Every finding on record at Putnam Ridge

Based on observations, interviews, and record review, the facility did not ensure that a resident was free from physical restraints for purposes of discipline or convenience that are not required to treat the resident's medical symptoms and did not ensure the evaluation of the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. This was evident for one resident investigated for Restraints out of three total sampled residents. Specifically, Resident # 1 had a diagnosis of dementia with documented behaviors in nursing progress notes and a history of falls. On 11/27/2025 at approximately 5:55 AM Resident #1 was placed in a wheelchair in the hallway of their unit with a bed sheet wrapped around their waist and the bedsheet was tied securely to the back of the wheelchair.Findings include:The facility policy titled Restraints dated 09/16/2025 documented A physical restraint will only be used in necessitating a resident's/patient safety and the of others. Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's/ patient's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.Resident #1 was admitted to the facility on [DATE] with diagnoses that include but are not limited to dementia, anxiety, and muscle weakness.An admission minimum data set (an assessment tool) dated 11/17/2025 documented Resident#1 had a brief interview of mental status score of one, indicating severe cognitive impairment. Resident #1 had no behaviors present. Resident #1 had no impairment on the upper and lower extremities and required set-up/clean up assistance with eating, maximum assist with toileting, and moderate assist with bed mobility and transfers. Resident # 1 had an indwelling catheter and was always continent of bowel.Review of physician orders dated 11/2025 indicated there were no orders in place for a physical restraint.The facility's document titled, State Report dated 11/27/2025 documented on 11/27/2025 at approximately 5:55 AM, during rounds Registered Nurse #1 came to the unit and witnessed the resident sitting in the wheelchair with a blanket wrapped around their waist and wheelchair. Registered Nurse #1 removed the blanket, checked the body noting no redness and/or pain, brought Resident #1 to their room and then to their bed per Resident # 1's request.During an interview with Registered Nurse #1 on 06/05/2026 at 11:20 AM they stated they walked on to the unit on 11/27/2025 and observed Resident #1 tied to the wheelchair by a bed sheet. Resident #1 was in the hallway near room [ROOM NUMBER] and Licensed Practical Nurse #1 was nearby doing their medication pass. The other aides were at the other end of the hallway. Registered Nurse #1 stated the first thing they did was untie the bed sheet. The bed sheet was wrapped around the stomach and tied around the back of the wheelchair; this looked like a restraint. They removed the bed sheet and spoke with Licensed Practical Nurse #1 who stated they did not know anything about it. Certified Nurse Aide #1 who had been assigned to Resident #1 was on the opposite side assisting the other aide with getting other residents out of bed. Registered Nurse #1 stated that the provider and Registered Nursing Supervisor# 1 assessed the resident and found no bruising, no excoriation, no redness or pain. Registered Nurse #1 stated Certified Nurse Aide #1 stated to them that Resident #1 kept trying to get up so they tried to keep Resident #1 safe. Registered Nurse #1 stated that they informed Certified Aide #1 even though Resident #1 had behaviors at the time tying them to the wheelchair was not acceptable. Certified Nurse Aide #1 stated to Registered Nurse #1, Well Resident #1 keeps trying to get up and they are trying to stop them from getting up. Registered Nurse #1 reported the incident to Registered Nurse Supervisor #1 on 11/27/2025 that Resident #1 was found on the unit tied to their wheelchair by a bed sheet. Registered Nurse Supervisor #1 then called Certified Nurse Aide #1 on the unit and informed them that restraints are not allowed.During an interview on 06/05/2026 at 2:51 PM with Certified Nurse Aide #1 they stated Resident #1 had behaviors where they would attempt to get out of bed, and they were a high fall risk. Certified Nurse aide #1 stated that at the time of the incident they were assigned to Resident #1 and they wrapped Resident #1 around with a bed sheet to bind them to the chair; so that the resident would not fall. Certified Nurse Aide #1 stated they were thankful that Resident #1 did not fall that shift, and it was the only time they ever binded