Housekeeping staff was observed pushing clean linen on an uncovered cart down a hallway. 3) A CNA was observed not using Personal Protective Equipment (PPE) and removed dishes from a resident's room that was on contact precaution, placed the dishes on a food truck, and continued to stack more dishes from the dining room on the food truck without performing hand hygiene. The findings are: 1) Resident #124 had diagnoses including dementia, chronic obstructive pulmonary disease (COPD) and need for assistance with personal care. The 6/14/23 Minimum Data Set (MDS, an assessment) documented the resident needed tray set up for meals. An observation was made in the 3rd floor dining room on 7/10/23 at 8:44 AM of CNA #4 taking a piece of toast from a package on Resident #124's tray and holding the toast in their bare hand to butter the toast. Resident #124 picked up the toast and took a bite. During an interview on 7/10/23 at 8:44 AM, CNA #4 stated no one told them they were not allowed to touch the resident's food while setting up the tray. CNA #4 stated they did not know they needed to use a barrier between their hand and the resident's food. Resident #26 had diagnoses not limited to atherosclerotic heart disease (ASHD) and adult failure to thrive. The resident's quarterly MDS dated [DATE] documented the resident needed limited assistance of 1 person for eating. An observation was made on 7/10/23 at 9:03 AM of CNA #5 taking a piece of toast from a package on Resident #26's tray and holding the toast in their bare hand to butter the toast. CNA #5 then handed the toast to Resident #26. During an interview on 7/10/23 at 9:03 AM, CNA #5 they stated they were buttering the toast but did not know they were not supposed to hold the toast in their bare hand. 2) The facility undated policy on Linen and Laundry Transportation documented linen and laundry was to be stored, transported, and processed in a manner to prevent the spread of infection and contamination. On 7/12/23 at 3:15 PM an observation was made on the 2nd floor hallway of a Housekeeping Staff #1 who pushed an uncovered cart of clean linen down the hallway. the cart was left on the 2nd floor unit with exposed clean towels and bed linens. During an interview with Housekeeping Staff #1, at the time of observation, they stated they usually delivered clean linen carts covered but made this delivery without a cover because they were in a rush. 3) Resident #115 had diagnoses including hypertension, dysphagia, and enterocolitis due to clostridium difficile (C-Diff). Physician orders dated 7/10/23 documented the resident was on contact precautions for clostridium difficile infection. An observation was made on 7/11/23 at 9:41 AM of CNA #6 who came out of Resident #115's room holding dirty cups and dishes and put them on a food truck outside the dining room. CNA #6 then went into the dining room, collected more dirty meal trays and put them on the truck. There was no hand hygiene with soap and water observed after the CNA #6 left Resident#115's room. During an interview with CNA #6 on 7/12/23 at 9:42 AM, they stated they were aware the resident was on contact isolation but forgot to use hand sanitizer after leaving the room. CNA#6 stated they was not aware they needed to don PPE and that soap and water was needed for hand hygiene after coming in contact with a resident who has C.Diff infection. During an interview with the Registered Nurse Unit Manager (RNUM) #1 on 7/11/23 at 9:46 AM, they stated Resident#115 was on contact precautions and staff should be wearing PPE to remove dishes and need to wash their hands with soap and water to prevent the spread of infection. RNUM#1 stated there were several in-services on isolation precautions and did not know why staff did not know this. During an interview with the Infection Preventionist (IP) on 7/13/23 10:30 AM, they stated precautions were discussed with staff routinely which always included appropriate PPE use. The IP was not aware staff were not using PPE and hand washing appropriately. 10NYCRR 415.19 48045

Based on observation, record review and interviews conducted during the recertification survey from 7/10/23 to 7/14/23, the facility did not ensure food was prepared, stored, and served in accordance with professional standards for food service safety to ensure prevention of foodborne illness. Specifically, 1. a food service worker was observed preparing food without a proper hair restraint, 2. the freezer and refrigerator logs in the meat kitchen were forged and, 3. a large pan of raw chicken was improperly stored. The findings are: A facility policy and procedure last revised in January 2022 titled 'Food Storage' stated all foods should be covered, labeled, and dated. The policy additionally stated refrigerator/freezer temperatures should be checked at least 2 times a day and documented on the refrigerator temperature sample form. 1. On 7/10/2023 at 6:26 AM, Food service worker (FSW) #1 was observed cutting onions in the meat kitchen without proper a proper hair covering. During an interview on 7/10/23 at 6:26 AM, FSW #1 stated, as they were cutting onions, they had just arrived to work. During an interview on 7/10/23 at 6:48 AM, the facility's Food Service Director (FSD) stated staff were expected to wear hair restraints in the kitchen. 