Every finding on record at Promenade Rehabilitation and Health Care Center

Based on record review and interviews, the facility failed to ensure sufficient nursing staff were available to provide nursing and related services necessary to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, Specifically, 1.) Residents reported the facility was short staffed of Certified Nursing Assistants which resulted in lack of timely staff response to residents who needed assistance, 2.) Multiple nursing staff members reported lack of sufficient staffing, 3.) Facility's staffing levels were repeatedly below facility assessed levels, and 4.) Excessively low weekend staffing was triggered in the Payroll Based Journal Staffing Data Report for Quarter 2 2026 (January 1 - March 31). The findings include but are not limited to:The Payroll Based Journal Staffing Data Report for Quarter 2 of 2026 (January 1 - March 31) identified the facility as having Excessively Low Weekend Staffing based on submitted weekend staffing data.The facility's Nursing Department Staffing Policy dated 01/2026 required sufficient nursing staff to provide care in accordance with physician orders, resident care plans, federal and state regulations and facility policy. The policy established minimum licensed nurse staffing of one Registered Nurse or Licensed Practical Nurse per shift on Units 2, 3, 4, 6, and 7; and two licensed nurses per shift on Unit 5 which was a ventilator unit.The policy further established minimum certified nursing assistant staffing as follows:Units 2, 3, 4, 6, and 7: five on the day shift, three on the evening, and two on the night shiftUnit 5: six on the day shift, four on the evening, and four on the night shiftThe facility assessment, last updated on 05/29/2026, documented a licensed bed capacity of 240 and an average daily census of 228. The assessment identified required staffing for a 24-hour period as follows:Units 2, 3, 4, 6, and 7: three licensed nurses and 10 certified nursing assistants per unitUnit 5: six nurses and 14 certified nursing assistantsThe assessment specified that weekend staffing was to remain at the same levels.Review of the actual weekend facility staffing schedule by units and shift from 01/02/2026-03/28/2026 revealed the following staff shortages:01/02/2026 -11:00PM-7:00AM shift - shortage of one Certified Nursing Assistant.01/03/2026-7:00AM-3:00PM shift - shortage of 10 Certified Nursing Assistants.01/04/2026- 7:00AM-3:00PM shift - shortage of eight Certified Nursing Assistants.01/04/2026 3:00pm-11:00PM shift - shortage of one Certified Nursing Assistants.01/10/2026 7:00AM-3:00PM shift - shortage of seven Certified Nursing Assistants.01/11/2026 7:00AM-3:00PM shift - shortage of nine Certified Nursing Assistants. 01/11/2026 3:00pm-11:00PM shift - shortage of one Certified Nursing Assistant. 01/11/2026 11:00PM-7:00AM shift - shortage of one Certified Nursing Assistant. 01/16/2026 11:00PM-7:00AM shift - shortage of one Certified Nursing Assistant. 01/17/2026 7:00AM-3:00PM shift - shortage of eight Certified Nursing Assistants. 01/17/2026 3:00pm-11:00PM shift - shortage of one Certified Nursing Assistant. 01/17/2026 11:00PM-7:00AM shift - shortage of one Certified Nursing Assistant. 01/18/2026 7:00AM-3:00PM shift - shortage of seven Certified Nursing Assistants. 01/18/2026 11:00PM-7:00AM shift - shortage of three Certified Nursing Assistants. 01/24/2026 7:00AM-3:00PM shift - shortage of seven Certified Nursing Assistants. 01/25/2026 7:00AM-3:00PM shift - shortage of three Certified Nursing Assistants. 01/25/2026 1:00PM-7:00AM shift - shortage of one Certified Nursing Assistant. 01/31 /2026 7:00AM-3:00PM shift - shortage of six Certified Nursing Assistant. 01/31 /2026 3:00pm-11:00PM shift - shortage of one Certified Nursing Assistant. 01/31 /2026:11:00PM - 7:00AM shift - shortage of one Certified Nursing Assistant. 02/02/2026 7:00AM-3:00PM shift - shortage of eight Certified Nursing Assistants. 02/02/2026 11:00PM-7:00AM shift - shortage of one Certified Nursing Assistant. 02/07/2026 7:00AM-3:00PM shift - shortage of eight Certified Nursing Assistants. 02/07/2026 11:00PM-7:00AM shift - shortage of one Certified Nursing Assistant. 02/14 /2026 7:00AM-3:00PM shift - shortage six Certified Nursing Assistants. 02/14 /2026 11:00PM-7:00AM shift - shortage of two Certified Nursing Assistants. 02/15/2026 7:00AM-3:00PM shift - shortage of six Certified Nursing Assistants. 02/15/2026: 3:00PM-11:00PM shift - shortage of one Certified Nursing Assistant.02/21/2026 7:00AM-3:00PM shift - shortage of seven Certified Nursing Assistants. 02/21/2026 11:00PM-7:00AM shift - shortage of one Certified Nursing Assistant. 02/22/2026 7:00AM-3:00PM shift - shortage of nine Certified Nursing Assistants. 02/22/2026 3:00pm-11:00PM shift - shortage of two Certified Nursing Assistants.02/22/2026 11:00PM-7:00AM shift - shortage of two Certified Nursing Assistants.02/28/2026 7:00AM-3:00PM shift - shortage of six Certified Nursing Assistants. 02/28/2026:3:00pm-11:00PM shift - shortage of one Certified Nursing Assistant.02/28/2026 11:00PM-7:00AM shift - shortage of three Certified Nursing Assistants. 03/01/26 7:00AM-3:00PM shift - shortage of 10 Certified Nursing Assistants. 03/01/26 11:00PM-7:00AM shift - shortage of three Certified Nursing Assistants03/07/2026 7:00AM-3:00PM shift - shortage of 11 Certified Nursing Assistants. 03/08/2026 7:00AM-3:00PM shift - shortage of seven Certified Nursing Assistants. 03/08/2026 11:00PM-7:00AM shift - shortage of one Certified Nursing Assistant.03/14/2026 7:00AM-3:00PM shift - shortage of four Certified Nursing Assistants. 03/15/2026 7:00AM-3:00PM shift - shortage of five Certified Nursing Assistants. 03/15/2026 3:00PM-11:00PM shift - shortage of one Certified Nursing Assistant.03/21/2026:7:00AM-3:00PM shift - shortage of seven Certified Nursing Assistants. 03/22/2026 7:00AM-3:00PM shift - shortage of seven Certified Nursing Assistants. 03/28/2026 7:00AM-3:00PM shift - shortage of seven Certified Nursing Assistants. 03/29/2026 7:00AM-3:00PM shift - shortage of six Certified Nursing Assistants. During an interview on 06/08/2026 at 11:15 AM, Resident #69 stated that staff were unable to meet residents' needs promptly because nursing assistants were assisting residents requiring more care. They reported there is generally one certified nursing assistant assigned to seven to 10 residents and that the night shift typically had two nursing assistants.During an interview on 06/08/2026 at 10:00 AM, Resident #245 stated that waited approximately 25 to 30 minutes for assistance with changing after using the bed pan during the 3:00 PM - 11:00 PM shift.During an interview on 06/07/2026 at 11:24 AM, Resident #102 stated weekends are like a ghost town and often they wait a long time for assistance getting out of bed.During an interview on 06/11/2026 at 8:39 AM, Certified Nursing Assistant #11 stated weekend staffing is typically four nursing assistants but sometimes there are only three, making the workload very heavy.During an interview on 06/11/2026 at 8:50 AM, Certified Nursing Assistant #10 stated some weekends, the facility is only staffed with three nursing assistants, when there was supposed to be five, resulting in increased time to provide resident care.During an interview on 06/11/2026 at 10:28 AM, Certified Nursing Assistant #5 stated there is normally only four nursing assistants on the weekends for the 7:00 - 3:00 PM shift. Residents experience longer waiting times due to larger assignments.During an interview on 06/11/2026 at 10:36 AM, Licensed Practical Nurse #1 stated the par level for certified nursing assistants for the 7:00 AM - 3:00 PM shift is 5, but they are staffed usually with four resulting in longer wait times for the residents to receive assistance.During an interview on 06/11/2026 at 3:47 PM, Licensed Practical Nurse #2 stated the 3:00 PM to 11:00 PM shift is usually staffed with three nursing assistants, but if one calls out and no replacement is available, the assignments are divided amongst the remaining staff.During an interview on 06/11/2026 at11:51 AM, the Staffing Coordinator stated staffing schedules are prepared monthly using full-time, part-time, per diem, and agency staff based on the staffing policy and facility assessment. Weekend coverage is challenging due to staff availability, religious observances, and second jobs. They stated weekend call-outs are managed by the Registered Nurse Supervisors using staff availability lists.During an interview on 06/12/2026 at 1:05 PM, the Director of Nursing stated staffing par levels have increased and are monitored through the Quality Assurance process. They stated overtime incentives, per diem staff, and agency personnel are used to address shortages, and schedules are prepared in advance to maintain established staffing levels.During an interview on 06/11/2026 at 12:14 PM, the Administrator stated they were aware of the Payroll Based Journal staffing trigger. They stated weekend staffing remains challenging due to competition with other facilities. They stated the facility continues to recruit nurses and certified nursing assistants directly while reducing agency use to improve retention.10 New York Code Rules and Regulations 415.13(a)(1) (i-iii)

Based on observation, record review, and interviews, the facility failed to ensure the resident representative was notified of an accident involving the resident which results in injury and has the potential for requiring physician intervention. This was evident in one of one resident (Resident #25) reviewed for notification of change out of 38 total sampled residents. Specifically, the facility failed to notify Resident #25's representative of the resident's fall with injury on 03/23/2026.The findings include:The Facility's Policy titled Family/Responsible Party Notification of Change in Condition and Hospital Transfer, last reviewed on 05/2026, requires timely notification of a resident's representative following accidents or injuries. The policy further requires that unsuccessful notification attempts must be documented and that all notifications or attempted notifications be recorded in the medical record.Resident #25 was admitted with diagnoses of stroke, lung cancer, and brain cancer.admission Minimum Data Set assessment dated [DATE] documented the resident was severely cognitively impaired, sustained a fall with injury since admission, and that only the representative participated in the assessment. The facility's resident matrix also identified Resident #25 as having sustained a fall with injury.A review of the progress note dated 03/23/2026 by Registered Nurse #1, documented that Resident #25 fell at 12:50 AM and sustained a 0.3-centimeter laceration to the left eyebrow with minimal bleeding. The note stated there was no emergency contact phone number available and that the Social Worker would be notified to follow up with the resident's representative.There was no documentation in the medical record that the representative was notified or that notification attempts were made.During an interview on 06/07/2026 at 11:13 AM, Resident #25's designated representative stated they were never notified of the fall or resulting injury and first became aware of the incident during the survey. The representative stated the facility routinely contacted them and had their telephone number.A record review showed the resident's initial face sheet dated 03/18/2026 did not include emergency contact information. An updated face sheet dated 03/24/2026 listed the designated representative as the primary emergency contact, including a telephone number and email address.During an interview on 06/11/2026 at 8:33 AM, Registered Nurse #1 stated there was no emergency contact information available at the time of the incident and that they verbally requested Social Worker #1 and Registered Nurse #2, who was the day shift nursing supervisor, to follow up with notification.During an interview on 06/10/2026 at 11:02 AM, Registered Nurse #2 stated the resident's representative was actively involved in the resident's care and could be reached by telephone but did not recall being asked to notify the representative.During an interview on 06/11/2026 at 9:22 AM, Social Worker #1 stated they obtained the representative's contact information on 03/24/2026 while addressing advance directives and discharge planning and updated the face sheet accordingly. Social Worker #1 further stated they were unaware Resident #25 had fallen on 03/23/2026 and were never asked to notify the representative.During an interview on 06/10/2026 at 11:59 AM, the Director of Nursing stated the nurse supervisor is responsible for notifying the resident's representative following an incident, documenting notification attempts, and ensuring follow-up with Admissions Office if emergency contact information is unavailable. The Director of Nursing was unable to explain why Resident #25's representative was not notified of the fall with injury on 03/23/2026.10 New York Code, Rules and Regulations 415.3(e)(2)(ii)(b)

Based on record review and interviews, the facility failed to ensure that a resident was free from physical restraints. This was evident in one (Resident #52)of three residents reviewed for abuse out of 35 total sampled residents. Specifically, on 09/26/2024, Resident #52 was observed by the staff with their hand mitten tied to the bed side rail.Refer to F609 - Reporting of Alleged ViolationsThe findings include:The facility's Physical Restraint-Free Care policy dated 05/2026 stated the use of physical restraint shall be considered only when clinically justified to address a specific assessed medical symptom. It should never be used for staff convenience and behavior management. The policy defined restraint as any manual method, physical or mechanical device, material or equipment attached or adjacent to the resident's body that the resident cannot move easily and restricts freedom of movement or normal access to the resident's body.Resident #52 had diagnoses that included chronic respiratory failure, ventilator dependent with a tracheostomy tube, Parkinsonism, seizure disorder, restlessness and agitation.The Minimum Data Set (a resident assessment tool) assessment dated [DATE] documented that Resident #52 had severe cognitive impairment.A review of interdisciplinary progress notes from 08/19/2024 through 08/31/2024 revealed that Resident #52 has history of restlessness and kept holding the tracheostomy tubing with their left hand. Left hand mitten was applied as ordered to prevent decannulation. A care plan for the use of hand mitten was initiated on 08/19/2024 with interventions to remove every two hours for 15 minutes for skin check.A review of the Accident/Incident Report dated 10/03/2024 documented that on 09/26/2024 the resident's family reported observing Resident #52's left hand mitten tied to the bed side rail. The facility's internal investigation documented that Registered Nurse #3 immediately untied the resident's hand mitten and assessed the resident for injury of which there was none noted. The nursing supervisor was immediately notified of the incident and also assessed the resident with no injury.A review of Registered Nurse #3's written statement documented they were summoned to Resident #52's bedside by the family at approximately 11:00 AM and observed the resident's left hand mitten attached to the side rail. The Registered Nurse immediately released the tie and did a thorough physical assessment; no injury was noted. The nursing supervisor was immediately notified and came to the bedside. The resident was reassessed throughout the shift and no delayed injury has been noted.During an interview on 06/09/2026 at approximately 12:05 PM, Registered Nurse #3 stated they could not remember the exact date, at around 11:00 AM while administering medication to another resident, Resident #52's family reported the resident's mitten was tied to the bed rail. Registered Nurse #3 stated they observed Resident #52 who was wearing a left hand mitten with the string tied to the side rail of the bed. They stated they immediately released the ties, removed the hand mitten, and did an assessment of the skin, circulation, and range of motion. They stated they notified the nursing supervisor.During an interview on 06/10/2026 approximately 11:00 AM, the Director of Nursing stated that on 10/03/2024, they were informed that Resident #52's next of kin reported during an interdisciplinary meeting that the resident's left hand mitten was tied to the side of the bed. The resident was assessed and nursing staff were re-educated on restraints. The Director of Nursing stated they investigated the incident and concluded no abuse or neglect had occurred.During an interview on 06/11/2026 at approximately 10:16 AM, the Administrator stated they were not aware of the alleged incident that Resident #52's left hand mitten was tied to the bed rail.10 New York Codes, Rules and Regulations 415.3(d)(1)(vii)