Resident #1 to the wheelchair, but they did this to keep Resident #1 safe and prevent them from falling. Certified Nurse Aide #1 stated they received training on resident rights and restraints after the incident.During an interview on 06/09/2026 at 11:00 AM with Director of Nursing #2 they stated they received the initial report on 11/27/2025 that Resident #1 was tied up. Director of Nursing #2 stated that after the incident they interviewed Certified Nurse Aide #1 who had told them that Resident #1 had an episode of bowel incontinence and Certified Nurse Aide #1 brought the resident into their room to provide care. Afterwards, Resident #1 pushed past the staff and was naked in the hallway. Director of Nursing #2 stated that when they interviewed Certified Nurse Aide #1, they were told that the bed sheet was wrapped around Resident # 1's waist for dignity purposes so they were not exposed in the hallway. Director of Nursing #2 stated they gathered statements from staff and the Administrator took over the investigation and conducted interviews with staff. Previously in the facility the director of nursing would be a part of the investigation process and summary to identify the root cause analysis, but this did not occur with this investigation.During a telephone interview with the Administrator on 07/13/2026 at 1:32 PM they stated that they were informed about the incident with Resident #1 on 11/27/2025, the same day it occurred. Administrator stated they investigated immediately to rule out abuse. The administrator stated that they were involved in the investigation by conducting interviews. Director of Nursing #2 collected the statements from the staff. The Administrator stated that when they interviewed Certified Nurse Aide # 1, they informed them that they secured the bed sheet around Resident # 1 with the intention to keep them safe and prevent them from falling. The Administrator informed Certified Nurse Aide #1 that this was not acceptable and considered a restraint. Certified Nurse Aide #1 was suspended pending investigation and reeducated on restraints and abuse. The Administrator stated that when they conducted the investigation, they interviewed the nursing supervisor, licensed practical nurse, and certified nurse aides. The social worker interviewed 11 residents that Certified Nurse Aide #1 had on their assignment, and they all stated that Certified Nurse Aide #1 never abused them and provided good care. At the conclusion of the facility's investigation the abuse was not verified because the resident was not injured and had a psychiatric consultation. The Administrator stated Certified Nurse Aide #1 did not intend to harm Resident #1.10 NYCRR 415.3(d)(1)(vii)

Based on observation, record review and interview conducted during the Recertification and Abbreviated Survey (#2601270, and #2577313), it was determined the facility failed to ensure each resident received adequate supervision and/or assistance to prevent accidents for two (2) of four (4) residents (Resident #164 and #116) reviewed for accidents. Specifically, 1) on the morning of 08/26/2025, Resident #164 was noticed in bed with a contusion (bruise) to their right face, right elbow, and a forehead laceration (skin wound). The facility investigation determined Resident #164 who required two (2) staff assist for bed mobility and/or transfers was provided one (1) staff assist which resulted in an 08/25/2025 fall from bed. Subsequently, Resident #164 was transferred to the hospital on [DATE] and was diagnosed with an acute (sudden) intertrochanteric (thigh) right femur (thigh bone) fracture (broken bone), and 2) Resident #116 was not provided with one (1) hour safety checks to prevent falls as per the plan of care which resulted in the resident falling out of their wheelchair unwitnessed by staff on 08/27/2025. This resulted in actual harm for Resident #164 that was not Immediate Jeopardy.The findings include: 1) Resident #164 was admitted to the facility with diagnoses including but not limited to history of cerebral infarction (ischemic stroke), pulmonary embolism (a blood clot to the lungs), and unspecified intellectual disability.The 06/20/2025 Quarterly Minimum Data Set (a resident assessment tool) documented Resident #164 had severely impaired cognition and required total assistance for activities of daily living. The August 2025 care plan titled Activities of Daily Living documented Resident #164 was dependent with bed mobility, transfers and required two (2) persons for assistance. The August 2025 Certified Nurse Aide Kardex and Tasks