2. On 7/10/23 at 10:52 AM, a temperature log for the meat refrigerator and freezer were observed signed by FSW #3 with the same initials every day between 7/1/23 and 7/10/23. A review of FSW #3's timecard revealed they did not work on 7/1/23, 7/2/23, 7/8/26, or 7/9/23 (Although their initials were signed on the temperature log on all listed dates). A written statement by FSW #3 dated 7/13/23 revealed they filled in the missing signatures on the temperature logs and they understand they should only for the temperatures that they check. During an interview on 7/13/23 at 11:17 AM, the facility's Administrator stated staff were expected to sign their own initials and accurately complete the temperature logs when they were at work. 3. On 7/10/23 at 6:38 AM, a large pan of raw chicken pieces and trimmings was observed uncovered and undated in the meat refrigerator, and a large bag of carrots was observed being stored on the floor of the walk-in refrigerator. During an interview on 7/10/23 at 6:38 AM, FSW #2 stated the large pan of chicken in the walk-in fridge should have been covered and dated. During an interview on 7/10/23 at 6:48 AM, the facility's FSD stated they made chicken yesterday and were saving the leftover raw chicken scraps to make gravy and they guess the staff just put it in the fridge. The FSD further stated it was not appropriate for raw meat to be stored uncovered and undated in the walk-in refrigerator. During a follow-up interview on 7/10/2023 at 11:01 AM, the facility's FSD stated the carrots should not have been stored on the floor. The FSD stated they did not work on weekends and every Monday they had to clean up. 10 NYCRR 415.14(h)

Based on observation, interview and record review conducted during the recertification survey from 7/10/23 to 7/14/23, it was determined for 1 of 3 residents (Resident # 48) reviewed for Nutrition and Hydration, the facility did not ensure the resident was provided the necessary care to maintain an acceptable body weight. Specifically, when Resident #48 lost 19 pounds the significant weight loss was not addressed by the dietitian for over one month. The findings are: The facility undated policy for weights documented that weights would be monitored regularly to evaluate potentially undesirable weight changes. The nurse on the unit and the registered dietitian (RD) would review weights for discrepancies from prior weights. Resident #48 had diagnoses including cerebral infarct, dysphagia (difficulty swallowing), and gastro-esophageal reflux. The Admission Minimum Data Set (MDS, a resident assessment tool) completed on 6/11/23 documented the resident's cognition was intact and the resident ate with supervision and tray set up. A physician order dated 3/9/23 documented monthly weights. The comprehensive care plan for Nutrition dated 3/10/23 documented the goals were that the resident would remain well hydrated and eat greater than 50% of meals. Interventions included a low sodium diet, thin liquids, skin review as needed, diet education as needed, and to provide food preferences as available. The resident's weight chart documented on 5/3/23 the resident weighed 167 pounds, on 6/1/23 the resident weighed 148 pounds and on 6/14/23 the resident weighed 151 pounds. Further review of the resident's record revealed no documented evidence the RD was aware of the resident's weight loss and the care plan was not updated address the 19 pound weight loss. When interviewed on 7/13/23 at 9:26 AM, certified nurse aide (CNA) #1 stated if there was a big difference in weights from prior weight, they would reweigh the resident. CNA #1 stated the weight was entered in the computer by the CNAs and then entered in the book at the nurses desk. They would inform the nurse if there was a weight loss. CNA #1 was unaware Resident #48 had a weight loss. When interviewed on 7/13/23 at 9:51 AM the Registered Nurse Unit Manager (RNUM) #1 stated they made sure that residents, who were not very alert, were closely watched and assisted with feeding. RNUM #1 stated the CNAs would tell them which residents were not eating well and they would follow up with the RD. The RNUM #1 stated they communicate with the RD regarding weight losses. RNUM #1 stated they were not aware of the resident's weight loss and the RD was responsible for monitoring the situation. When interviewed on 7/13/23 at 8:14 AM, RD #1 stated they had not seen the Resident #48 lately and was not aware of a weight loss. RD#1 reviewed the record and stated the resident was 148 pounds on 6/1/23, but was rechecked on 6/14/23 and their weight was 151 pounds which still showed a loss. RD#1 stated they should have been monitoring the resident's weight and implemented weekly weights and checking meal intakes. When interviewed on 7/13/23 at 9:56 AM, the physician stated the weight of 147 pounds was probably not accurate and should have been rechecked the next day, not two weeks later. The physician stated RD#1 should have seen the resident sooner and the weight loss should have been acted upon. 10 NYCRR 415.12 (g)(1)