Based on observation, record review, and interviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility, including to the State Survey Agency. This was evident in two (Residents #52 and #75) of five residents reviewed for abuse and accidents out of 35 total sampled residents. Specifically, 1.) On 09/26/2024, Resident #52 was observed by a licensed nurse with the hand mitten tied to the bedrail restricting the resident's movement. This alleged violation was not reported immediately to the Administrator. In addition, this alleged violation was not reported to the New York State Department of Health within the required timeframe. 2.) On 05/01/2026, Resident #75's family reported that a staff allegedly hit Resident #75 on the face. This facility failed to report this abuse allegation to the New York State Department of Health within the required timeframe. Refer to F604 - Right to be Free from Physical RestraintsRefer to F656 - Develop/Implement Comprehensive Care Plan The findings include: The facility's Abuse, Neglect, Mistreatment, Exploitation, and Misappropriation of Property Policy, reviewed May 2026, required all allegations involving abuse or resulting in serious bodily injury to be reported immediately, but no later than two hours after the allegation was made, to the Administrator and the appropriate state agency; or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 1. Resident #52 had diagnoses that included chronic respiratory failure, ventilator dependent with a tracheostomy tube, restlessness, and agitation. The Minimum Data Set (a resident assessment tool) assessment dated [DATE] documented that Resident #52 had severe cognitive impairment. The facility's Accident/Incident Report dated 10/03/2024 documented, on 09/26/2024 at 11:00 AM, the resident's family reported that Resident #52's left hand mitten had been tied to the bed side rail. The licensed staff's written statement documented that the resident's family approached them and reported that the resident's left hand mitten was tied to the bed siderail. They immediately released the tie and did a thorough physical assessment and no injury was noted. The Registered Nurse Supervisor was immediately notified. During an interview on 06/10/2026 at approximately 11:00 AM, the Director of Nursing stated the incident occurred on 09/26/2024 and was not reported to the Director of Nursing or the Administrator when it occurred. The Director of Nursing stated the nurse supervisor addressed the concern with an assessment and staff in-service but did not elevate the allegation to the Director of Nursing or the Administrator. During an interview on 06/11/2026 at approximately 10:16 AM, the Administrator stated allegations of abuse are required to be reported immediately to the Director of Nursing and Administrator for reporting to the Department of Health. The Administrator stated they were not aware of Resident #52's allegation. 2. Resident #75 had diagnoses that included cerebrovascular accident with left hemiplegia and hemiparesis (paralysis and weakness of the left extremities), diabetes mellitus, and major depressive disorder. The Minimum Data Set assessment dated [DATE] documented that Resident #75 was cognitively intact, required maximal assistance for bathing, dressing and mobility, and was dependent on transfers. The facility's incident report documented on 05/04/2026, the Director of Social Service received an email from Resident #75's family member reporting that the resident alleged being struck in the face by a nursing assistant on 05/01/2026. The facility initiated an abuse investigation on 05/04/2026 and concluded there was no evidence of abuse, neglect, or mistreatment. The nursing home investigative report documented that the facility staff was made aware of the incident on 05/04/2026 at 10:45 AM. The alleged abuse was submitted to the New York State Department of Health on 05/04/2026 at 6:24 PM. During an interview on 06/09/2026 at 12:30 PM, the Director of Social Service stated the email reporting that the allegation was received on 05/01/2026 but was not reviewed until 05/04/2026 to which they telephoned the resident's son at 10:49 AM. The resident was also contacted, and Director of Nursing was notified. During an interview on 06/10/2026 at 3:57 PM, the Director of Nursing stated the allegation was not reported within two hours because they believed allegations that could not be substantiated could be reported within 24 hours. They stated they received the report on the morning of 05/24/2026 and completed the investigation on the same day and found no evidence of abuse. They stated they reported the incident that same evening to the New York State Department of Health. During an interview on 06/10/2026 at 3:15 PM, the Administrator stated allegations of abuse are required to be reported to the New York State Department of Health within two hours and acknowledged the allegation involving Resident #75 was not reported within the required timeframe. 10 New York Codes, Rules and Regulations 415.4

Based on observation, record review, and interview, the facility failed to ensure a comprehensive person-centered care plan was developed and implemented to address the resident's medical, physical, mental, and psychosocial needs. This was evident in one (Resident # 75) of three residents reviewed for abuse out of 35 total sampled residents. Specifically, following Resident #75's allegation of abuse reported on 05/04/2026, the facility failed to develop and implement an abuse related care plan until 06/01/2026.The findings include:The facility's Care Planning policy, dated May 2026, required individualized, person-centered care plans to be developed, implemented, reviewed, and revised whenever a resident's condition, risks, or identified problems changed. The policy further required event-driven care plan updates to be completed as soon as practicable, ordinarily within 48 hours, following allegations, investigations, or findings involving abuse, neglect, mistreatment, exploitation, or misappropriation of property.Resident #75 had diagnoses that included cerebrovascular accident with left hemiplegia and hemiparesis (paralysis and weakness of the left extremities), diabetes mellitus, and major depressive disorder. The Minimum Data Set assessment dated [DATE] documented that Resident #75 was cognitively intact, required maximal assistance for bathing, dressing and mobility, and was dependent on transfers.The facility's incident report documented that on 05/04/2026, the Director of Social Service received an email from Resident #75's family member reporting that the resident alleged being struck in the face by a nursing assistant on 05/01/2026. The facility initiated an abuse investigation on 05/04/2026 and concluded there was no evidence of abuse, neglect, or mistreatment.A review of the resident's care plan revealed an Abuse/Neglect care plan was not initiated until 06/01/2026. The care plan documented No Reports of Abuse/Neglect and contained no goals or interventions addressing the abuse allegation or investigation initiated on 05/04/2026.During an interview on 06/08/2026 at 12:06 PM, Resident #75's family member stated the resident telephoned them on 05/01/2026 and reported being hit on the right side of the face but gave no additional details. The family member stated they notified the Social Worker by email that day and was later informed the allegation could not be substantiated, although the staff member was removed from the resident's assignment.During an interview on 06/10/2026 at 10:33 AM, Resident #75 stated a nursing assistant hit them on the right side of the face and shoulder after the resident was unable to turn during morning care. The resident stated they cried for help, no one responded, and they subsequently called their son to report.During an interview on 06/10/2026 at 4:58 PM, Registered Nurse #7, the nursing supervisor, stated abuse care plans are initiated when an allegation of abuse is reported. Registered Nurse #7 further stated the abuse care plan for Resident #75 should have been initiated when the allegation was reported on 05/04/2026 and stated the delay until 06/01/2026 was an oversight.During an interview on 06/10/2026 at 3:57 PM, the Director of Nursing stated the abuse care plan should have been initiated at the time of the allegation and investigation on 05/04/2026 with appropriate goals and interventions. The Director of Nursing further stated the nursing supervisor should have initiated the abuse care plan, and the Assistant Director of Nursing should have ensured the care plan was initiated. 10 New York Codes, Rules and Regulations 415.11(c)(1)

Based on observation, record review, and interview, the facility failed to ensure quarterly Minimum Data Set assessments were completed within the required timeframe. This was evident in three (Residents #23, #59, and #225) of 13 residents reviewed for resident assessment. Specifically, the quarterly Minimum Data Set assessments were not completed within 14 days of the Assessment Reference Date.The findings include:The facility's policy and procedure dated 05/2026 titled Resident Assessment Instrument, Minimum Data Set, Care Area Assessment, Care Planning, Transmission, and Quality Assurance Policy required all Minimum Data Set assessments to be completed and transmitted in accordance with the timeframes established in the Centers for Medicare and Medicaid Services Resident Assessment Instrument Manual.Resident #23's quarterly Minimum Data Set assessment with a reference date of 05/21/2025 was completed on 06/10/2025. The Centers for Medicare & Medicaid Services Minimum Data Set 3.0 Nursing Home Final Validation Report documented Resident #23's Minimum Data Set assessment was completed late, more than 14 days after the assessment reference date.Resident #59's quarterly Minimum Data Set Assessment with a reference date of 03/14/2026 was completed on 05/07/2026. The Centers for Medicare & Medicaid Services Minimum Data Set 3.0 Nursing Home Final Validation Report documented Resident #59's Minimum Data Set assessment was completed late, more than 14 days after the assessment reference date.Resident #225's quarterly Minimum Data Set Assessment with a reference date of 02/10/2025 was completed on 03/11/2025. The Centers for Medicare & Medicaid Services Minimum Data Set 3.0 Nursing Home Final Validation Report documented Resident #59's Minimum Data Set assessment was completed late, more than 14 days after the assessment reference date.During an interview on 06/12/2026 at approximately 10:10 AM, the Minimum Data Set Director acknowledged the quarterly Minimum Data Set assessments were not completed timely and stated the delays occurred because they were working alone.10 New York Codes, Rules and Regulations 415.11(a)(4)

Based on observation, record review, and interview, the facility failed to ensure Minimum Data Set assessments were electronically transmitted to the Centers of Medicare/Medicaid Services Data System within 14 days after assessments were completed. This was evident in two (Residents #98 and #149) of 13 residents reviewed for timely Minimum Data Set transmission. Specifically, quarterly [NAME] Data Set assessments for Residents #98 and #149 were submitted after the required timeframe.The findings include:The facility's policy and procedure dated 05/2026 titled Resident Assessment Instrument, Minimum Data Set, Care Area Assessment, Care Planning, Transmission, and Quality Assurance Policy required all Minimum Data Set assessments to be completed, electronically transmitted, and accepted by Centers for Medicare and Medicaid Services no later than 14 days after the Minimum Data Set completion date. The policy required compliance with CMS transmission deadlines for all required assessments.Resident #98's Quarterly Minimum Data Set assessment was completed on 05/20/2026 and was transmitted to the Centers for Medicare and Medicaid Services Data System on 06/04/2026.Resident #149's Quarterly Minimum Data Set assessment was completed on 05/26/2025 and was transmitted to the Centers for Medicare and Medicaid Services Data System on 06/10/2025.A second Quarterly Minimum Data Set assessment was completed for Resident #149 on 11/26/2025 and was transmitted to the Centers for Medicare and Medicaid Services Data System on 01/02/2026.A third Quarterly Minimum Data Set assessment was completed for Resident #149 on 05/12/2026 and was transmitted to the Centers for Medicare and Medicaid Services Data System on 06/03/2026.During an interview on 06/12/2026 at approximately 10:10 AM, the Minimum Data Set Director acknowledged the quarterly Minimum Data Set assessments were submitted late and stated the delays occurred because they were working alone. 10 New York Codes, Rules and Regulation 415.11

Based on observation, record review, and interviews, the facility failed to ensure the Minimum Data Set assessments accurately reflected residents' clinical status. This was evident in two (Residents #21 and #29) of 38 total sampled residents. Specifically, The Minimum Data Set assessment inaccurately documented internal bleeding for Resident #21, and failed to identify an indwelling urinary catheter for Resident #29. The findings include: A review of the facility's policy titled Resident Assessment Instrument, Minimum Data Set, Care Are Assessment, Care Planning, Transmission, and Quality Assurance Policy', last revised on 05/2026, required the facility to complete accurate resident assessments in accordance with Centers for Medicare & Medicaid Services requirements. 1) Resident #21 had diagnoses of dementia, anemia, and pulmonary embolism. The Annual Minimum Data Set assessment dated [DATE] documented Resident #21 was receiving anticoagulant therapy and had internal bleeding. The physician orders dated 10/31/2025 documented Xarelto 10 milligrams daily and Aspirin at 81 milligrams daily. There was no documentation supporting that Resident #21 experienced internal bleeding. During an interview on 06/10/2026 at 11:18 AM, Registered Nurse #2 stated there was no documentation or report that Resident #21 had abnormal or internal bleeding. During an interview on 06/10/2026 at 1:19 PM, Minimum Data Set Assessor #1 stated they documented internal bleeding in error. During an interview on 06/10/2026 at 1:22 PM, the Minimum Data Set Director stated the Minimum Data Set was coded incorrectly and confirmed the documentation of internal bleeding was an error. 2. Resident #29 had diagnoses that included urinary retention, benign prostatic hyperplasia, obstructive and reflux uropathy. A nurse admission progress note dated 04/22/2026 documented Resident #29 was readmitted to the facility with a foley catheter attached to a drainage bag. A care plan for indwelling urinary catheter was initiated on 04/22/2026. The Comprehensive Minimum Data Set assessment dated [DATE] did not identify the resident as having an indwelling urinary catheter. Section H0100A, Bladder and Bowel, was left blank. During an interview on 06/11/2026 at approximately 10:44 AM, Minimum Data Set Assessor #2 stated the information entered into Resident #29's Minimum Data Set was intended for another resident and acknowledged that the assessment was completed in error. During an interview conducted on 06/11/2026 at approximately 10:39 AM, Minimum Data Set Director stated Resident #29's Minimum Data Set assessment should have been coded to reflect an indwelling urinary catheter. They acknowledged responsibility for ensuring the accuracy of completed assessments. 10 New York Codes, Rules and Regulations 415.11(b)