documented Resident #164 required two (2) person staff assist for bed mobility and transfers.The 08/26/2025 at 10:30 AM Accident/Incident Investigation documented Licensed Practical Nurse #10 went into Resident #164's room to administer medications. Resident #164 was found in bed with bruising and swelling to the right eye and surrounding area. Medical Doctor/Nurse Practitioner assessment and orders: x-ray of the face, nose, shoulder and hip on the right side.The 08/26/2025 at 11:07 PM progress note, written by Nurse Practitioner #1, documented they were asked to see the resident who had a swollen/ bruised right eye. Resident #164 was found to have a bruise on the forehead, laceration on the right nose, evidence of a nosebleed with dried blood in the left nostril and bruising to the right upper arm. The assessment and plan documented status post fall, resident is on Eliquis and after initially ordering x-rays, the resident will be sent to the hospital emergency room. The 08/26/2025 hospital emergency room note documented on 08/26/2025 the resident presented as a level 2 trauma after a presumed fall. A computed tomography scan (a non-invasive imaging procedure) showed an acute intertrochanteric right femur fracture. The 09/01/2025 Incident Summary written by Director of Nursing, documented that on 08/26/2025 at approximately 6:30 AM, Resident #164 was noted with bruising to the right eye, bruise to the right elbow, and a small laceration to the right forehead. The resident is noncommunicative and could not provide a statement as to what caused the bruise. An investigation into the incident found the 11:00 PM to 7:00 AM Certified Nurse Aide # 7 provided care with no assistance to the resident at 11:00 PM on Monday 08/25/2025. During that care, Resident #164 had a fall from bed and suffered an injury from the fall. Certified Nurse Aide #7 placed the resident back in bed with a mechanical lift. During an interview on 09/24/2025 at 3:00 PM, Licensed Practical Nurse #9 stated they were the nurse on 08/26/2025 during the 11:00 PM to 7:00 AM shift and were working with two (2) Certified Nurse Aides. They stated at approximately 11:00 PM, Certified Nurse Aide #7 was in Resident #164's room attending to their care. They stated around midnight; they noticed Certified Nurse Aide #7 came out of the room to obtain a mechanical lift and brought it to Resident #164's room. They stated Certified Nurse Aide #6 came from another unit, entered Resident #164's room and after a few minutes, left Resident #164's room. They stated in the morning; they went into Resident #164's room and noticed a small area around Resident #164's right eye. They stated, they thought it was a scratch and did not know if it was new. During an interview on 09/29/2025 at 10:44 AM, Licensed Practical Nurse Supervisor #8 stated on the morning of 08/26/2025 they were in morning report when they received a text from Licensed Practical Nurse #10 (the medication nurse) about bruising on Resident #164. They stated when they went to the unit and noted bruising and edema around the resident's eye. They stated at the time they felt the resident may have hit the side of their head on the side rail. They stated Nurse Practitioner #1 was notified and gave orders for staff to apply ice and obtain x-rays. They stated when Nurse Practitioner #1 assessed Resident #164, they ordered the resident be sent to the emergency room for further evaluation. During a phone interview on 09/29/2025 at 11:07AM, the Medical Director stated they reviewed the hospital records but were unsure as to what caused Resident #164's injury. During the interview, the Medical Director was made aware of the witness statement regarding the mechanical lift being brought to the room during the night shift prior to finding the injury that morning. They then stated it appeared the resident may have had a fall on the hip resulting in the femur fracture. During an interview on 09/29/2025 at 11:30 AM, the Director of Nursing stated they were not in the building on 08/26/2025 but arrived after they were made aware of Resident #164's injury. They stated an investigation had been started prior to their arrival at the facility. They stated when Certified Nurse Aide #7 returned to work, they obtained a statement and then suspended Certified Nurse Aide #7. They stated after review of all statements and the hospital's findings, the facility determined it was likely that Resident #164 had fallen out of bed during incontinence care, while turning the resident in bed. They stated Certified Nurse Aide # 7 was terminated for