Based on observation, record review and interview conducted during the 7/10/23 to 7/14/23 recertification survey it was determined for 1 of 4 residents (Resident #75) reviewed for Activities of Daily Living (ADL) Decline, the facility did not ensure all residents with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent a further decrease in range of motion. Specifically, Resident #75 had a Physical Therapy/Occupational Therapy screen on 5/13/23 that recommended restorative nursing that was not ordered until 7/12/23. The findings are: The Policy and Procedure titled Restorative Nursing last revised 2/2019 documented the following as the purpose: range of motion is the movement of a joint though its full range in all appropriate planes. It may be passive, active or active assistive. The objective is to maintain function and prevent deterioration and to maintain motion of the joint. Additionally documented procedure can be done by licensed practical nurse or certified nursing assistant. Resident # 75 was admitted to the facility 5/4/18 and had diagnoses that included arthritis, non-alzheimer's dementia and parkinson's. The 4/25/23 Significant Change Minimum Data Set (MDS, resident assessment tool) assessment dated [DATE] documented Resident #75 had severe cognitive impairment; required extensive assist of one person for bed mobility, toileting and eating and required extensive assist of two persons for transfer. The physical therapy/occupational therapy screen dated 5/13/23 documented recommendation for restorative nursing, range of motion with care. The certified nurse aide accountability record for May, June, and July 2023 did not document directions or signatures for restorative nursing, range of motion with care. The physicians order dated 7/10/23 documented restorative nursing; passive range of motion (ROM) to right arm, left arm, right leg, left leg every day during day shift. The comprehensive care plan 7/12/23 Restorative Nursing Care Plan created 7/12/23 documented resident is on passive range of motion for bilateral upper extremities (BUE) and bilateral lower extremities (BLE). During an observation on 07/13/23 11:56 AM resident was in bed with sheet covering most of body, resident had a wedge pillow under the left shoulder. During an interview with certified nurse aid (CNA) #3 on 7/14/23 at 1:46 PM, CNA #3 stated the resident has gotten progressively worse over time. CNA #3 stated the resident was able to transfer but now needs a Hoyer lift. CNA #3 stated they change the resident's depends, wash the resident and get the resident dressed for dialysis. On the non-dialysis days, they change the resident and leave the resident in bed on the resident's side. CNA #3 stated restorative nursing is when they do the ADL care and try to keep the resident moving such as raise legs up and down and also positioning the legs straight. CNA #3 stated CNA accountability record does not have a spot for them to document range of motion but has seen range of motion as part of their CNA documentation on other resident records. During an interview with Director of Rehabilitation (DOR) on 7/14/23 at 2:21 PM, DOR stated residents are screened quarterly and recommendations are documented in the rehabilitation tab of the electronic medical record (EMR). DOR stated rehab puts in the rehab orders for restorative nursing and will put in the functional status under the rehabilitation recommendation. DOR stated they put in the orders for rehab and were unsure of what happened with the order for restorative nursing after the recommendation was made in May. DOR stated there is also a shared rehab form tab in the electronic medical record (EMR) that documents a change in status that nursing can also look at. During an interview with registered nurse (RN)#6 on 7/14/23 at 4:34 PM, RN #6 stated the rehab director will provide a list of residents who will benefit from restorative nursing to the nurse manager. RN #6 stated nursing is instructed on what is needed for restorative nursing including range of motion. RN #6 stated range of motion can be done by a nurse or CNA. When asked where they document when ROM is completed, RN #6 stated they document ROM in the progress notes. RN #6 stated they were unsure why there was a delay in getting the restorative nursing order and implementing the restorative nursing care plan. 10 NYCRR 415.12(e)(1)