Based on observation, record review, and interviews conducted during a survey, the facility failed to ensure that each resident received adequate supervision to prevent elopement. This was evident for one (1) out of three (3) residents (Resident #1) sampled for elopement. Specifically, on two (2) occasions Resident #1exited the facility without the facility's knowledge and supervision. On 08/03/2025 at 5:57 PM, Housekeeping [NAME] #1 left the facility's exit back door alarm disabled and Resident #1 exited the facility without activating the alarm. Resident #1 was located at their adult sibling's house and transferred to hospital. Resident #1 returned to the facility on [DATE] at 9:15 PM with no injury. On 12/31/2025 at 2:25 AM, Resident #1 exited the front door after Security Guard #1 pressed the button at front desk to open the door and let Resident #1 out of the facility. Resident #1 was located by a family member on 01/01/2026 at 2:30 PM and was taken to the emergency room. Resident #1 returned to facility on 01/02/2026 at 3:47 AM without any injury. The findings include:The facility's policy and procedure titled, Elopement Prevention and Elopement dated 01/2025 documented it is the policy of the facility that residents will be maintained in safe and secure manner and protected from actual harm while encouraging a restraint free environment. The facility will make every positive effort to identify residents who have the potential for elopement.The facility's policy and procedure titled, Delivery Door Alarm Override dated 01/2025 documented it is the policy to ensure safety and security of residents, staff, visitors, and facility property while permitting necessary operational access through the delivery door. This policy establishes clear requirements for the controlled use of the delivery door alarm override key and is intended to prevent unauthorized access, resident elopement, and security breaches in compliance with New York State Department of Health regulations. The alarm override key may be utilized by authorized staff for operational purposes only and must be used in a manner that ensures continuous supervision of the door and immediate re-arming of the alarm once the task is completed. The morning porter and evening porter are authorized to utilize the delivery door alarm override key for deliveries and trash removal. Authorizations are limited to the performance of assigned duties and do not permit unsupervised or prolonged disarming of the alarm.The facility's policy and procedure titled Reception Logging In and Out, dated 01/2025 documented all visitors must log in upon entering and log out when leaving the facility in a logbook at the reception area. Receptionist/security guard/designee assigned at the reception area will assess all visitors for appropriate identity, are they a visitor resident. Do not allow anyone to leave the building without knowing if it is a visitor or a resident.Resident #1 was admitted to the facility with diagnoses including depression( mood disorder that causes feeling of sadness and loss of interest) and schizophrenia (serious mental illness that affects how a person thinks, feels and behaves).Incident 08/03/2025The Minimum Data Set (an assessment tool) dated 07/24/2025 documented Resident #1 had intact cognition. Resident #1 ambulates with supervision or touching assistance.An admission elopement and unsafe wandering screen dated 07/17/2025 documented that Resident #1 was not at risk for elopement/wandering.A review of hourly rounds monitoring form dated 08/03/3035 at 5:00 PM, documented code 15 (observed in bed awake) for Resident #1 location.A review of facility digital video recording timeline of events dated 08/03/2025 (camera was not calibrated correctly, there is an hour, and 3 minutes delayed) on digital video recorder showed at 16:54:46 (5:54 PM real time) Resident #1 observed walking down the hallway and exited through the exit back door on the first floor. At 16:54: 58 (5:57 PM) Resident #1 exited through the back door.A review of the facility's internal investigation form dated 08/03/2025 at 7:15 PM, documented Licensed Practical Nurse #1 noted Resident #1 was not in their room prior to medication administration. A search was done on the unit and all other areas. Registered Nurse Supervisor #1 was notified at 7:25 PM and a head count was called on all units. At 7:45 PM, Resident #1 was not visible in the facility. The Director of Nursing and Administrator was notified and responded at 8:10 PM. Emergency number 911 was called and responded at 9:45 PM. The facility reviewed their surveillance recording and showed Resident #1 exited the facility ground through the exit back door at approximately 5:57 PM. At 10:10 PM, Resident #1's family member called the Administrator and stated Resident #1 was at their adult sibling's house. Resident #1 was transferred to hospital and returned to the facility on [DATE] at 9:15 PM in stable condition.A late entry nursing note dated 08/04/2025 at 1:10 AM by Registered Nurse Supervisor #1 documented notified by Licensed Practical Nurse #1 that prior to giving medications on 08/03/2025 approximately 7:15 PM, Resident #1 was missing from their room and further reported they checked/searched rooms, bathrooms, closets in the unit and stairs, Resident #1 could not be found. All units were notified. The Director of Nursing, Assistant Director of Nursing, Administrator, Medical Doctor and family member #1 were notified. 911 was called and responded at 9:45 PM. At approximately 10:25 PM, the administrator called that Resident #1 was found by their family member at Resident #1's adult sibling 's house. Resident #1 was transferred to emergency room for evaluation.A nursing note dated 08/04/2025 at 9:15 PM by Registered Nurse Supervisor #4 documented Resident #1 returned from the hospital at 9:15 PM with no recommendations. A wander alert guard was applied to Resident #1's left wrist.During an interview on 01/05/2026 at 12:39 PM, Housekeeping [NAME] #1 stated they worked in the evening shift (3:00 PM-11:00 PM) on 08/03/2025. Housekeeping [NAME] #1 stated they used the back door exit to throw the garbage in the designated container between 7:00 PM to 10:30PM. Housekeeping [NAME] #1 stated they have the key to the exit back door to disable the alarm. Housekeeping [NAME] #1 stated they remember locking the exit back door with their key. Housekeeping [NAME] #1 stated prior to the end of their shift they locked the exit back door. Housekeeping [NAME] #1 stated the exit back door has a code and other staff uses to exit the facility. Housekeeping [NAME] #1 stated they made sure they enabled the alarm after disposal of garbage but maybe they forgot to lock the exit back door and Resident #1 exited. Housekeeping [NAME] #1 stated they notified them that Resident #1 exited the back door to exit the facility. During an interview on 01/06/2026 at 1:13 PM, Certified Nursing Assistant #1 stated they were assigned to Resident #1 on 08/03/2025 on 3:00 PM-11:00 PM shift. Certified Nursing Assistant #1 stated Resident #1 was ambulatory and pleasant with all staff and residents. Certified Nursing Assistant #1 stated they observed Resident #1 approximately at 5:30 PM they finished their dinner and observed holding a coffee cup and went to the next door to other Resident's room. Certified Nursing Assistant #1 stated later the Licensed Practical Nurse #1 came to them and looked for Resident #1. Certified Nursing Assistant #1 stated they started searching for Resident #1 in their unit and even to other units but failed. Certified Nursing Assistant #1 stated Resident #1 did not show any signs of exit seeking behavior and they did not verbalize of wanting to go outside. Certified Nursing Assistant #1 stated because it was dinner time at that time Resident #1 took the opportunity to leave the unit without permission and they did not notice them. Certified Nursing Assistant #1 stated they did not suspect Resident #1 because they keep on saying they liked the facility. Certified Nursing Assistant #1 stated they visually monitored Resident #1 hourly in the unit. During an interview on 01/07/2026 at 10:21 AM, Registered Nurse Supervisor #1 stated they notified them on 08/03/2025 at approximately 7:20 PM by Licensed Practical Nurse #1 that Resident #1 was missing in the unit, and it could not be found despite initial searching. Registered Nurse Supervisor #1 stated they immediately called for headcount of all units (code butterfly initiated), immediate searches of in and out of the facility were conducted. Registered Nurse Supervisor #1 stated they notified 911, Director of Nursing, Assistant Director of Nursing, Administrator and family. Registered Nurse Supervisor #1 stated the administrator arrived in the facility and reviewed the video surveillance and showed that Resident #1 used the exit back door on the first floor without triggering the alarm. Registered Nurse Supervisor #1 stated the exit back door used by the housekeeping porter to dispose the facility's garbage to the designated container. Registered Nurse Supervisor #1 stated the door should alarm but because the housekeeping porter #1 disarmed the door alarm, Resident #1 exited the facility unsupervised, and the exit back door did not alarm. Registered Nurse Supervisor #1 stated Resident #1 was located within three (3) hours and transferred to hospital for evaluation and returned to facility in a stable condition. Registered Nurse Supervisor #1 stated Resident #1 was oriented three (3) times and able to make needs known. Registered Nurse Supervisor #1 stated they interviewed Resident #1, and they apologized for leaving without informing them because they wanted to speak to their adult sibling. Registered Nurse Supervisor #1 stated they placed a wander guard and Resident #1 was monitored every 30 minutes for safety. Incident dated 12/31/2025 The Minimum Data Set (an assessment tool) dated 10/24/2025 documented Resident #1 had intact cognition. Resident #1 ambulates with supervision or touching assistance. A comprehensive care plan for elopement-wandering initiated dated 08/04/2025 with interventions applied wander guard to check for placement every shift, wander guard check for placement and function by registered nurse in night shift (11:00 PM-7:00 AM) and to monitor Resident #1 every 30 minutes. The care plan was reviewed on 11/02/2025 with no changes.The Physician's order dated 08/05/2025 Resident #1 had ordered wander guard check for placement every shift, report if missing every eight (8) hours and wander guard check for placement and function every night shift.An elopement evaluation dated 11/07/25 at 10:01 PM documented Resident #1 had history of elopement and voices desire to leave. Resident #1 identified at risk for elopement.The Visual/Bedside Kardex Report dated 11/07/2025 documented Resident #1 was on hourly round monitoring and wander guard applied to left wrist, check placement/skin integrity and if missing and skin impairment observed, notify the nurse. A review of the hourly monitoring form revealed there was no documented monitoring performed for Resident #1 on 12/31/2025. The facility review of timeline of events from video surveillance recording dated 12/31/2025 revealed a digital video recording #1, at 2:19:03, Resident #1 leaves the unit and gets on the elevator. A digital video recording #2 (camera was not calibrated correctly- an hour and two (2) minutes delayed). At 3:25:28 (2:25 AM), Resident #1 appeared at the front desk walking towards the front door, wearing hat, blue jacket and jeans. At 3:25:34, Security Guard #1 clicked to unlock the door for Resident #1 to leave. At 3:25:50, Security Guard #1 stood up and went to front door to check whom they let out of the door. At 3:26:34 (2:26 AM), Security Guard #1 retrieved a box to use a doorstep so they can check who they let out of the building. At 3:28:20 (2:28 AM) Security Guard #1 returned to their seat at the front desk without reporting the incident. A digital video recording #3 (camera was off by 57 minutes) revealed at 3:21:38 Resident #1 appeared outside the front door. At 3:21:46, Resident #1 goes down the block. At 3:22:47, Security Guard #1 goes outside to look for who left the building. At 3:23:46, Security Guard #1 goes back inside the facility. A review of Internal investigation dated 12/31/2025 documented at approximately 3:00 AM, Certified Nursing Assistant #3 entered Resident 1's room to do their hourly checks and noted Resident #1 was not in their room and thorough search was done. Resident #1 was last seen in their room at 2:00 AM sitting on their bed. The Registered Nurse Supervisor #3 was notified, and a search of the whole building and surrounding areas was immediately done. 911 was notified and responded in ten (10) minutes. The Director of Nursing and Administrator arrived at the facility. The family was notified. The facility reviewed their surveillance recording and showed Resident #1 exited the facility through the front door wearing a thick blue jacket, a hat and blue jeans. Security Guard #1 let Resident #1 out because they do not look like a resident but then followed outside but no longer seen. A Certified Nursing Assistant who was in their break inside their car did not recognized Resident #1. Security Guard #1 did not inform the Registered Nurse Supervisor #3 of the occurrence. Security Guard #1 was suspended pending investigation. On 01/01/2026 at approximately 2:30 PM, administrator received a call from family member #1 that Resident #1 was located at a store. 911 was notified and Resident #1 was transferred to hospital for evaluation. Resident #1 stated they left the facility because they had a misunderstanding with family member #1 and adult sibling #1. Resident #1 returned to facility on 01/02/2026 at 3:47 AM in stable condition. Resident #1 was placed on one-to-one supervision. Wander guard was applied. The facility concluded that there was no abuse, neglect and/or mistreatment identified. A nursing note dated 12/31/2025 at 6:34 AM by Licensed Practical Nurse #2 documented at approximately 3:00 AM Certified Nursing Assistant #3 notified them that Resident #1 was missing in their room, and their wander guard was left in their room. They immediately searched everywhere in the building without success. Licensed Practical Nurse #2 documented they called the Security Guard #1 at the front desk who reported that a man matched the description who left the building at approximately 2:40 AM. Licensed Practical Nurse #2 notified Registered Nurse Supervisor #3, 911 was called, family notified, and a missing resident was initiated. 911 responded. The family, assistant director of nursing, director of nursing and administrator were notified. During an interview on 01/05/202 at 2:02 PM, Security Guard #1 stated they worked on 12/31/2025 from 12:00 midnight to 8:00 AM. Security Guard #1 stated when Resident #1 appeared in the lobby walking from approximately 2:20 to 2:25 AM. Security Guard #1 stated Resident #1 does not look like a resident in the facility. Security Guard #1 stated they asked them to sign but refused and they let them go out of the facility. Security Guard #1 stated when they realized why they let them go they stood up right away and followed them outside. Security Guard #1 stated they saw a staff member who was inside their car question them if they saw Resident #1 and they said they did not see them. Security Guard #1 stated then later a staff member looking for Resident #1. Security Guard #1 stated they notified Registered Nurse Supervisor #3 of the incident. Security Guard #1 stated they know the policy that any visitor that comes to the facility must sign in and sign out. Security Guard #1 stated that any staff or visitor cannot exit in the front door until the button is pressed or clicked out to exit by them. Security Guard #1 stated they were suspended from their work. During an interview on 01/07/2026 at 8:37 AM, Certified Nursing Assistant #3 stated they were assigned to Resident #1 on 12/31/2025 in the night shift (11:00 PM-7:00 AM). Certified Nursing Assistant #3 stated Resident #1 has wander guard in place when they did their rounds in the unit. Certified Nursing Assistant #3 stated Resident #1 was ambulatory and at approximately 1:30 AM, they observed Resident #1 walked to the vending machine to buy snacks and they went back to their room. Certified Nursing Assistant #3 stated Resident #1's had a routine of being awake around 1:00 AM to 3:00 AM to buy snacks, watch television and lay down in their bed. Certified Nursing Assistant #3 stated they checked Resident #1 approximately 2:00 AM, they were in their room sitting in bed watching television. Certified Nursing Assistant #3 stated at approximately 3:00 AM, they went to Resident #1's room to check after they attended care of other resident and did not see Resident #1 in their room. Certified Nursing Assistant #3 stated they notified Licensed Practical Nurse #2, and all staff checked the whole unit but were unsuccessful. Certified Nursing Assistant #3 stated they did not observe Resident #1 with signs of wanting to go outside or did not verbalize to them that they wanted to leave the facility. Certified Nursing Assistant #3 stated they found Resident #1's wander guard at their bedside. During an interview on 01/07/2026 at 8:24 AM, Registered Nurse Supervisor #3 stated they worked on 12/30/2025 from 11:00 PM to 7:00 AM. Registered Nurse Supervisor #3 stated they notified them by Licensed Practical Nurse #2 on 12/31/2025 approximately 3:15 AM that Resident #1 was in their room at 2:00 AM and while during their rounds at 3:00 AM, Resident #1 cannot be found. Registered Nurse Supervisor #3 stated they activated the elopement (code butterfly), and all units did head count, searching all units and surrounding areas of the facility. Registered Nurse Supervisor #3 stated when they saw security guard #1 approximately 3:30 AM, they asked them and provided description of Resident #1. Registered Nurse Supervisor #3 stated security guard #1 said the description matched Resident #1 that does not look like a resident, they were asked to sign out but refused and allowed to leave the facility. Registered Nurse Supervisor #3 stated the security guard #1 did not report the occurrence to them initially. Registered Nurse Supervisor #3 stated they notified 911, Director of Nursing, Assistant Director of Nursing, Medical Doctor, Administrator and family immediately. Registered Nurse Supervisor #3 stated Resident #1 was confirmed missing in the facility at approximately 3:30 AM. The police arrived at approximately 3:40 AM. Registered Nurse Supervisor #3 stated Resident #1 had their wander guard checked for functioning done prior the incident. Registered Nurse Supervisor #3 stated they found the wander guard at Resident #1's bedside table cut off. During an interview on 01/02/2026 at 2:41 PM, Director of Nursing stated they were notified on 08/03/2025 incident approximately 7:45 PM by Registered Nurse Supervisor #1 and reported that Resident #1 was missing and cannot be found. Director of Nursing stated Resident #1 was identified not at risk for elopement and there were no signs of exit seeking behavior since their admission. Director of Nursing stated that through the help of family member #1 Resident #1 was located in their adult sibling #1's house. Director of Nursing stated 911 was called and taken Resident #1 to the hospital for evaluation. Director of Nursing stated the Housekeeping [NAME] #1 was suspended and eventually terminated. Director of Nursing stated Resident #1 eloped the second time and Resident #1 exited the facility ground when Security Guard #1 allowed Resident #1 to exit without identifying them prior pressing the button in their desk. Director of Nursing stated they observed Resident #1's wander guard's bracelet cut off and found at Resident #1's bedside table. Director of Nursing stated Resident #1 used a plastic butter knife to cut the wander guard bracelet. Director of Nursing stated to prevent the recurrence Resident #1 was placed to one-to-one supervision and to remove the plastic utensils after each meal. Director of Nursing stated they provided facility wide in-service to all staff on elopement prevention. During an interview on 01/07/2026 at 11:40 AM, Administrator stated they were aware of both incidents on 08/03/2025 and 12/31/2025 by Registered Nursing Supervisors #1 and #3. Administrator stated both incidents video surveillance recordings were reviewed right after the incident and confirmed that Resident #1 exited the facility ground unsupervised. Administrator stated after reviewing the video surveillance, they confirmed that Resident #1 exited the exit back door, and no alarm was triggered because it was off. Administrator stated the Housekeeping [NAME] #1 provided them with a statement and after they reviewed the video surveillance, the Housekeeping [NAME] #1 provided a second statement of what really happened. Administrator stated the incident on 12/31/2025 the Security Guard #1 did not follow the facility policy protocol that if anyone exiting the facility, they should find out if it is a resident or visitor before exiting and they must sign out prior leaving the facility. The Administrator stated when they reviewed the video surveillance, they observed Security Guard #1 allowed Resident #1 to exit the facility without asking them and did not report to Registered Nurse Supervisor #3 of the incident. The Administrator stated they have lists of residents with pictures at risk for elopement posted at the front desk. Security Guard #1 was suspended and reported to their agency. 10New York Codes, Rules, and Regulations 415.12(h)(2)