performing a one (1) staff assist during cares for Resident #164 who required two (2) staff assist with bed mobility. During an interview on 09/29/2025 at 1:20 PM, Nurse Practitioner #1 stated they were called on 08/26/2025 regarding Resident #164 who had bruising around the eye. They stated they gave verbal orders over the phone for staff to apply ice and have x-rays done. They stated when they saw Resident #164, they noted it was more than a bruise around the eye. They stated they also saw bruising on the right arm. They stated they checked Resident #164's leg but had difficulty assessing due to contractures. They stated they had no doubt the resident's physical exam reflected that something happened to the resident consistent with a fall. 2) Resident #116 was admitted to the facility with diagnoses including, but not limited to, Alzheimer's disease, diabetes and dementia.The care plan titled 'At Risk for falls' last updated on 07/02/2025, documented one (1) hour safety checks, keep the resident in staff view as much as possible, anticipate needs, and review falls with a root cause analysis. The 07/06/2025 behavior note documented Resident #116 was at high risk for falls and they had a chair/bed alarm because of how quickly they get up. The 07/29/2025 Annual Minimum Data Set documented Resident #116 had severely impaired cognition and required partial to moderate assist for activities of daily living. The August 2025 Certified Nurse Aide Tasks documented one (1) hour safety checks, keep the resident within view of staff as much as possible.A review of the Accident & Incident Report, dated 08/27/2025 with a time stamp of 9:12 PM, revealed Resident #116 was found sitting on their buttocks in the hallway, next to the handrail, in front of a wheelchair with the chair alarm ringing. The resident stated they tried to walk. A review of the Certified Nurse Aide hourly rounds book dated 08/27/2025 revealed no documented evidence that hourly round checks were performed between 3:00 PM and 11:00 PM. The 08/27/2025 nurse progress note, written by the Director of Nursing, documented Resident #116 was found in the hall next to the handrail on the floor in front of their wheelchair. The resident was assessed and had no injuries. During an observation on 09/25/2025 from 10:15 AM to 10:45 AM, Resident #116 was unsupervised in the day room. Resident #116 was sliding forward while sleeping in a wheelchair. The wheelchair had a chair alarm. No staff were supervising the day room. All Certified Nurse Aides were providing morning care, and two (2) Licensed Practical Nurses were passing medications. During an interview on 09/25/2025 at 10:28 AM, Licensed Practical Nurse #5 stated since there was no unit manager, the medication nurse was responsible for checking the one (1) hour safety rounds book at the end of each shift to ensure it was complete. They stated the unit clerk usually supervised the day room but was out of the building. They stated they were unsure which staff should be supervising the day room. They stated they were aware Resident #116 was at risk for falls and tried to ensure supervision. During an interview on 09/25/2025 at 10:40 AM, Licensed Practical Nurse #3 stated Resident #116 was at high risk for falls and should have every one (1) hour safety checks. They stated they were aware the hourly checks were not being signed consistently. They stated residents in the day room should be supervised by staff, especially residents that were at high risk for falls. During an interview on 09/25/2025 at 10:43 AM, Certified Nurse Aide #4 stated they did the one (1) hour safety checks and were educated to sign the one (1) hour safety check book but never signed it. They stated the unit assistant usually observed the dayroom, but no staff were assigned to supervise the dayroom in their absence. During an interview on 09/25/2025 at 11:46 AM, the Director of Nursing stated after a 07/03/2025 fall, Resident #116 was placed on one (1) hour safety checks. They stated they were aware Resident # 116 was at high risk for falls. The Director of Nursing stated Resident #116 had a fall on 08/27/2025 but they were unaware the one (1) hour safety check log was incomplete on 08/27/2025 during the 3:00 PM to 11:00 PM shift, therefore they had not followed up with the assigned certified nurse aide. 10NYCRR 415.12(h)(2)