Based on observation, record review and interview during the recertification survey from 7/10/2023 to 7/14/2023, the facility did not ensure that 1 (Resident #118) of 5 residents reviewed for quality of care received treatment and care in accordance with professional standards of practice. Specifically, on 6/24/2023 Resident #118 reported they had sustained a right thigh burn after staff provided heated water from the microwave and the facility did not implement interventions for the treatment a skin impairment on the thigh until 6/26/2023. Additionally, the medical provider was unaware the resident had spilled hot water and the blister on the resident's thigh was not identified as a burn, and treated with Silvadene until 6/28/2023 when the nurse practitioner (NP) assessed. The findings are: Resident #118 had diagnoses including hypertension, renal insufficiency, and malnutrition. The 6/22/2023 Minimum Data Set (MDS: an assessment tool) documented Resident #118 was cognitively intact for decision making, received assistance with set up and supervision for eating, had limited range of motion of their upper extremity on one side, and had no skin impairments. During the initial screening on 7/10/2023 at 2:02 PM, Resident #118 was interviewed and stated they had a burn to their right upper thigh from hot water that was served to them in their own lidded mug. The resident stated and the nurse who served them the hot water did not screw on the top of the mug, and they spilled hot water on themselves. Resident #118 pointed to her mug on the table and then showed the surveyor their right upper thigh. Resident #118 stated the burn had been treated with Silvadene cream. Discolored skin was observed on the resident's right thigh. A written statement dated 6/24/2023 at 6:40 AM, by the Licensed Practical Nurse (LPN) #3 documented that the resident had requested hot water to make tea for herself, LPN #3 gave the hot water to the resident as requested, LPN #3 overheard the resident shout I burned myself, and asked the resident what happened, and the resident stated, I spilled the hot water on myself and got burned. There was no documented evidence in the electronic medical record (EMR) on 6/24/2023 regarding the resident's report that they sustained a burn on 6/24/2023. A nursing progress note dated 6/26/2023, by licensed practical nurse LPN #5, documented an open area on Resident #118's right thigh and that nurse practitioner (NP) #2 was notified and ordered bacitracin ointment until resolved. The initial Skin Condition Assessment, dated 6/26/2023 at 8:00 PM by the Director of Nursing (DON), documented Resident #118 had a blister on the right thigh that measured 2.0 centimeters (cm) x 2.0 cm x 0.1 cm (length x width x depth), with a scant amount of serous (clear fluid) drainage, and treatment was initiated. A nursing progress note dated 6/28/2023 by LPN #5, documented redness noted on Resident #118's right thigh and NP #1 was notified and ordered Silvadene cream and a non-stick dressing to the right thigh until burn is healed. The Acute Visit Progress Note, dated 6/28/2023 at 4:00 PM by NP #1, documented Resident #118 was examined and the right thigh had redness and an open blister likely due to old burn per patient. The treatment plan was to apply Silvadene until healed. The June 2023 Medication Administration Record (MAR) documented: -on 6/26/2023, apply bacitracin to open area on right thigh until resolved. The order was discontinued on 6/28/2023. -on 6/28/2023, apply Silvadene cream and non-stick dressing to the right thigh burn until healed. During an interview on 7/13/23 at 8:04 AM, the Director of Nursing (DON) stated they were notified of Resident #118's burn to right thigh, it occurred on 6/24/2023 but was not reported to them until 6/26/2023. The DON stated and it was undetermined how the burn happened. In an interview on 7/13/23 at 11:28 AM, NP #1 stated that on 6/26/23 NP #2 reported to them that Resident #118 had a skin tear of the right thigh and bacitracin had been ordered. NP #1 stated they tried to see the resident on 6/26/23 but the resident was not around, and on 6/27/2023 the resident was out of the building. NP #1 stated that on 6/28/2023 they evaluated the resident and found two (2) open blisters with surrounding redness on the resident's right thigh. NP #1 stated that the two (2) blisters looked like some kind of burn. NP #1 stated that the resident told them the burn was old and was from hot water but did not ask resident when the burn occurred. NP #1 stated that they immediately changed the resident's treatment order to Silvadene cream, a non-stick dressing, and to document for signs and symptoms of infection. In an interview on 7/14/23 at 11:33 AM Nurse Practitioner (NP) #2 stated that on a date they could not recall, LPN #5 came into their office and stated that Resident #118 had a skin tear on their leg. NP #2 stated she gave an order to wash the skin tear with saline wash, apply bacitracin, and cover the area with a bandage. NP #2 stated the issue reported to them regarding Resident #118 was a skin tear, so they ordered a treatment until the resident assigned NP could evaluate the resident further. In an interview on 7/14/23 01:38 PM LPN #3 stated that, Resident #118 asked them