Based on observations and interviews during the recertification survey on 07/31/2024 to 08/07/2024 the facility did not ensure that housekeeping and maintenance services were provided to maintain a safe, clean, comfortable, and homelike environment. Specifically, observations of multiple floors revealed rooms, corridors, and dining rooms with chipped, broken plaster, bubbled up paint, furniture and wall hanging in disrepair, torn window screens, loose and dirty moldings. This was evident on 5 of 6 Units. (Units 3, 7, 2, 5, and 6) The findings include but are not limited to: The facility policy & procedure titled Environmental Services Policy revised 01/24 documented that the facility is committed to provide a safe, sanitary, comfortable, and attractive environment for our residents, staff, and visitors. 1. During the initial tour of Unit 3 on 07/31/2024 at 10:00AM the following was observed: Rooms 311, 313, 314, 315, 318 and 319 were observed with, -rusted air conditioners and the walls had peeling paint. -some air conditioners leaking and there was linen on the floors to absorb the leaking water. -the corners of the rooms with accumulated dust and dirt. _window sills with accumulated dirt on the corners and cracks. -the bathroom door in room [ROOM NUMBER] was with splattered a dried, reddish, brownish colored substance. The Dining room had a Cabinet labeled Recreation which was rusty and dirty. During a Quality Assurance interview on 08/07/2024 at 4:00 PM, the Administrator stated that weekly rounds are done with the Building Maintenance and Housekeeping Director, and they are aware of the need of painting in some areas of the facility. The Administrator also stated that they are in the process of reviewing plans and receiving contract quotes. 41709 2. During observations on 08/01/24 at 12:25 PM through 08/07/24 at 08:55 AM the following was observed: room [ROOM NUMBER] Broken plaster surrounding the air conditioner unit and on wall above the unit. The air conditioner was leaking and there was a pink container under the unit with water in it and a white sheet was spread on the floor. room [ROOM NUMBER] Air conditioner was leaking, clear fluid observed on floor. A white sheet was spread under the air conditioner which was wet, with clear water around the sheet. Above the air conditioner was rusted with dark brown areas. 7th Floor: Stained blood pressure cuff. Broken uneven ceiling tiles outside room [ROOM NUMBER]. room [ROOM NUMBER]: Large hole opening just above the room air conditioner. Broken peeling plaster. Broken dresser and missing dresser drawer. On 08/06/24 at 10:53 AM, an interview was conducted with Housekeeper #2 assigned to the unit for the unit who stated that leaking air conditioners were all reported to maintenance, and they are working to fix the areas. On 08/06/24 at 11:02 AM, an interview was conducted with Certified Nursing Assistant #8 who stated that the air conditioner in room [ROOM NUMBER] leaks and staff put a sheet and a container under the air conditioner to collect the water. Certified Nursing Assistant #8 also stated that they did not put the sheet down originally, but they replace the sheet when it is wet. The issue was reported to the nurse, and they believe maintenance is working on the area to fix it. Certified Nursing Assistant #8 further stated they followed the chain of command when reporting to the nurse and put it in the log book on the unit but was unable to show the State Surveyor the log book for the unit. On 08/06/24 at 11:08 AM, an interview was completed with Registered Nurse Supervisor #1 who stated that there is protocol for reporting environmental issues: staff will report to the nurse and the nurse will report to the Registered Nurse Supervisor who will place it in the red book on the unit. Registered Nurse Supervisor#1 was unable to show the State Surveyor the red book on the unit. Registered Nurse Supervisor #1 stated they are aware that the air conditioner is leaking, and of the issues in room [ROOM NUMBER]. Maintenance was made aware of the issues and the air conditioner company has been contacted for parts. 19546 3. During observations made on 07/31/24 at 10:03 AM, and on 08/07/24 at 08:18 AM, the following environmental concerns were noted: 2nd Floor Dining Room: Torn stained window shades. Ceiling tiles above the television were uneven, and not firmly affixed to ceiling. Broken chipped plaster. Accumulation of dirt and dust on top of the air conditioner Window frame with broken plaster Radiators: dried yellowish stains layered with dirt and dust. Five (5) of nine (9) blue vinyl chairs with torn and cracked seat cushion Molding embedded with dirt and dust. 2nd Floor Corridor: Corridor wall paper torn, stained dirty. Loose molding in across Pantry Door. Corridor moldings layered with dirt dust and debris. room [ROOM NUMBER]: Cracked broken plaster and bubbled up paint around window and ceiling area. Missing wall tile in room bathroom. Large patch of plaster underneath bathroom sink. Splintered bathroom door. Bathroom door splintered and does not fully close. room [ROOM NUMBER]: Chipped ceiling paint above window area. Splintered bathroom door. Room door does not fully close. room [ROOM NUMBER]: Peeled cracked ceiling paint above window area. room [ROOM NUMBER]: Torn window screen. Bent window shade. room [ROOM NUMBER] b: Cracked and peeled paint. Head board in disrepair. Squeaky noise when cranked in the up or down position. On 08/07/24, review of the 2nd floor Maintenance Log Book dated from 08/25/23 to 10/24/23 contained no documented evidence of the above concerns. Other observations included: 5th Floor: room [ROOM NUMBER] c stained and dirty privacy curtains. Blood pressure stand embedded with dirt and dust observed on the low side of the corridor. 6th Floor: Dining Room: broken picture frame hanging slanted on the wall. Missing ceiling tiles. room [ROOM NUMBER]: Torn wall paper. Broken paint and plaster to the wall around the air conditioner. room [ROOM NUMBER] a: Feeding pump pole stained with dried encrusted substance. Wall behind the bed stained and streaked. Orange colored wheelchair armrest torn and cracked. On 08/07/24 at 10:26 AM, Certified Nurse Aide # 4 was interviewed and stated that a maintenance log book is located at the nurse station. When we have to notify the maintenance department to repair or replace something we can write it on the book or just notify the unit nurse. The housekeeper is always on the unit, and we can easily go to them to report a concern that needs to be taken of right away. On 08/07/24 at 10:37 AM, Registered Nurse Supervisor # 3 was interviewed and stated that a call to the Maintenance Department will be made if issues or concerns are reported or identified. We keep log book on the unit where anyone can make note of any environmental issues. Our housekeeper is always on the unit, and we can directly advise them of anything to be addressed. We can also notify the operator to notify the Maintenance department as they do carry their walkie talkie for emergent concerns. On 08/07/24 at 10:46 AM, Housekeeper # 1 was interviewed and stated that there a regular cleaning routine that is followed daily on the units. Housekeeper # 1 also stated that the feeding pump poles are the responsibility of housekeeping services but not the pump itself when in use. Privacy curtains are changed when needed and are often changed due for cleaning or they are replaced. Housekeeper # 1 further stated that the dirt on the molding has been difficult to remove, and the wallpaper is cleaned but there are stains that are difficult to remove. On 08/07/24 at 10:59 AM, the Director of Housekeeping Services stated that their role is important and ensures the facility is sanitized and help control the spread of infection to protect staff residents and visitors. The Director of Housekeeping Services also stated that they make daily rounds and at times more frequent rounds and sometimes come in on weekends for the purpose of ensuring a safe and clean environment, and to ensure that staff has access to the necessary cleaning supplies to perform their jobs. The Director of Housekeeping Services further stated that there have been occasions when making my rounds that they come across staff concerns regarding proper cleaning protocol, and they do on the spot in service to correct the issue. The Director of Housekeeping Services stated that privacy curtains are changed every three months and as needed, and their department is responsible for ensuring that all resident equipment is safe and clean which includes wheelchairs, blood pressure stands, intravenous poles and walls. 2 wheelchairs are washed each week on each floor. The Director of Housekeeping Services also stated that they all have the responsibility for communicating across departments in identifying environmental concerns. On 08/07/24 at 11:51 AM, the Director of Maintenance stated they are responsible for the safety, maintenance, and repair of the entire facility to ensure safety for all staff residents and visitors. The Director of Maintenance also stated that the facility is near the beach which creates an environment of high salt content. Environmental factors especially with heavy rains cause water to seep inside the building and the bubbled and cracked plaster is a response to the water seepage. On 08/07/24 at 12:27 PM, the Administrator was interviewed and stated they are responsible for the overall environmental safety for all residents staff and visitors. The Administrator also stated that the 4th Unit was entirely replaced approximately 1 year and a half ago, with new floors, walls, resident rooms, nurse station, furniture. This floor was chosen to be done first because there was less disruption to the residents and the floor was most in need at the time. The Administrator stated that a plan was being talked about to renew other units. 10 NYCRR 415.5(h)(2)

Based on interviews and record review conducted during the Recertification survey from 07/31/2024 to 08/07/2024, the facility did not ensure a resident, or their designated representative was provided appropriate notification at the termination of Medicare Part A benefits. This was evident for 1 (Resident #581) of 3 residents reviewed for Beneficiary Notification out of 38 total sampled residents. Specifically, the Notice of Medicare Non-Coverage was not mailed out to Resident #581 designated representative on the same day that telephonic notification was made. The facility policy titled Notice of Medicare Non-Coverage, Benefits Exhaust Letter with an effective date of 1/2024 states that the notice must be validly delivered which means that the beneficiary must be able to understand the purpose and contents of the notice to sign for receipt of it. If the beneficiary is not able to comprehend the contents of the notice, it must be delivered and signed by a representative. A copy of the notice will then be mailed via certified mail and all notices will be kept in a binder in the MDS Office. Resident #581 was discharged from skilled services on 03/28/2024 to Assisted Living Facility. The Notice of Medicare Non-Coverage form documented a note written by Minimum Data Set Coordinator on 03/25/2024 which stated that Resident #581 met their rehab goal and returned to prior level of function. Resident was unable to sign due to cognition and Next of Kin was notified. The Notice of Medicare Non-Coverage form did not document the date and time of notification, and how the notification was done. In addition, there was no documented evidence provided that the Notice of Medicare Non-Coverage form had been mailed to Resident #581's Representative. On 08/06/24 at 10:52 AM, the Minimum Data Set Coordinator was interviewed and stated that if a resident is not alert or is confused, the resident's next of kin will be contacted regarding resident's discharge from skilled services. If the next of kin is available in person, they are asked to sign the notice. If not, a phone call to the next of kin would be made. The Minimum Data Set Coordinator also stated that once they have spoken to the resident's next of kin and they agree with the planned discharge from skilled services, then the Notice of Medicare Non- Coverage is not mailed out. If the next of kin does not answer the phone, then the Notice of Medicare Non-Coverage is mailed out. The Minimum Data Set Coordinator further stated that the Notice of Medicare Non-Coverage was not mailed out at all since the next of kin was notified over the phone, however, it should have been mailed out. 10 NYCRR 415.3 (g)(2)(i)

Based on observation and interview conducted during the Recertification survey from 07/31/2024 to 08/07/2024 the facility did not ensure that residents' personal privacy and confidentiality was maintained. Specifically, during observation of the Medication Administration Task, Registered Nurse #1 left the computer screen on the Electronic Health Record open and in public view displaying a resident's Personal Health Information. (Resident #140). The finding is: The facility's policy and procedure dated 04/2024 titled Health Insurance Portability and Accountability Act (HIPPA) documented that it is a privacy and confidentiality act as it relates to residents' health care related issues. The Lesson Plan for Health Insurance Portability and Accountability Act, dated 04/2024, documented, Do Not leave your computer/laptop unattended when the screen is open showing a resident's information. On 08/01/24 at 8:13 AM, during the Medication Administration Task, Registered Nurse #1 was observed walking away from an open medication cart computer screen, displaying Resident #140's personal health information, On 08/01/24 at 9:31 AM, Registered Nurse #1 was interviewed and stated that forgetting to close the computer screen before entering a residents room to give medications is a violation of the Health Insurance Portability and Accountability Act. Registered Nurse #1 also stated that they are required to close the screen to protect the residents personal information from anyone outside of the residents medical providers. Registered Nurse #1 further stated that they were in-serviced on the Health Insurance Portability and Accountability Act this year. On 08/01/24 at 9:46 AM, Registered Nurse Supervisor #2 was interviewed and stated that closing the computer screen before walking away from the medication cart is to ensure the privacy and confidentiality of the resident's personal health information. Registered Nurse Supervisor #2 also stated that they monitor nursing staff during random medication administration observations to ensure that resident's personal health information is protected and kept confidential, which includes closing the computer screen before walking away from the medication cart. On 08/01/24 at 12:43 PM, the Director of Nursing was interviewed and stated that leaving the computer screen open in view for all to see is in violation of the Health Insurance Portability and Accountability Act which is to ensure the privacy and confidentiality of personal health information of our residents. The Director of Nursing also stated that they provide their nursing staff with ongoing in-services and education about the laws requiring the protection, privacy, and confidentiality of our resident's personal health information. 10 NYCRR 415.3(e)(1)(ii)