Based on record review and interview during the recertification survey and an abbreviated survey (#2601270 and 2577313), the facility did not ensure development and/or implementation of comprehensive person-centered care plans that included measurable objectives and timeframes to meet resident needs for two (2) of four (4) residents (#164 and #116) reviewed for accidents, three (3) of five (5) residents (#20, #44, and #63) reviewed for activities, one (1) of two (2) residents (#41) reviewed for positioning and one (1) of three (3) residents (#142) reviewed for restraints. Specifically, 1. implementation of two person staff assistance for transfer/bed mobility was not provided for Resident #164 as per care plan 2. there was no documented evidence of a care plan to address the use/release schedule of a lap/seat belt for Resident # 142 and 3. the use of hand rolls was not implemented as per physician order and there was no documented evidence of a care plan to address the physician ordered use of rolled gauze in the hands and knee abductor roll when in the wheelchair for Resident #41. Additionally: there was no documented evidence of a care plan to address activities for Resident #63, #20 and #44 and every one-hour safety checks were not consistently implemented as per care plan for Resident #116. The findings include: The January 2025 policy and procedure titled, Care Plans-Comprehensive documented individualized comprehensive care plan that include measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological need is developed for each resident. 1) Resident #164 was admitted to the facility with diagnosis including but not limited to history of cerebral infarction (ischemic stroke), pulmonary embolism (a blood clot to the lungs), and unspecified intellectual disability. The 06/20/2025 Quarterly Minimum Data Set (a resident assessment tool) documented Resident #164 had severely impaired cognition and required total assistance for activities of daily living. The August 2025 care plan titled Activities of Daily Living documented Resident #164 was dependent with bed mobility, transfers and required two (2) persons for assistance. The August 2025 Certified Nurse Aide Kardex and Tasks documented Resident #164 required 2 person staff assist for bed mobility and transfers. The 09/01/2025 Incident Summary written by Director of Nursing documented that on 08/26/2025 at approximately 6:30AM Resident #164 was noted with bruising to the right eye, bruise to the right elbow, and a small laceration to the right forehead. An investigation into the incident found Certified Nurse Aide # 7 provided care with no assistance to the resident at 11PM on Monday 08/25/2025. During that care, Resident #164 had a fall from bed and suffered an injury from the fall. Certified Nurse Aide #7 placed the resident back in bed with a mechanical lift. During an interview on 09/29/2025 11:30 AM the Director of Nursing stated Certified Nurse Aide # 7 performed one (1) staff assist during cares for Resident #164 who required two (2) staff assist with bed mobility. 2) Resident #142 was admitted to the facility with diagnoses including but not limited to Dementia, fracture of the femur, and repeated falls. The 06/14/2025 physician order documented velcro alarm seatbelt in the wheelchair, release every two (2) hours to provide cares and release at meals. Monitor residents' ability to self-release alarmed seat belt on command daily. There was no documented evidence in the care plan to address the use/release schedule of a lap/seat belt or any other restraint. The 09/15/2025 Minimum Data Set documented, Resident #142 had severe cognitive impairment, was dependent for sit to stand and transfers, and did not use physical restraints or alarms. During an observation on 09/22/2025 at 12:40 PM Resident # 142 was wearing the lap/seat belt at lunch. During an observation on same day at 3:20 PM Resident #142 was wearing the lap/seat belt in the day room. When this surveyor asked Resident #142 to remove the lap/seat belt three (3) separate times, Resident #142 was unable to complete the request. During an observation on 09/24/2025 at 1:18 PM and 3:35 PM Resident #142 was in a wheelchair in the day room with a lap/seat belt in place. During an interview on 09/24/2025 at 3:35 PM Certified Nurse Aide #18 was asked to check the Kardex for information on procedure regarding the lap/seat belt. Certified Nurse Aide #18 stated there is no information about the lap/seat belt and if the direction is not in the Kardex the staff would not be aware of how to care for the residents. During an interview on 09/24/2025 at 3:35 pm Licensed Practical Nurse #3 stated they were not aware of the order to release the lap/seat belt every two (2) hours. They stated it is probably in place due to Resident #142 being a fall risk. Licensed Practical Nurse #3 stated Resident #142 can take the lap/seat belt off but had not witnessed them take it off upon request. During an interview on 09/24/2025 at 12:58 PM Registered Nurse Unit Manager #11 stated they did not see anything in the care plan to address the lap/seat belt and that they thought it was in place for a previous hip fracture. 