for warm water to make tea, LPN #3 used a foam cup and warmed the water in the microwave, they checked the temperature of the water with a thermometer that is in the microwave on unit 2 West, and the water was 100 F degrees. LPN #3 stated that the resident told them to put the foam cup of water on the bedside table which was in front of the resident. LPN #3 then returned to the nurse's station. LPN #3 stated that about 10-15 minutes later they were at the nurse's station and overheard the resident saying that they had burned themselves. LPN #3 stated they went into the resident's room, and resident told LPN #3 that they had burned themselves. LPN #3 stated they asked the resident what had happened, and they responded that they had dropped the water on themselves and got burned. LPN #3 stated they asked the resident where they had burned themselves, and resident showed them their right thigh. LPN #3 stated that she observed resident's skin on the right thigh had an open blister, and the skin around the blister was darkened, dry skin. LPN #3 stated that they told the resident that they thought the injury was an old burn. LPN #3 stated that they then called the Registered Nurse Supervisor (RNS) #1, who then came to look at the resident and thought the injury was old. 10 NYCRR 415.12

Based on interview and record review conducted during a recertification survey, it could not be ensured that the facility thoroughly investigated an injury of unknown origin for 1 (Resident #118) of 5 residents reviewed for accidents. Specifically, Resident #118 stated they had a burn to their right upper thigh on 6/24/2023 from hot water that was served to them in their own lidded mug, when the nurse who served the hot water did not screw on the top of the mug. The findings are: The facility policy and procedure (P/P) dated 11/2022 and titled Accidents/Incidents (A/I) documented examples of accidents included second- and third- degree burns. Procedures for the Charge Nurse/Licensed Nurse included completion of sections 1 through 17 on the A/I form and give to Registered Nurse Supervisor. Registered Nurse Supervisor procedures included review of section 1 through 17 of the A/I form, determines if an accident or incident, and completes sections 18 and 20. The A/I P/P documented in bold type: In the event an A/I occurs that is either unwitnessed or involves questionable factors the following will be completed. All A/I will be reviewed by the Safety Committee/Department Head AM meeting and further investigation will be determined at that time and listed the actions to be taken by the LPN, supervisor, comprehensive care plan team (CCP), attending physician, and Director of Nursing (DON) or designee. Resident #118 was admitted with diagnoses hypertension, renal insufficiency, and malnutrition. The Minimum Data Set (MDS: an assessment tool) dated 6/22/2023 documented that Resident #118 was cognitively intact for decision making, received assistance with set up and supervision for eating, had a functional limitation in range of motion of their upper extremity on one side, and had no skin problems present. The statement dated 6/24/2023 at 6:40 AM and written by the 11 PM - 7:00 AM Licensed Practical Nurse, LPN #3, who was on shift on 6/23 - 6/24/2023 documented that the resident had requested hot water to make tea for themselves LPN #3 gave the hot water to the resident as requested, LPN #3 overheard the resident shout I burned myself, and asked the resident what happened, and the resident stated, I spilled the hot water on myself and got a burn. There was no documented evidence that a thorough accident/incident investigation was conducted and/or completed to address Resident #118's right thigh blistered area. During an interview on 7/13/23 at 8:04 AM the Director of Nursing (DON) stated for the time frame June 1, 2023 - July 12,2023 there were no accidents/incident reports identifying skin conditions and/or injuries of unknown origin. The DON stated Resident #118's burn to the right thigh was not reported to her until 6/26/2023, and she conducted a major investigation. The DON stated that the accident investigation was on their computer at home but then revised their statement and stated that they had parts of the investigation in the facility but had to look for them. The DON stated that they had interviewed staff over the phone and did not have written, signed statements from staff. The DON stated that they interviewed day 7-3 and night staff 3-11 over phone but could not produce documented evidence of those interviews. The DON also stated she reviewed video footage but did not save it. On 7/13/23 around 10 AM, the DON provided a document titled Major Investigative Summary. The summary documented that at approximately 5:00 PM on Monday 6/26/2023, Resident #118 came to the Director of Nursing office and reported they had a blister on the right inner thigh and it was my fault; I spilled hot water on myself. There was one statement attached to the investigative