Based on observations, interview, and record review conducted during the Recertification Survey from 7/31/2024 to 8/07/2024, the facility did not ensure a resident remained free of physical restraints. This was evidenced for 1 (Resident #10) of 2 residents reviewed for Physical Restraints out of 38 total sampled residents. Specifically, Resident #10 was observed with bilateral half siderails in place and was unable to independently use or release the side rails. The findings are: The facility's policy titled Side Rails dated 01/2024, documented that an assessment will be made to determine the resident's symptoms or reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's bed mobility and the ability to change positions, transfer to and from bed or chair, and to stand and toilet. The use of side rails as an assistive device will be addressed in the resident care plan. Resident #10 was admitted to the unit with diagnoses that include Aphasia, Hemiplegia and Cerebrovascular Accident. The Quarterly Minimum Data Set, dated dated dated [DATE], documented Resident #10 had severely impaired cognition, demonstrated no behaviors, and was dependent on staff for bed mobility, transfers, eating, and toilet use. The Quarterly Minimum Data Set did not document the use of bed rails. The Physician's Order dated 7/1/24 documented enablers, bilateral half side rails use as enablers, for bed mobility and transfers. On 08/01/24 at 10:32 AM, Certified Nursing Assistant #1 was observed performing morning care. Bilateral half side rails that there were raised were observed. Resident #10 was dependent on Certified Nursing Assistant #1 for turning and bed mobility during morning care. When asked to hold on to the side rails, Resident #10 was unable to follow the command to hold on to the side rail to assist with turning. Certified Nursing Assistant #1 then physically turned Resident #10 to the left side and placed Resident #10's hand on the side rail. On 08/02/24 at 09:51 AM and 08/05/24 at 11:16 AM Resident #10 was observed lying in bed, asleep, with bilateral upper half siderails raised. On 08/05/24 at 11:31 AM, Registered Nurse Supervisor #1 was observed talking with Resident #10, who did not respond. Registered Nurse Supervisor #1 asked Resident #10 to hold unto the side rails, however Resident #10 did not respond to the command. The Comprehensive Care Plan titled Side rails as related to use of devices for enhancing bed mobility, onset 11/10/20, reviewed on date 7/14/24. Goal included resident will continue to utilize side rails to help with bed mobility and transfer in the next 90 days, target date of 10/6/24. Interventions include side rail as per Physician's order for mobility and positioning in bed, quarterly and as needed assessment for inability to use side rail to help in turning and further need for side rail use, continue to encourage resident to utilize side rail to assist with turning and positioning and transfer while in bed. The Physical Therapy Progress Note Re-admission Assessment note dated 7/2/24 documented Resident #10 was alert and oriented to name only, and aphasic was not able to follow commands. The Comprehensive Care Plan titled Cognition dated 11/20/20 due to resident's current medical condition, is nonverbal, needs are anticipated and met. Goals include Resident #10 will maintain current level of cognitive status, monitor for changes. The Restraint and Side Rail assessment dated [DATE], documented half side rail that do not prevent rising (not a restraint), and stated that the medical symptom for side rail use was that Resident # 10 uses device/s for enhancing bed mobility. The Restraint and Side Rail Assessment also documented that the Comprehensive Care Plan Team recommends 2 half side rails for enhancing bed mobility. The Side Rails care plan Evaluations note dated 7/1/24 documented patient readmitted from the hospital with diagnosis of hyponatremia. Patient utilizes 2 half side rails for bed mobility. Will continue to monitor and continue plan of care. The Side Rails care plan Evaluations note dated 7/14/24 documented Quarterly review, no complication arises from side rails use, plan of care continues. A Physician's Assistant note dated 7/17/24, documented follow up for functional decline, deconditioning. Assessment and plan documented diagnosis of muscle weakness, contracture of muscle, deconditioning, walking difficulty. A Physiatry consultant note dated 7/15/24 documented functional decline, deconditioning, seen and examined, documented right side hand and leg contracted, patient not following commands today, used their left hand to pull sheet up on themselves. Recommendations include passive range of motion as tolerated. On 08/01/24 at 10:32 AM, Certified Nursing Assistant #1 was interviewed and stated Resident #10 needs total assistance with turning and positioning and bed mobility. Certified Nursing Assistant #1 also stated that Resident #10 is unable to hold unto the side rails by themselves and can hold onto the side rail for a brief time when the Certified Nursing Assistant places Resident's #10 hand on the side rail. On 08/05/24 at 11:17 AM, Registered Nurse Supervisor #1 was interviewed and stated that a side rail assessment is done quarterly, and they check the patient's cognition and their diagnosis. The side rail is used primarily for bed mobility so the nurse will assess to see if the resident can hold it themselves to change position or to pull up to help them get them out of bed. Registered Nurse Supervisor #1 also stated that the Certified Nursing Assistants must give the command to the resident and see if the residents are able to use it themselves to transfer from bed to chair. Registered Nurse Supervisor #1 further stated that Resident #10 is a two person assist with care, so during the care, one of the care givers will be on the side closest to Resident #10. Registered Nurse Supervisor #1 stated that Resident #10 just returned from the hospital and had experienced a decline. Registered Nurse Supervisor #1 also stated that they did not do the admission assessment for Resident #10 upon return from the hospital on 7/1/24. On 08/05/24 at 11:37 AM, the Physical Therapist Director was interviewed and stated that they did an assessment when Resident #10 was readmitted to the facility on [DATE]. The Physical Therapist Director stated that the Resident #10 requires total assistance with activities of daily living, and that the side rail assessment is done by whoever admits the patient, then it is discussed with the interdisciplinary team and in the care plan meeting, where they decide on implementing the use of the side rails. It is the Nurse Manager who would complete the side rail forms. The Physical Therapist Director also said that it is documented as such in the chart, since Resident #10 cannot follow commands, that the side rails are used to facilitate the Certified Nursing Assistants for bed boundaries when they take care of the resident. On 08/05/24 at 12:52 PM, the Director of Nursing was interviewed and stated that Rehab and Nursing assess the needs of the resident and that the criteria for the side rails is for bed mobility. The assessment is done on initial admission, every quarter, and after hospitalization s. The Director of Nursing also stated that Resident #10 is supposed to be able to hold onto the side rails for bed mobility and side rails are not for the Certified Nursing Assistants' use. 10 NYCRR 415.4(a)(2-7)

Based on interview and record review conducted during a Recertification and Abbreviated survey (NY00327342) from 7/31/2024 to 08/07/2024, the facility did not ensure that an alleged violation involving a resident was reported to the New York State Department of Health. This was evident for 1 (Resident #112) of 4 residents reviewed for Abuse out of 38 sampled residents. Specifically, the facility did not report an allegation of abuse to the New York State Department of Health. The findings include: The facility policy titled Abuse, Neglect and Exploitation dated 1/2024 documented that alleged abuse should be reported immediately but no later than 2 hours. If there is serious bodily injury or no later than 24 hours if the events that cause the allegation do not involve abuse and serious bodily injury. Resident #112 was admitted with diagnoses of Aphasia and Cerebrovascular Accident. The Quarterly Minimum Data Set 3.0 assessment dated [DATE] documented Resident #112 had severe cognitive impairment. The Intake Information Form (NY00327342) dated 11/2/23 at 14:21 documented that a family member stated they visited Resident #112 and found their nose and towel were full of blood. The Grievance Resolution Form dated 11/2/23 stated that a family member visited Resident #112 and Resident #112 reported that they had been hit by someone. The Grievance Resolution Form also documented that Resident #112 did not disclose who had hit them, whether it was staff or another resident, and Resident #112 stated that after breakfast they had been hit on the cheek. The Accident/Incident Report dated 11/2/23 at 12:45 PM, documented that Resident #112 verbalized that they had been hit in the nose. There was no documented evidence that an allegation of abuse was reported to the State Survey Agency immediately but not later than two hours after the allegation is made. On 8/7/24 at 3:16 PM, the Director of Nursing was interviewed and stated police officers arrived onsite and stated that they were called by Resident 112's family member regarding blood in Resident #112's nose. The Director of Nursing also stated that they did not see any blood, swelling, or redness in Resident 112's nose, and they did not call the state because they did not see anything to report. On 8/7/24 at 3:47 PM, the Administrator stated that the facility did not report anything to the state about that case because no one saw anything to report to the state. 10 NYCRR 415.4 (b)

Based on record review and staff interviews conducted during the Recertification and Complaint survey (NY00326505) conducted from 07/31/2024 to 08/07/2024, the facility did not ensure that resident Comprehensive Care Plans were reviewed and revised after each assessment. This was evident for 1 (Resident #38) of 5 Residents reviewed for Unnecessary Medications and 1 (Resident #69) of 4 residents reviewed for Abuse out of 38 sampled residents. Specifically, Resident #38 has a diagnosis of Non-Alzheimer's Dementia and the Comprehensive Care Plan for Dementia had not been reviewed and revised, and Resident #69's care plan was not revised to include verbally abusive behavior, biological needs, and verbal sexual expressions toward staff. The findings are: The facility policy titled Care Plans-Comprehensive dated 8/21 stated each resident's comprehensive care plan is designed to identify problem areas and their causes and develop interventions that are targeted and meaningful to the resident. The policy also stated that assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. 1. Resident #38 was admitted to the facility with diagnosis that included Schizoaffective Disorder, Dementia and Sepsis Pneumonia. The Significant Change Minimum Data Set 3.0 dated 5/9/24 document that Resident #38 had moderately impaired cognition. A Comprehensive Care Plan titled Dementia established on 12/19/2023 included a goal of resident will receive the appropriate treatment and services to maintain the highest practicable, physical, mental, and psychosocial well-being through the review date for 90 days. The interventions were to focus on the resident's strengths and remaining available. The care plan was last revised on 3/18/2024. There was no evidence that the Comprehensive Care Plan for Dementia was reviewed or revised after the Significant Change Minimum Data Set, dated dated dated [DATE]. On 8/6/2024 at 11:51 AM, Registered Nurse Supervisor #5 was interviewed and stated that the nurse supervisors are responsible for updating care plans every three months and as needed. Registered Nurse Supervisor #5 also stated that if someone falls or there is any change of condition, the care plan will be reviewed and revised. During the interview, Registered Nurse Supervisor #5 reviewed the record and confirmed that the Dementia care plan had not been updated and did not offer an explanation as to why this was not done. 41709 2. Resident #69 was admitted to the facility with diagnoses of Bipolar Disorder, Schizoaffective Disorder, and Quadriplegia. The Annual Minimum Data Set, dated dated dated [DATE] documented Resident #69 had intact cognitive status. The Minimum Data Set also documented that Resident #69 had impairment in both upper and lower extremities, required dependent care for all Activities of Daily Living, was not ambulatory and had one Stage 2 and one Stage 4 Pressure Ulcer. On 07/31/24 at 10:36 AM, Resident #69 was observed lying in bed and stated that he hears residents and staff having sexual contact with each often but refuse to give specific details of which staff and which residents. A Nursing progress note dated 2/9/2024 documented Resident stated #69 stated they were aware that sexual activity was occurring in the facility, and they can identify the resident that was involved. A Nursing progress note dated 2/13/2024 documented Resident #69 told writer that their testosterone level was too high, and that their penis needed to be relieved. Resident #69 later called an escort service trying to get someone to come to the facility. The Psychiatry Consultation dated 4/19/2024 documented that Resident #69 was seen for agitation and paranoia and calling 911. Resident #69 was currently receiving Risperdal 3 mg twice daily and Depakote 250 mg twice daily and had diagnoses of Schizoaffective Disorder-Bipolar. The consultation also documented that Resident #69 also had multiple psychiatric admissions and mental status examination revealed that Resident #69 was alert, verbal, mood is angry, paranoid, cursing, threatening, demanding, and easily agitated. Nursing progress notes dated 5/21/2024 documented that Resident #69 was alert, responsive, and verbally abusive cursing at staff. Nursing progress notes dated 5/19/2024 documented Resident #69 refused all activities of living care despite encouragement. Psychology consults dated 1/3/2024, 1/8/2024, 1/31/2024, 2/6/2024, 3/4/2024, 3/13/2024, 3/26/2024, 4/17/2024, 5/3/2024 contained no documented evidence that Resident #69's behavior towards staff, and biological desires related to sex and sexual verbalization towards staff was addressed. A Comprehensive Care Plan titled Inappropriate Behavior as evidence by (this was left blank) as related to diagnosis of Bipolar Disorder at risk for inappropriate behavior, as related to suicidal ideation was created on 8/23/2023, and revised on 7/27/2024. Interventions included administer psychiatric medications, encourage family contact/support, follow up with Psychiatry, implement behavior modification program, monitor behavior changes, provide calm environment, provide emotional support, and set limits. There was no documentation on the care plan of the evidence of the inappropriate behavior was displaying and no description of the specific behavior modification that was to be done for Resident #69. There was no documented evidence that Resident #69's comprehensive care plan had been revised to include verbally abusive behavior towards staff, and their biological desires related to sex and sexual verbalization towards staff. During an interview on 08/05/24 at 11:39 AM, Certified Nursing Assistant #7 stated that Resident #69 curses, yells, shouts, and refuses to turn and position, likes to remain on their back most of the time. Certified Nursing Assistant #7 also stated that Resident #69 shouts at staff, calls staff names like pedophiles, molesters, sex offenders. Certified Nursing Assistant #7 further stated that Resident #69 asks the staff to sexually touch their penis and will ask female staff to sit on their and speaks in a graphic sexually manner to staff. Certified Nursing Assistant #7 also stated that Resident #69 would ask staff to open Resident #69's personal computer and phone and view pornographic material with them. During an interview on 08/06/24 at 03:48 PM, Licensed Practical Nurse #1 stated that Resident #69 curses at staff without an apparent reason, calls staff prostitutes, and will ask Licensed Practical Nurse #1 to manually stimulate their penis as Licensed Practical Nurse #1 is being paid to do this. During an interview on 08/06/24 at 10:17 AM, Registered Nurse Supervisor #4 stated that they are aware of Resident #69's behaviors and Registered Nurse Supervisor #4 provided some behavior notes written for Resident #69 regarding behaviors related to sexual verbalizations toward staff. Registered Nurse Supervisor #4 also stated that they are responsible for initiating care plans, updating care plans and gave no reason why Resident #69's behavior as reported by staff had not been included and addressed in their Comprehensive Care Plan. During an interview on 08/07/24 at 01:44 PM, the Director of Nursing stated that Resident #69 makes a lot of demands and at times is inappropriate. The Director of Nursing also stated that Resident #69 is able to express self and is seen by Psychiatry and Psychology. The Director of Nursing further stated that Resident #69' behaviors are addressed but staff most likely do not want to use the exact words that Resident #69 is using and put explicit words in writing. The Director of Nursing stated that the Registered Nurse Supervisor is responsible for initiating all care plans and did not know why a care plan to address Resident #69's verbal abuse, and biological needs and verbal sexual expressions towards staff had not been created. 10 NYCRR 415.11(c)(2)(i-iii)