3) Resident #41 had diagnoses including but not limited to Alzheimer's disease, contracture of the knee, and muscle weakness. The 08/13/2025 Minimum Data Set documented, Resident #41 had severe cognitive impairment and was dependent for all activities of daily living. The 06/12/2025 physician order documented knee abductor roll when in bed and when in wheelchair, and right and left-hand protector/roll of gauze at all times, remove for frequent skin checks and hygiene. There was no documented evidence in the comprehensive care plan to address the use of rolled gauze in the hands or knee abductor roll when in the wheelchair. During an observation on 09/23/2024 at 9:48 AM Resident #41 was in the day room in a wheelchair with right foot crossed over the left foot, leaning to the right. No devices (rolled gauze) were present in either hand. During an observation on 09/24/2025 at 1:22 PM Resident #41 was in the day room with no devices (rolled gauze) present in hands. During an interview on 09/25/2025 at 4:36 PM Occupational Therapist #21 stated Resident #41 should have rolled gauze in both hands for contractures and the abductor roll between legs. They stated nursing should enter the recommendations made by therapy into the care plans. During an interview on 09/29/2025 at 12:58 PM Registered Nurse Unit Manager #11 stated the treatment administration record included the directive for application of the gauze rolls by the medication nurse. Upon review of the care plan Registered Nurse Unit Manager #11 stated they could not locate the documentation in the care plan to address the use of the gauze rolls or the knee abductor. They stated the care plan must not have gotten transferred over from the previous electronic medical record to the current medical record. 10 NYCRR415.11(c)(1)

Based on observation, interview, and record review during the recertification and abbreviated surveys (#2582376) the facility did not ensure resident choice related to provider of health care services was met for one (1) of one (1) resident investigated for choices. Specifically, Certified Nurse Aide #23 continued to provide care for Resident #75 after their representative communicated a preference of not having Certified Nurse Aide #23 provide care to Resident #75.The findings include:Resident #75 had diagnoses that included but were not limited to dementia, anxiety, and major depressive disorder. The grievance dated 07/11/2025 documented a request was made on 12/14/2024 that Certified Nurse Aide #23 not be assigned to care for Resident #75. On 01/12/2025, Certified Nurse Aide #23 was observed by Resident #75's son providing cares to Resident #75.The Significant Change Minimum Data Set, dated [DATE] documented Resident #75 had severely impaired cognition, no behaviors, and was dependent on staff assistance for all activities of daily living.During an interview on 09/29/2025 at 10:43 AM, the Director of Social Work stated Resident #75's son communicated that they did not want Certified Nurse Aide #23 providing cares to their mother on 12/14/2024. They stated residents and their representatives had the right to determine who provided them with care. They stated they were not certain why Certified Nurse Aide #23 provided care to Resident #75 on 01/12/2025. During an interview on 09/29/2025 at 11:12 AM, the Assistant Director of Nursing stated the unit manager would know how the certified nurse aide was made aware that they should not provide cares to Resident #75. They stated Certified Nurse Aide #23 should not have been assigned to, or provided cares to, Resident #75 on 01/12/2025. During an interview on 09/29/2025 at 11:54 AM, Registered Nurse Unit Manager #11 stated Resident #75's son requested that Certified Nurse Aide #23 not care for their mother. They stated when communicated to them, they informed the Director of Nursing, Staffing Coordinator, the floor nurses, and Certified Nurse Aide #23. They stated Certified Nurse Aide #23 should not have provided care for Resident #75 on 01/12/2025 since the request was made on 12/14/2024. They stated they were not working on 01/12/2025 and were unaware why Certified Nurse Aide #23 took the assignment. 10NYCRR 415.5(b) (1-3)