summary, dated 6/24/2023 at 6:40 AM and written by the 11 PM - 7:00 AM Licensed Practical Nurse, LPN #3, who was on shift on 6/23 - 6/24/2023, and documented that the resident had requested hot water to make tea for themselves, LPN #3 gave the hot water to the resident as requested, LPN #3 overheard the resident shout I burned myself, and asked the resident what happened, and the resident stated, I spilled the hot water on myself and got a burn. The investigative summary did not include any other written statements. The summary documented camera footage was reviewed, and it was noted that on Saturday 6/24/2023 around 6:30 AM nurse was observed holding a foam cup and entering into the resident's room; around 6:40 AM nurse was observed going into the resident's room, around 6:41 AM LPN #3 left the room, and at 6:43 AM Registered Nurse Supervisor was observed entering the room. The investigation determined that burn was old; and possible and believed that happened during transport. Resident is independent with her out on pass and medical appointments. Resident is known to stop for coffee when coming back from dialysis/appointments. The investigation summary form had a place to document the person completing the form and was to be signed off by the DON, Administrator, and Medical Director, however it was unsigned and undated. In an interview on 7/14/23 01:38 PM LPN #3 stated Resident #118 asked them for warm water to make tea, LPN #3 used a foam cup and warmed the water in the microwave, they checked the temperature of the water with a thermometer that is in the microwave on unit 2 West, and the water was 100 F degrees. LPN #3 stated that the resident told them to put the foam cup of water on the bedside table which was in front of the resident. LPN #3 then returned to the nurse's station. LPN #3 stated that about 10-15 minutes later they were at the nurse's station and overheard the resident saying that they had burned themselves. LPN #3 stated they went into the resident's room, and resident told LPN #3 that they had burned themselves. LPN #3 stated they asked the resident what had happened, and they responded that they had dropped the water on themselves and got burned. LPN #3 stated that they observed an open blister on the resident's right thigh and the skin around the blister was darkened, dry skin. LPN #3 stated that they told the resident that they thought the injury was an old burn. LPN #3 stated that they then called the Registered Nurse Supervisor (RNS) #1, who then came to look at the resident and thought the injury was old. 10 NYCRR 415.4

Based on observation, record review and interview conducted during a recertification survey (7/10/23-7/14/23) the facility did not ensure that care was provided in a manner that maintained dignity for 3 of 3 residents (#34, #21, #6). Specifically, Residents #34, #21, and #6's urinary catheter drainage bags were not concealed to prevent direct observation of urine by others. The findings are: Resident # 34 had diagnoses that included cerebral infarction, dysphagia and obstructive and reflux uropathy. The resident's 5/20/23 quarterly Minimum Data Set (MDS) documented the resident had an indwelling catheter. The resident's Urinary Catheter care plan dated 6/21/22 included an intervention to cover the drainage bag with dignity cover. An observation was made on 7/10/23 at 6:55 AM of Resident #34 lying in bed with their Foley bag hanging from their bed facing the hallway. There was urine in tubing and bag, which was visible from the hallway. Resident #21 had diagnoses that included acute kidney failure, Type 2 Diabetes, and obstructive and reflux uropathy. The resident's quarterly MDS dated [DATE] documented the resident had an indwelling catheter. The resident's urinary catheter care plan included an intervention to cover the drainage bag with dignity cover. An observation was made on 7/10/23 at 06:57 AM of Resident #21's urinary drainage bag to be uncovered and in clear view of others in the hallway. Resident #6 had diagnoses that included Parkinson's disease, obstructive and reflux uropathy and congestive heart failure. The 3/3/23 admission MDS revealed that the resident had an indwelling urinary catheter. An observation was made on 07/10/23 at 06:58 AM of Resident #6's urinary drainage bag hanging on the side of the bed without a privacy bag and urine was visible in the bag and tubing from the hallway. During an interview with the Certified Nurse Aide (CNA) #1 on 07/13/23 at 09:26 AM, they stated dignity bags were needed on all Foley catheter bags at all times. CNA#1 stated they made sure that the residents had the covers on throughout the day as the covers were important for the resident's right to dignity. In an interview with the Registered Nurse Unit Manager (RNUM) #1 on 07/13/23 09:45 AM, they stated dignity covers were supposed to be on Foley bags at all times to preserve the resident's dignity. RNUM#1 stated the CNAs were aware, but sometimes forgot to cover the bags. S483.10(a)