Based on observation and interviews conducted during the Recertification survey from 07/31/2024 to 08/07/2024, the facility did not ensure that services provided or arranged by the facility meet the current professional standards of quality. Specifically, medications were left unattended on the medication cart, the medication cart was left opened, unlocked, and unattended, and the Electronic Medical Record on the medication cart was left open and unattended exposing a resident's confidential medical information. This was evident during a Medication Administration Task. The finding is: The facility policy and procedure dated 01/2024 titled Professional Standards stated that all employees are expected to maintain high standards of professional conduct, ethics, and competence in their roles. On 08/01/24 at 8:13 AM, during observation of Medication Administration Registered Nurse #1 walked away from medications left on top of the medication cart unattended, left the medication cart opened, unlocked and unattended, and left the Electronic Medical Record screen on top of the medication cart open in full view displaying a resident's personal health information. On 08/01/24 at 9:31 AM, Registered Nurse #1 was interviewed and stated they had been in-serviced on the topic of Medication Administration and the Health Insurance Portability and Privacy Act. Registered Nurse #1 also stated they need to slow down and think about the whole process and technique when administering medications and preparing the medication cart. On 08/01/24 at 12:43 PM, the Director of Nursing was interviewed and stated that it is not the policy of the facility to leave medication carts unattended with medications on top of it, nor is it the policy of the facility to leave the medication cart open and unlocked and the medical record screen left open for anyone passing by to see. The Director of Nursing also stated that they do provide ongoing in-services to their nurses on how to administer medications and what not to do during this process. 10 NYCRR 415.11 (c)(3)(i)

Based on observations and staff interviews conducted during the Recertification survey conducted from 07/31/2024 to 08/31/2024, the facility did not ensure that all medications and biological's were stored and labeled properly. Specifically, medications on the medication cart, were left unattended, and the medication cart was left unlocked and unattended. This was evident during observations conducted for the Medication Administration Task. The findings are: The facility policy titled Administering Medications dated 1/2024 documented that during administration of medications, no medications are kept on top of the cart unattended. The policy also documented that the medication cart will be kept closed and locked when out of sight by the medication nurse. On 08/01/24 at 8:13 AM, during observation of Medication Administration, Registered Nurse #1 removed the Clonazepam 1 milligram, Eliquis 5 milligrams, Amantadine 100 milligram, Escitalopram 20 milligram, and Lactulose 15 milliters from the medication cart. Registered Nurse #1 crushed four of the medications that were in pill form and placed each in separate medication cups. Registered Nurse #1 then walked away from medication cart, left the prepared medications on top of the medication cart, and did close or lock the medication cart. Registered Nurse #1 was interviewed on 08/01/24 at 9:31 AM and stated that walking away from the medication cart and leaving medications on top of the cart was something they did not think about at the moment. Registered Nurse #1 also stated that they needed to find some apple sauce or pudding to give with the medications. Registered Nurse #1 further stated that it was not a good practice to walk away from unattended medications and an open medication cart because any unauthorized person or resident can take the medications from on top of the cart or from the inside of the medication cart which was left open and unlocked. On 08/01/24 at 9:46 AM, Registered Nurse Supervisor #2 was interviewed and stated that random medication pass observations are conducted to ensure that their nurses are practicing proper facility protocols. Registered Nurse Supervisor #2 also stated that it is not safe to walk away from medications because any confused resident can pick them up and potentially ingest them. Registered Nurse Supervisor #2 further that the medication cart should not be open and unlocked as they do not want any unauthorized person or resident to have access to an open medication cart. On 08/01/24 at 12:43 PM, the Director of Nursing was interviewed and stated that it is not the policy of the facility to leave medication carts unattended with medications on top of it, nor is it the policy of the facility to leave the medication cart open and unlocked. The Director of Nursing also stated that any resident or visitor can take the medications or have access to the unlocked medication cart. 10 NYCRR 415.18(3)(1-4)

Based on observation and staff interviews conducted during the Recertification survey from 07/31/2024 to 08/07/2024, the facility did not ensure that infection control prevention practices and procedures were maintained to provide a safe and sanitary environment, and to help prevent the development and transmission of communicable diseases and infections. This was evident for 1 (Resident #180) of 6 residents observed for Respiratory Care and for 1 (Resident #514) of 3 residents observed for Pressure Ulcer out of a total sample of 38 residents. Specifically, Respiratory Therapist #1 failed to practice proper hand hygiene for Resident #180 while doing respiratory care, and Registered Nurse #2 failed to practice proper hand hygiene for Resident #514 while doing wound care. The facility policy dated 01/2024 titled Handwashing/Hand Hygiene states that employees must wash their hand for at least 15 seconds using antimicrobial or non-antimicrobial soap and water before and after changing a dressing. If hands are not visibly soiled, use an alcohol-based rub containing 60-95% ethanol or isopropanol before handling clean or soiled dressings, gauze pad and after handling used dressings. 1. Resident #180 was admitted to the facility with active diagnoses that included Seizure Disorder and Respiratory failure. The Quarterly Minimum Data Set, dated dated dated [DATE] documented that Resident #180 has a feeding tube, is receiving mechanically altered diet, and was receiving antibiotic therapy. The Quarterly Minimum Data Set also documented that Resident #180 was on continuous oxygen therapy, suctioning as scheduled, trach care and an invasive mechanical ventilator. The Order Details dated 3/28/2024 for Resident #180 documented Tracheo-Bronchial Suctioning every shift, oropharyngeal suction for secretions every shift, and Trach care done, and stoma site observed every shift. On 08/02/24 at 11:13 AM, Resident #180 was observed with secretions dripping on the neck and trach dressing in place. Respiratory Therapist #1 performed hand hygiene and then donned gown and gloves. Respiratory Therapist #1 opened suction tubing and performed tracheobronchial suctioning. Respiratory Therapist #1 was observed removing soiled trach gauze dressing. Respiratory Therapist #1 opened sterile gauze package which was then placed on the bed without sterile surface or barrier in between. Respiratory Therapist #1 was then observed taking the same gauze and wiping the secretions off Resident's #1 neck. A second package of gauze was opened and used to clean the area around the stoma. Without first performing hand hygiene, Respiratory Therapist #1 retrieved another package of sterile gauze from the drawer. Respiratory Therapist #1 opened the package and applied the new gauze dressing around trach but failed to perform hand hygiene or change gloves prior to application of the clean dressing. On 08/02/24 at 11:18 AM, Respiratory Therapist #1 was interviewed and stated that Resident #180 is on contact precautions and gets suctioned 5-6 times a day as they have a lot of secretions. Respiratory Therapist #1 stated that they did not change gloves after cleaning the area around the stoma and before application of a new dressing. Respiratory Therapist #1 stated that for most residents, gloves are changed depending on how soiled the gloves are but should be changed after dressing is removed, stoma area is cleaned and before application of new dressing as there is a risk of introducing bacteria to the stoma site when the site is improperly cleaned. Respiratory Therapist #1 stated they last completed infection control training over one year ago. On 08/07/24 at 10:48 AM, the Director of Respiratory Therapy was interviewed and stated that infection control trainings are done yearly with nursing. Most of the staff are trained in competences in handwashing, hand hygiene and infection control policies. The Director of Respiratory Therapy also stated that they do random checks on staff from time to time to ensure infection control is being done properly. Hand hygiene is very important because improper hand hygiene can lead to cross contamination and risk of infection. The Director of Respiratory Therapy further stated that after removal of a dirty dressing and cleaning of the stoma, hands should be washed, followed with donning of clean gloves. There is a severe risk of cross contamination and introducing bacteria if this is not done. 2. Resident #95 was admitted to the facility with diagnoses that included Alzheimer's Disease and sacral Stage 4 pressure ulcer. The Quarterly Minimum Data Set, dated dated dated [DATE] documented that Resident #95 had one Stage 4 and one unstageable pressure ulcer and one unstageable Deep Tissue Injury. The Treatments Order Form dated 08/06/2024 documented to cleanse left foot dorsal medial Deep Tissue Injury with Normal Saline, pat dry, paint with betadine, protect with dry protective dressing and secure with Kling. The Treatments Order Form dated 08/06/2024 documented to cleanse Right heel with Normal saline, pat dry, apply calcium alginate, protect with dry protective dressing, and secure with Kling. On 08/09/2024 at 9:48 AM, Registered Nurse #2 was observed performing wound care on the left foot for Resident #95. Registered Nurse #2 did not perform hand hygiene or don clean gloves prior to application of betadine on gauze which was then applied to wound. Registered Nurse #2 was also observed performing right heel wound care. Registered Nurse #2 did not perform hand hygiene and don clean gloves prior to application of calcium alginate dressing which was then covered with gauze and secured with Kling wrap. On 08/06/24 at 10:12 AM, Registered Nurse #2 was interviewed and stated that they thought they had changed their gloves and performed hand hygiene after cleaning the wound. Registered Nurse #2 also stated that they were nervous and might have missed performing hand hygiene after cleansing of wound but usually do change gloves and perform hand hygiene after cleaning of wound. On 08/06/24 at 11:19 AM, Registered Nurse Supervisor #2 was interviewed and stated that performing handwashing and observing aseptic technique is important. Gloves must be changed after removal of soiled dressing and after cleaning of wound to prevent cross contamination. If dirty gloves are used to touch clean instruments or clean dressings, there is a serious risk of infection because dirty touches the clean. On 08/06/24 at 11:42 AM, the Director of Nursing Services who was the Infection Preventionist was interviewed and stated that there are annual mandatory in-services on infection prevention, hand washing and antibiotic stewardship. Handwashing is the most important protocol when it comes to infection control. The Director of Nursing Services also stated that after cleaning any wound, hands should be washed and after a dressing is removed, hands should be washed again, and clean gloves donned before putting on the new dressing. The Director of Nursing Services further stated that there is a break in infection prevention protocol and potential of introducing infection to the resident when gloves are not changed after cleaning of wound and removal of soiled dressing. It is a serious issue if gloves are not changed. 10 NYCRR 415.19 (b)(4)

Based on observation and interviews conducted during a Recertification Survey from 07/31/2024 to 08/07/2024, the facility did not ensure handrails remain firmly affixed to the wall. Specifically, there were observations of handrails in the hallways on 2 (Unit 2 and Unit 6) that were not firmly affixed to the wall. The findings are: The facility policy & procedure dated 01/24 titled Environmental Staff Cleaning Duties documented clean handrails daily. On 07/31/24 at 10:03 AM and subsequent observations on 08/01/24 at 11:50 AM, of the 2nd and 6th floor Unit were made. Unit 2 was observed with handrails outside the Oxygen Room and handrails outside the Training Toilet loose and not firmly affixed to the wall. Handrails observed on Unit 6 outside room [ROOM NUMBER] were loose and not firmly affixed to the wall. On 08/07/24 at 10:46 AM, Housekeeper # 1 was interviewed and stated that cleaning and disinfecting hand rails is a daily routine and part of their daily work schedule. Housekeeper # 1 stated that if handrails are loose, it is to be reported to the Maintenance Department for immediate so that resident can have a safe environment. On 08/07/24 at 10:46 AM, the Maintenance Director was interviewed and stated they make rounds and check the Maintenance logbook on each of the units. The Maintenance Director checks for loose handrails when they walk through the units and check with the nurses to ask if there is anything that needs to be addressed. If handrails are loose and need fixing that should be reported to our department by the housekeeping department. There is a Maintenance Log Book on the units, where any staff can ticket any issue that has been identified. On 08/07/24 at 11:00 AM, the Director of Housekeeping Services was interviewed and stated that staff frequently clean and disinfect the highly touched area like handrails daily. I make frequent daily rounds to ensure that my staff are doing their jobs, check for cleanliness and maintenance of resident environment. I depend on my staff to identify and report loose handrails to ensure the safety of residents. 10 NYCRR 415.29

Based on record review and staff interview conducted during the Recertification/Complaint survey, the facility did not ensure that the resident and their representatives were provided with a written summary of the baseline care plan. This was evident for 1 of 2 residents reviewed for Care Planning out of a sample of 37 residents. (Resident #74). The finding is: The facility policy and procedure titled Baseline Care Plan Summary dated 01/2020 documented: The facility will develop and implement a Baseline Care Plan Summary for each new resident within 48 hours of admission . The Social Services Director/designee will print the 48-Hour Baseline Care Plan Summary and review it with the resident/representative. The resident/representative signature will be obtained to verify the meeting and agreement with the plan. A signed copy will be maintained in the medical record. Resident #74 was admitted to the facility on [DATE], with diagnoses that included Anemia, CHF, Hypertension, Diabetes Mellitus. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. The MDS assessment also documented that the resident participated in the assessment and that no family or significant other participated in the assessment and goal setting. On 02/14/2023 at 1:14 AM, Resident #74 was interviewed and stated that they did not receive a copy of the baseline care plan since admission to the facility. The baseline care plan, initiated on 6/6/22, was last signed off by the Interdisciplinary Team members on 6/8/22 and completed by 8/5/22. There was no documented evidence in the medical record that a copy of the baseline care plan was provided to the resident. On 02/21/23 at 09:52 AM, an interview was conducted with the Social Worker (SW#1). SW#1 stated that Resident's base line care plan was completed within 48 hours of admission, but they could not confirm that it was given to Resident #74. SW#1 was not able to provide documented evidence that the summary was given to the resident. On 02/21/23 at 10:14 AM, an interview was conducted with the Physical Therapist (PT). The PT stated that after the baseline care plan was completed by the team, the social worker was responsible for providing the summary to the resident. On 02/22/23 at 10:16 AM, an interview was conducted with the Administrator. The Administrator stated they are not sure when the written summary of the initial care plan should be provided to the resident or who is responsible for providing the document. The Administrator further stated that they were not aware that the document was not being provided. 415.11 (c)