Based on observation, interview, and record review conducted during the recertification and abbreviated surveys (#2601270), the facility did not ensure all alleged violations of abuse were reported immediately, but not later than 2 hours to the state survey agency for one (1) of two (2) residents reviewed for abuse (Resident #164). Specifically, on the morning of 08/26/2025 Resident #164 was observed with a bruise to the right eye and bruise to the right arm that was not reported to the state agency until 08/26/2025 at 11:05 PM. The findings include:The policy and procedure titled Abuse Prevention and Reporting dated 01/09/2001, last revised 09/2024 documented if the events that cause the reasonable suspicion (but no later than 2 hours after forming suspicion). Resident #164 had diagnoses including Cerebral Infarction, Pulmonary Embolism, and an unspecified intellectual Disability.The Quarterly Minimum Data Set (A resident assessment tool) dated 06/20/2025 documented the resident had severe cognitive impairment. And was dependent with all activities of daily living. The Accident and Incident Report dated 08/26/2025 at 11:00 AM documented discoloration to the right eye, Nurse Practitioner notified. Interventions ice and x-rays.The Nurse Practitioner progress note dated 08/26/2025 (late entry) at 1:11 PM documented right forehead ecchymosis, swelling to the right orbit. Assessment and Plan status Post Fall- sent to emergency room for evaluation.The incident Report documented it had not been submitted until 8/26/2025 at 11:05 PM The reportable incident written by the Director of Nursing on 09/01/2025 summarized on 8/26/25 at 10:30 AM Licensed Practical Nurse #10 entered Resident #164's room and noted bruising to the right eye and notified Licensed Practical Nurse # 8, who assumed the resident had accidently hit the side of her face on the side rail and intervened by padding the siderail, called the Nurse Practitioner and initiated an Accident and Incident Report. On 8/26/25 at 11:07 AM the Nurse Practitioner assessed the resident and noted increased swelling around the eye and a bruise on the right arm and subsequently concluded the resident's injuries were consistent with a fall. The Assistant Director of Nursing was made aware and began an investigation. During an interview on 09/29/2025 at 11:30 AM the Director of Nursing stated they came to the building after a concern regarding injuries sustained by Resident #164. They stated an investigation started prior to their arrival at the facility and statements were being taken. They stated after Certified Nurse Aide #7 provided a statement on 08/26/2025 at 11:00PM that they provided care alone, a report was called to the Health Department on 08/26/2025 at 11:05PM. They Stated the bruises as identified by the Nurse Practitioner could be considered injuries of unknown origin. They stated they knew injuries of unknown origin should be reported to the Health Department with in two (2) hours.During an interview on 09/29/2025 at 12:19 PM the Administrator stated they were aware of the event of 08/26/2025 but were not involved in the investigation. They stated all injuries of unknown origin should be reported to the Health Department within 2 hours. During an interview on 09/29/2025 at 12:53 PM the Assistant Director of Nursing stated they recalled the event of 8/26/25. They stated they evaluated the resident after the Nurse Practitioner assessed the resident. They stated they started an investigation into how the injury of unknown origin may have occurred and notified the Director of Nursing and the Administrator around 2 PM. They stated they were unaware of when the incident was reported to the Health Department. 10 NYCRR 415.4(b)(2)

Based on observation, interview, and record review conducted during the recertification and abbreviated surveys (#2583366), the facility did not ensure that activities of preference and interest were available and designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for one (1) of one (1) resident (Resident #20) reviewed for behavior-emotional care and one (1) of three (3) residents reviewed for restraints (Resident #7). Specifically, 1) Resident #20 was observed on multiple occasions wandering in the hallways of the unit and not participating in activities; 2) Resident #7 missed an activity that was held off the unit because the activities staff was unable to transfer the resident from an enclosed frame walker to a wheelchair.The findings include1)Resident #20 had diagnoses that included, but were not limited to, dementia, schizophrenia, and