Based on record review and staff interview during the recertification survey, the facility did not provide medically-related Social Services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was evident for two of twenty-nine stage 2 sampled residents. Specifically, for 1) Resident #114 and 2) Resident #123, the Social Worker did not communicate with the Interdisciplinary Care Plan Team that these residents had reoccurrences of unsupervised/unplanned smoking behaviors and therefore no interdisciplinary plan was developed to address the unplanned smoking behaviors. This resulted in no actual harm with the potential for more than minimal harm that is IMMEDIATE JEOPARDY and SUBSTANDARD QUALITY OF CARE for all residents in the facility. The findings are: 1) Resident #114 has [DIAGNOSES REDACTED]. The resident's Psycho-Social History dated 10/16/13 and completed by a Social Worker revealed that the resident was a smoker. The Social Service Progress Note dated 10/16/13 revealed that the resident was provided with the facility's policies (Admission Agreement and Appendix), Bill of Rights, and information on Advanced Directives. The Nurse's Note dated 10/21/13 at 10:30 PM revealed that the resident was smoking, as per the resident's roommate. There was a strong smell of cigarette smoke in the resident's room and a lighter was taken from the resident. The resident was counseled on the dangers of smoking and a Social Service Referral slip was made out. The Social Service Referral dated 10/21/13 revealed that the resident's roommate claimed that the resident was smoking in their room, the resident refused a body search, and a lighter was found at the resident's bedside. The Social Service Progress Note dated 10/22/13 revealed that the Social Worker counseled the resident regarding his roommate's claim that he was smoking. The resident denied the claim. The Social Worker reiterated the facility's non-smoking policy and the dangers associated with smoking. The Social Worker also documented that the resident would be monitored for further occurrences. The Admission Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was understood and could understand and had a Brief Interview for Mental Status (BIMS) score of 11 which indicated that the resident had moderately impaired cognitive skills for daily decision making. The quarterly MDS assessment dated [DATE] revealed that the resident was understood and could understand and had moderately impaired cognitive skills for daily decision making with long and short term memory problems. The Social Service Progress Note dated 12/16/13 documented that the resident was identified as a smoker, the Social Worker offered the resident a patch as an aid to smoking cessation and the resident refused. The Nurse's Note dated 1/17/14 at 6:30 PM revealed that the resident was noted to go to the lobby and try to light half a cigarette. The cigarette was removed from the resident, the resident was counseled, and a memo (Social Service Referral) was sent to Social Services. The Social Service Referral dated 1/17/14 revealed that the resident tried to light a cigarette in the lobby, the cigarette was removed from the resident, and the resident was counseled regarding smoking rules. Review of the Social Service Progress Notes revealed no documented evidence that the Social Worker was aware of the resident trying to light a cigarette in the lobby on 1/17/14. The Nurse's Note dated 1/27/14 at 5:45 AM revealed that as the Nurse (not indicated whether a Licensed Practical Nurse or a Registered Nurse) was making rounds to do fingersticks, the resident was observed sitting on his bed, smoking a cigarette. The Social Service Referral dated 1/27/14 revealed that the resident was seen on his bed smoking a cigarette. The Registered Nurse (RN) Supervisor was made aware and came to the floor and spoke to the resident. The Social Service Progress Note dated 1/27/14 revealed that the resident was counseled regarding the facility's smoking policy since it was alleged that the resident smoked in his room. The Social Worker explained to the resident the dangers of smoking in room and the resident appeared to understand. The resident's family was also notified. The quarterly MDS assessment dated [DATE] revealed that the resident was understood and could understand and had a BIMS score of 5 which indicated that the resident had severely impaired cognitive skills for daily decision making. The Nurse's Notes dated 3/8/14 at 2:00 PM revealed that the resident was noted to be smoking in his bathroom and a strong scent of smoke was coming from his bathroom. The resident denied smoking. The RN Supervisor was made aware and a Social Service Referral was written. The Social Service Referral dated 3/8/14 revealed that the resident was noted smoking in his room, strong scent (of smoke) coming from his bathroom which the resident denies. The Social Service Progress Note dated 3/10/14 revealed that it was reported that the smell of cigarette smoke was coming from the resident's room on 3/8/14. Cigarettes were confiscated by staff. The Social Worker met with the resident who denied the allegation. The resident's daughter was called and made aware of the situation. The Social Worker advised the resident's daughter not to leave any cigarettes with the resident as the resident has a [DIAGNOSES REDACTED]. Review of the resident's entire Comprehensive Care Plan on 3/11/14 revealed no documented evidence of the resident's smoking related occurrences. The resident's Social Worker (#1) was interviewed on 3/13/14 at 9:25 AM and stated that when she receives a Social Service Referral from Nursing, she speaks to the resident and counsels them. The Social Worker stated that when she counseled the resident not to smoke and the dangers of smoking in the facility, he understood. The Social Worker stated that she had never done a search of the resident's room, only Nursing had. The Social Worker recalled that after the resident's 3/8/14 smoking incident, she received from Nursing 4 or 5 cigarettes and some broken cigarettes with loose tobacco. The Social Worker never received a lighter. The Social Worker never brought this information forward to any other department, never had a meeting with other staff regarding the resident's smoking occurrences, and never discussed the issue during Morning Report. The Social Worker stated that a Smoking CCP should have been developed by another Social Worker (#3 - no longer employed at the facility) who completed the resident's initial Psycho-Social History dated 10/16/13 when the resident was identified as a smoker. The Social Worker also stated that she or Nursing should have initiated a CCP after the resident was found smoking in his room. The Social Worker stated that she offered the resident a smoking cessation program on 12/16/13, which he refused, and never offered it to him again. The Social Worker stated that she had a special CCP meeting with the resident's son once, but no mention of smoking was made. 2) Resident #123 has [DIAGNOSES REDACTED]. The facility Psycho-Social History form dated 4/8/13 documented that the resident was independent in decision making with total memory recall ability. The form also documented that the resident was admitted for short term rehabilitation. The part of the form which indicated whether or not (yes or no) the resident was a smoker was left blank. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) Score of 12 which indicated that the resident had moderately impaired cognitive skills for daily decision making. The MDS documented a Mood Score of 10 which indicated Moderate Depression. The MDS also documented that the resident required staff assistance in all activities of daily living. The MDS documented that the resident was administered Antipsychotic Medication, Antidepressive Medication and Antianxiety Medication for the 7 days of the assessment period. The Social Service Progress Note dated 4/9/13 and documented by Social Worker (SW) #1 revealed that it was reported by Nursing that the resident's room smelled of smoke. The resident's room was searched and cigarettes and a lighter were confiscated. An Initial Psychological Diagnostic Interview dated 4/22/13 documented that the resident "reports smoking cigarettes since adolescence". The Social Service Progress Note dated 4/24/13 and documented by SW #1 revealed that the resident attended a Comprehensive Care Plan (CCP) on that date and the facility's smoking policy was reinforced with her since it had been reported that she had smoked in her room. The Comprehensive Care Plan (CCP) for Behavior Problem dated 6/4/13 documented that the resident exhibited non-compliance to care as evidenced by refusing showers, floor ambulation program (FAP), and assistance from staff. There was no reference made to the resident smoking. The Social Service Progress Note dated 8/26/13 and documented by SW #1 revealed that it was reported that staff discovered a cigarette on the resident's night table. The SW reviewed the facility's smoking policy with the resident and her friend and that the resident verbalized an understanding of the policy. The Quarterly MDS assessment dated [DATE] documented that the resident had a BIMS score of 14 which indicated that the resident was cognitively intact. The MDS documented that the resident had a Mood Score of 11 which indicated Moderate Depression. The MDS also documented that the resident had verbal behavior symptoms directed towards others one to three days during the assessment period. A Social Service Progress Note dated 12/27/13 and documented by SW #1 revealed that the resident attended a "special" CCP meeting on that date and the smoking policy was reviewed. The SW also documented that the resident continued to deny smoking in her room and was aware of the dangers to person and property. There was no clear explanation as to the reason for the "special" meeting. There was no documented evidence in the resident's medical record that specific interventions were identified related to the resident's history of cigarette smoking and non-compliant behaviors. The resident was examined by the Psychiatrist on 12/20/13 for reasons which included non-compliance with staff assistance. There was no documented evidence that the Psychiatrist had been notified of the non-compliance with the facility's non-smoking policy. On 1/3/14 the Psychiatrist examined the resident for refusing care and sitting herself on the floor regularly. A Psychiatric Evaluation report from the hospital dated 2/21/14 documented that the resident was a former smoker and had been smoking in the past 12 months. Review of the resident's entire Comprehensive Care Plan on 3/11/14 revealed no documented evidence of the resident's smoking related occurrences. Social Worker #1 was interviewed on 3/12/14 at 9:30 AM and stated that she did not recall any smoking problems with Resident #123. The SW stated that the resident did have behavior problems, but she did not recall smoking as a particular problem. The SW stated that the Psycho-Social History had not been completed for smoking history because the facility was non-smoking and that part of the History is not looked at. The SW stated that the resident was told before admission that the facility was smoke free. Social Worker #1 was interviewed again on 3/13/14 at 12:20 PM. The SW stated that she had no recall of the incidents of smoking with reference to Resident #23. The SW stated that if she counseled the resident for cigarette smoking or the finding of paraphernalia for smoking, it was most likely referred to her from Nursing. The SW stated that she may have received referrals or it may just have been told to her verbally, however she could not recall the specifics. The Administrator was interviewed on 3/13/14 at 2:00 PM and stated that administration had no idea that the resident had been suspected of smoking in the building. The Administrator stated that the resident's boyfriend visited daily and believed that it was the boyfriend's backpack and paraphernalia that had been found in the resident's room. Social Worker #1 was not available for follow-up interview on 3/17/14. 415.5(g)(1)(i-xv)

Based on record review and staff interview during the recertification survey, the facility did not address unsupervised/unplanned smoking occurrences for two of four residents reviewed for Accidents in a total sample of twenty-nine stage 2 residents. Specifically, 1) Resident #114 was suspected of smoking on two occasions, attempted to smoke on one occasion, and was observed to smoke on another occasion and 2) Resident #123 was suspected of smoking on two occasions, was found with smoking paraphernalia on another occasion, and counseled on another unidentified smoking occurrence. This resulted in no actual harm with the potential for more than minimal harm that is IMMEDIATE JEOPARDY and SUBSTANDARD QUALITY OF CARE for all residents in the facility. The findings are: 1) Resident #114 has [DIAGNOSES REDACTED]. The resident's Psycho-Social History dated 10/16/13 and completed by a Social Worker revealed that the resident was a smoker. The Social Service Progress Note dated 10/16/13 revealed that the resident was provided with the facility's policies (Admission Agreement and Appendix), Bill of Rights, and information on Advanced Directives. The Nurse's Note dated 10/21/13 at 10:30 PM revealed that the resident was smoking, as per the resident's roommate. There was a strong smell of cigarette smoke in the resident's room and a lighter was taken from the resident. The resident was counseled of the dangers of smoking and a Social Service Referral slip was made out. The Supervisor's Report System (green log book) was reviewed. On 10/21/13, an entry was made which revealed that the resident's roommate claimed that the resident was smoking in the room. The Nurse went to the room and smelled smoke. The resident denied smoking, the Nurse took the lighter, and the resident refused a body search. The resident was reminded of the no smoking policy of the facility, verbalized understanding at that time. Social Service Referral was made. The 24 Hour Nursing Report was reviewed. On 10/21/13, on the 3:00 PM-11:00 PM shift, an entry was made that the resident's roommate had reported that the resident was smoking in their room. Smell of cigarette smoke was present. The resident was counseled. The Social Service Referral dated 10/21/13 revealed that the resident's roommate claimed that the resident was smoking in their room, the resident refused a body search, and a lighter was found at the resident's bedside. The Social Service Progress Note dated 10/22/13 revealed that the Social Worker counseled the resident regarding his roommate's claim that he was smoking. The resident denied the claim. The Social Worker reiterated the facility's non-smoking policy and the dangers associated with smoking. The Social Worker also documented that the resident would be monitored for further occurrences. The Admission Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was understood and could understand and had a Brief Interview for Mental Status (BIMS) score of 11 which indicated that the resident had moderately impaired cognitive skills for daily decision making. The Psychological Services Diagnostic Evaluation dated 10/24/13 revealed that the resident was a current tobacco user - not in the facility. The quarterly MDS assessment dated [DATE] revealed that the resident was understood and could understand and had moderately impaired cognitive skills for daily decision making with long and short term memory problems. The Social Service Quarterly assessment dated [DATE] documented that the resident had trouble concentrating at times and was often sleepy. The Social Service Progress Note dated 12/16/13 documented that the resident was identified as a smoker, the Social Worker offered the resident a patch as an aid to smoking cessation, and the resident refused. The Nurse's Note dated 1/17/14 at 6:30 PM revealed that the resident was noted to go to the lobby and try to light half a cigarette. The cigarette was removed from the resident, the resident was counseled, and a memo (Social Service Referral) was sent to Social Services. The Supervisor's Report System (green log book) was reviewed. There was no entry made on 1/17/14 in reference to the resident attempting to smoke in the lobby. The 24 Hour Nursing Report was reviewed. There was no entry made on 1/17/14 in reference to the resident attempting to smoke in the lobby. The Social Service Referral dated 1/17/14 revealed that the resident tried to light a cigarette in the lobby, the cigarette was removed from the resident, and the resident was counseled regarding smoking rules. Review of the Social Service Progress Notes revealed no documented evidence that the Social Worker was aware of the resident trying to light a cigarette in the lobby on 1/17/14. The Nurse's Note dated 1/27/14 at 5:45 AM revealed that as the Nurse was making rounds to do fingersticks, the resident was observed sitting on his bed and smoking a cigarette. The Supervisor's Report System (green log book) was reviewed. There was no entry made on 1/27/14 in reference to the resident smoking in his room. The 24 Hour Nursing Report was reviewed. There was no entry made on 1/27/14 in reference to the resident smoking in his room. The Social Service Referral dated 1/27/14 revealed that the resident was seen on his bed smoking a cigarette. The Registered Nurse (RN) Supervisor was made aware and came to the floor and spoke to the resident. The Social Service Progress Note dated 1/27/14 revealed that the resident was counseled regarding the facility's smoking policy since it was alleged that the resident smoked in his room. The Social Worker explained to the resident the dangers of smoking in room and the resident appeared to understand. The resident's family was also notified. The Psychological Services Progress Note dated 1/27/14 revealed that the resident was reported smoking in his room. The quarterly MDS assessment dated [DATE] revealed that the resident was understood and could understand and had a BIMS score of 5 which indicated that the resident had severely impaired cognitive skills for daily decision making. The Social Service Quarterly assessment dated [DATE] revealed that the resident was often lethargic. The Nurse's Notes dated 3/8/14 at 2:00 PM revealed that the resident was noted to be smoking in his bathroom and a strong scent of smoke was coming from his bathroom. The resident denied smoking. The RN Supervisor was made aware and a Social Service Referral was written. The Supervisor's Report System (green log book) was reviewed. On 3/8/14, an entry was made which documented that the resident was noted to be smoking in the bathroom in his room with a strong scent of smoke coming from his bathroom. Social Service Referral was made. The 24 Hour Nursing Report was reviewed. On 3/8/14, on the 7:00 AM-3:00 PM shift, an entry was made which documented that the resident was noted to be smoking in his room. There was a strong scent of smoke coming from the resident's bathroom. The resident denied smoking, the RN Supervisor was made aware, and a Social Service Referral was made. The Social Service Referral dated 3/8/14 revealed that the resident was noted smoking in his room, strong scent (of smoke) coming from his bathroom which the resident denies. The Social Service Progress Note dated 3/10/14 revealed that it was reported that the smell of cigarette smoke was coming from the resident's room on 3/8/14. Cigarettes were confiscated by staff. The Social Worker met with the resident who denied the allegation. The resident's daughter was called and made aware of the situation. The Social Worker advised the resident's daughter not to leave any cigarettes with the resident as the resident has a [DIAGNOSES REDACTED]. Review of the resident's entire Comprehensive Care Plan on 3/11/14 revealed no documented evidence of the resident's smoking related occurrences. The Administrator was interviewed on 3/11/14 at 11:55 AM and stated that there were no residents in the facility who smoked as the facility was a "non smoking facility". The Administrator stated that a resident's Patient Review Instrument (PRI) is looked at prior to the resident being accepted by the facility. The Administrator stated that when a resident is coming from a hospital, they have not been smoking there, so we expect them not to smoke at the facility. If a resident still wants to smoke upon coming to the facility, the resident is offered a smoking cessation program and the Physician orders [REDACTED]. The Administrator further stated that there was no facility policy regarding smoking as the facility was a "non smoking facility" which was documented in the facility's Admission Agreement. On 3/12/14 at 8:15 AM in the resident's room, the resident was asked if he had any cigarettes ar smoking paraphernalia by the Surveyor. The resident responded by handing the Surveyor an empty pack of Parliament cigarettes from the pocket of his pants that he was wearing. A search of the resident's room in the presence of the Administrator and Surveyor, revealed no other smoking paraphernalia at this time. The facility's undated Admission Agreement Appendix revealed under Smoking that visitors are not permitted to smoke while on the premises. Residents are permitted to smoke only in the designated areas strictly under the direct supervision of the assigned staff. All lighting instruments and fire hazardous materials must be turned over to the appropriate staff. The facility would appreciate your assistance in the discouragement of smoking. The Appendix also included a "Resident Smoking Safety Rules" form which included, but not limited to that residents are permitted to smoke only in designated areas. The Appendix further included a "No Smoking Safety Rules" form which documented that 1) the facility is a non smoking facility; 2) Residents with documented history of smoking will be searched upon admission to the facility; 3) Those residents who are known to purchase cigarettes will be checked upon entering the facility and asked to relinquish cigarettes from their possession. These residents and others that break the No Smoking Safety Rules by having cigarettes in their possession will have their room checked for cigarettes and matches by nursing daily; 4) Use of alternatives (i.e.. nicotine patch, e-cigarette) will be offered as indicated and appropriate to residents admitted with history of smoking; 5) All residents with history of smoking will have an individualized Comprehensive Care Plan (CCP) and will be evaluated quarterly at the CCP Team Meeting to ensure compliance to the facility's Safety Rules; 6) Cigarettes discovered on a resident will be confiscated and given to the appropriate Social Worker and family/designated representative will be notified; 7) Residents who repeatedly fail to comply with these no Smoking Safety Rules will be discharged to a more appropriate facility because this behavior presents a serious danger to themselves and others. At the end of this form there was a signature and date space for the resident/designated representative. Therefore, the facility's Admission Agreement Appendix contained conflicting documentation. The Director of Nursing (DON) was interviewed on 3/12/14 at 10:15 AM and stated that only the "No Smoking Safety Rules" form should have been included in the facility's Admission Agreement Appendix. The DON stated that the other two forms should have been removed and must have been left in the packet by accident when the facility still allowed residents to smoke in designated areas. The DON also stated that the facility had been a non smoking facility for the past two years. The Administrator was interviewed again on 3/12/14 at 11:30 AM and stated that she first became aware of Resident #114's smoking occurrences on 3/11/14 after reading the 24 Hour Nursing Reports that the Surveyors had requested. The Administrator stated that she was fairly new to the facility, but knew that the facility became a non smoking facility about two years ago. The Administrator stated that she does not receive a copy of the 24 Hour Nursing Report. Had an Accident/Incident Report been generated after each smoking occurrence, as it should have been, the Administrator stated that she would have been aware. The Administrator also stated that she does attend Morning Report most of the time and no discussion was ever had regarding the resident's smoking occurrences. Had she known, the Administrator stated that she would have met with the resident, notified the Physician and family, monitored the resident, and developed a CCP. The Administrator stated that the 24 Hour Nursing Reports are not brought to Morning Report. The RN Nursing Supervisors transcribe issues into the Supervisor's Report System (green log book) which is then taken to Morning Report. The resident's Social Worker (#1) was interviewed on 3/12/14 at 1:45 PM and stated that she is in charge of providing the facility's Admission Agreement Appendix to newly admitted resident's. The Social Worker stated that she does not go over the packet with the resident, but only makes them sign a Document Distribution at Time of Admission form which states that they were provided the facility's Admission Agreement Appendix which includes the Facility Smoking Policy. This facility form was signed and dated by the resident on 10/16/13. The RN Supervisor who was on duty when the resident attempted to smoke a cigarette in the lobby of the facility on 1/17/14 was interviewed on 3/12/14 at 3:30 PM. The RN stated the resident would often sit in the lobby of the facility and wait for his family to come. The RN stated that on the evening of 3/8/14, the resident was in the lobby with half a cigarette and a broken lighter. The resident was asking staff if they would light his cigarette for him. The RN stated that she removed the cigarette and the lighter from the resident and counseled him regarding no smoking in the facility. The RN stated that she wrote out a Social Service Referral and left it in the Social Worker's mailbox, but she could not recall why she had not documented the incident on the 24 Hour Nursing Report or in the Supervisor's Report System (green log book). The resident's Social Worker (#1) was interviewed again on 3/13/14 at 9:25 AM and stated that when she receives a Social Service Referral from Nursing, she speaks to the resident and counsels them. The Social Worker stated that when she counseled the resident not to smoke and the dangers of smoking in the facility, he understood. The Social Worker stated that she had never done a search of the resident's room, only Nursing had. The Social Worker recalled that after the resident's 3/8/14 smoking incident, she received from Nursing 4 or 5 cigarettes and some broken cigarettes with loose tobacco. The Social Worker never received a lighter. The Social Worker never brought this information forward to any other department, never had a meeting with other staff regarding the resident's smoking occurrences, and never discussed the issue during Morning Report. The Social Worker stated that a Smoking CCP should have been developed by the Social Worker (no longer employed at the facility) who completed the resident's initial Psycho-Social History dated 10/16/13 when the resident was identified as a smoker. The Social Worker also stated that she or Nursing should have initiated a CCP after the resident was found smoking in his room. The Social Worker stated that she offered the resident a smoking cessation program on 12/16/13, which he refused, and never offered it to him again. The Social Worker stated that she had a special CCP meeting with the resident's son once, but no mention of smoking was made. 2) Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility Psycho-Social History dated 4/8/13 documented that the resident was independent in decision making with total memory recall ability. The Psychosocial documented that the resident was admitted for short term rehabilitation. The resident's smoking status was not documented as completed on the Psycho-Social. A Social Service (S/S) Progress Note dated 4/9/13 documented that a referral was made by Nursing to the Social Worker (SW). The SW documented that it was reported to her that the resident's room had a smell of smoke and a room search resulted in finding cigarettes and a lighter, which was confiscated. There was no further documentation in the medical record regarding this incident. This incident was not documented on the 24 hour report. There was no documented evidence that an Interdisciplinary Plan of Care was developed for the resident's potential for smoking and disregard for the non-smoking policy following this incident. There was no Accident/Incident Report developed for this incident. The MDS assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) Score of 12, moderately impaired. The MDS documented a Mood Score of 10, Moderate Depression. The MDS documented that the resident required staff assistance in all activities of daily living. The MDS documented that the resident was administered Antipsychotic Medication, Antidepressive Medication and Antianxiety Medication for the 7 days of the assessment period. An Initial Psychological Diagnostic Interview dated 4/22/13 documented that the resident was referred for symptoms of Depression. The interview documented that the resident stated that the resident reported smoking cigarettes since "adolescence". A Nurses Note (N/N) dated 4/23/13 at 12:00 AM documented that during the nurse's rounds on the unit, the smell of cigarette smoke was noted. The N/N documented that the Supervising/Registered Nurse (RN) was notified and responded. The N/N documented that the resident's room and belongings were searched and cigarettes and a lighter were found in the resident's back pack. The N/N documented that a referral was sent to S/S. This was not documented on the 24 hour nursing report or the supervisors communication book. There was no Accident/Incident Report developed. The Supervisor/RN documented on 4/23/13 at 12:00 AM the resident was counseled regarding smoking in the room. The RN documented that the resident became agitated and verbally abusive to staff. The RN documented that referral was sent to the SW. The SW documented on 4/24/13 that the resident attended a Care Plan Meeting and that the no smoking policy was reinforced with the resident. The SW documented that the resident denied smoking. There was no documented evidence that an Interdisciplinary Plan of Care was developed for the resident's potential for smoking and disregard for the non-smoking policy following this incident. . A N/N dated 8/24/13 at 11:00 PM documented that the resident was found with a cigarette on the night table. There was no further documentation in the N/N regarding this incident. A Social Service Progress Note dated 8/26/13 documented that the staff discovered a cigarette on resident's night table. The SW documented that the no smoking policy was reviewed with the resident. There was no further documentation in the medical record regarding this incident and no Accident/Incident Report was documented. There was a S/S progress note dated 12/27/13 documented that the resident attended a Care Plan Meeting for review of the Smoking Policy. The SW documented that the resident continued to deny smoking in the room and is aware of the dangers to person and property. There was no further documentation in the medical record regarding the incident which prompted the SW to meet with the resident on the Smoking Policy. The N/N and 24 Hour Nursing Reports were reviewed from 12/23/13 through 12/27/14. There was no further documentation regarding the reason for the SW referral and care plan meeting specific to smoking. The Licensed Practical Nurse (LPN) Charge Nurse stated during an interview on 3/12/14 at 5:00 PM that the resident had been non-compliant with the non-smoking policy in the past. The LPN was unsure as to the actual time of the incidents but stated that there had been several in the past few months. The LPN stated that the resident had not had any recent incidents of smoking in the facility. Social Worker #1 was interviewed on 3/12/14 at 9:30 AM and stated that she had no recall about any smoking problems with Resident #123. The SW stated that the resident does have behavior problems but she did not recall smoking as a particular problem. The SW stated that the resident had been notified before admission that the facility was non-smoking. The SW also stated that the resident was given a packet on Admission with facility policies to read and the No-Smoking Policy was included. The SW stated that she does not review each policy with the resident. The SW stated that the resident signed for the Admission Packet which included the no-smoking policy. A second interview was conducted with SW #1 on 3/13/14 at 12:20 PM. The SW stated that she had no recall of the incidents of smoking with reference to Resident #123. The SW stated that if she counseled the resident for cigarette smoking or the finding of paraphernalia for smoking, it was most likely referred to her from Nursing. The SW stated that she may have received referrals or it may just have been told to her verbally, however, she could not recall the specifics. The resident was interviewed by the Administrator and Director of Nursing Services (DNS) on 3/13/14 at 1:00 PM. The resident stated that she does not smoke. The Administrator was interviewed on 3/13/14 at 2:00 PM. The Administrator stated that administration had no idea that the resident had been suspected of smoking in the building. The Administrator stated that the resident's boyfriend visited daily and believed that it was the boyfriends back pack and paraphernalia that had been found in the resident's room. The resident was observed in the dining room on 3/17/14 at 12:30 PM. The resident was in the dining room having the lunch meal. There was a black backpack noted on the resident's lap. 415.12(h)(1)(2)

Based on record review and staff interviews during the recertification survey, it was determined that the administrator failed to ensure that there was a system in place to assure that the facility operates in a manner that maintains the safety of all residents. Specifically, the Administrator failed to ensure that there was a system in place to readily identify residents who had the potential to smoke and to develop a system to prevent unsafe smoking occurrences. Specifically, 1) Resident #114 was suspected of smoking on two occasions, attempted to smoke on one occasion, and was observed to smoke on another occasion and 2) Resident #123 was suspected of smoking on two occasions and was found with smoking paraphernalia on another occasion. This resulted in no actual harm with the potential for more than minimal harm that is IMMEDIATE JEOPARDY for all residents in the facility. The findings of deficient practice are cited in F323 L - Accidents and Supervision, F250 L - Social Services, F501 L - Medical Director, and F520 L - Quality Assurance Committee. On 3/12/14 at 11:30 AM the Administrator was interviewed. The Administrator stated that she first became aware of the smoking issue for Resident #114 on 3/11/14 due to the surveyors request for the 24 Hour Nursing Report for specific dates. The Administrator stated that the facility was a non smoking building for the past two years and that she was fairly new to the facility. The Administrator stated she does not receive a copy of the 24 hour report. The Administrator further stated that had an Accident/Incident Report been generated for all smoking occurrences as it should have been, she would have then been aware. The Administrator stated that she does attend morning report most of the time but that no discussion was ever had with regards to Resident #114 and his smoking issues. The Administrator also stated that if she had known about the smoking issues for Resident #114 she would have met with the resident, notified the Physician and the family, monitored the resident and developed a plan. On 3/13/14 at 2:00 PM the Administrator was again interviewed. The Administrator stated that she had no idea that Resident #123 was smoking in the facility. The Administrator further stated that the resident's boyfriend used to leave his backpack in the resident's room and the Administrator believed it contained smoking paraphernalia. The Administrator also stated that the care plan for non-compliance should have included those incidents of smoking related problems. Additionally, the fact that the boyfriend's back pack was left in the facility should have been addressed. 415.26

Based on record review and staff interviews during the recertification survey, the Medical Director failed to ensure that the facility implemented a system that identified and prevented smoking occurrences. Additionally, the Medical Director failed to ensure that policies and procedures related to Smoking were developed and implemented. This resulted in no actual harm with the potential for more than minimal harm that is IMMEDIATE JEOPARDY for all residents in the facility due to Resident #114 and Resident #123 who were identified as having incidents of unsafe smoking. The finding is: On 3/12/14 at 3:15 PM the Medical Director was interviewed and stated that he visits the facility three or four times a week. The Medical Director stated that he had only been made aware of the smoking issues with Resident #114 today and that these smoking occurrences should have been brought to his attention. He further stated that had an Accident/Incident Report been generated, he would have known, since he reviews and signs all of them. The Medical Director stated that he was not aware of any smoking policy, but he does have input in the development of policies and procedures. The Medical Director stated that he is part of the Quality Assurance Committee and cannot recall any discussions pertaining to smoking. 415.15(a)

Based on record reviews and staff interviews during the recertification survey, the facility did not ensure that an effective Quality Assessment and Assurance Committee (QAAC) was developed and implemented to readily identify residents who had the potential to smoke and to develop a system to identify and prevent smoking occurrences. The QAAC failed to ensure that facility policies and procedures were developed and implemented related to smoking. This was evident for two of four residents reviewed for accidents in a total sample of twenty-nine Stage 2 residents. Specifically, Resident #114 and #123 were noted to have unsafe smoking occurrences which were not identified by the facilities QAAC. This resulted in no actual harm with the potential for more than minimal harm that is IMMEDIATE JEOPARDY for all residents in the facility. The finding is: During the recertification survey, two residents (Resident #114 and #123) were identified as having four smoking occurrences each. These occurrences were not identified by the facility's QAAC. The Director of Nursing Services was interviewed on 3/12/14 at 2:45 PM and stated that no policies or procedures had been developed for smoking since the facility became non smoking several years ago. The Administrator was interviewed on 3/17/14 at 2:30 PM and stated that the facility was a non smoking facility and therefore, smoking occurrences had not been identified as part of the quality assurance process. The Administrator further stated that every department is required to report a concern and a root cause analysis would be done by the committee. The Administrator stated that incident reports would now be generated for smoking occurrences, smokers will be identified upon admission, and smoking will now be an issue requiring quality assessment review. 415.27(a-c)