depression. The 05/25/2025 care plan titled Behavior Symptoms Wandering documented exhibits wandering as evidenced by entering peer rooms, wanders aimlessly. Provide pleasant diversions included redirection, activities, food, and conversation.The 07/18/2025 Annual Minimum Data Set documented severe cognitive impairment, and religion and music activities were very important.The 07/30/2025 Interdisciplinary Care Plan Meeting note documented Resident #7 enjoys singing, going outside for fresh air and walking around the unit. The care plan titled Behavior Management Program with an 08/04/2025 revision date documented requires ongoing redirection, monitoring, and structured activities to alter behavior.There was no documented evidence of a care plan to address activities for Resident #20During an observation on 09/22/2025 at 11:17 AM, Resident #20 was sitting in the unit common area with other residents. Music was playing and no activities were taking place. During an observation on 09/23/2025 9:44 AM, Resident #20 was observed walking down the hallway unsupervised. An activity was in progress, but Resident #20 was not participating.During an observation on 09/24/2025 at 9:34 AM, Resident #20 was wandering in the unit hallway. At 9:41 AM, Resident #20 took a seat in the unit common area by the nurse's station. There was an activity going on inside the common room, but Resident #20 was not involved with the activity. During an interview on 09/24/25 at 1:35 PM, the Director of Activities stated activities care plans were their responsibility. They stated the facility transferred to a new electronic medical record in June, and some care plans were not in the current system. They stated Resident #20 did not have a current activity care plan so their preferences would need to be communicated verbally amongst staff. During an observation on 09/25/2025 at 10:29 AM Resident #20 was ambulating on the unit in the common area. Resident #20 attempted to walk out of the area, but staff redirected them to sit in a chair. During an observation on 09/26/2025 at 10:01 AM an activity was going on in the common area on the unit, Resident #20 was not participating. Resident #20 was wandering unsupervised in the hallway checking doors, not engaged by staff, and playing with the window by an exit door. Resident #20 walked back toward the nurse's station and went behind the nurse's desk. Resident #20 was then redirected by staff to the activity in the common area and assisted into a chair by the window. Resident #20 did not engage in the activity. 2) Resident # 7 had diagnoses that included but were not limited to Alzheimer's Disease, anxiety, and depression.The 08/26/2025 Significant Change Minimum Data Set documented severe cognitive impairment, music, outdoor, animal, group, and religious activities were moderately important. The 09/10/2025 care plan titled Resident deemed a Significant Change dated 09/10/2025 documented enjoys music, talking, and being outdoors. Will participate in on unit programs with encouragement and participate in off unit events with transport assistance. Invite resident to events and provide assist with transport. During an observation on 09/25/2025 at 10:52 AM, Resident #7 was invited to a coffee social by an activities staff member and accepted the invitation. The activities staff member stated they would have to transfer them to another chair to attend and would return. Resident #7 waited in the common area, resting in an enclosed frame walker with their eyes closed. At 11:01AM, Resident #7 was still sitting in the unit common area in an enclosed frame walker. At 11:16AM, Resident #7 remained on the unit in an enclosed frame walker. During an interview on 09/29/2025 12:41 PM, Registered Nurse Unit Manager #11 stated Resident #7 may attend activities off the unit, but they go off the unit in a transport chair. They stated recreation handles transport when taking the residents off the unit. During an interview on 09/29/2025 at 2:46 PM, the Director of Recreation stated Resident #7 was not at the coffee social on 09/25/2025 but does attend off unit activities on occasion. They stated since the introduction of the enclosed frame walker, Resident #7's attendance at off unit activities had decreased. They stated activities staff could not transfer residents from walkers to wheelchairs. They stated nursing staff must assist, and if they nursing staff were busy, it could be difficult finding assistance. 10NYCRR 415.12

Based on observation, interview, and record review conducted during the recertification and abbreviated surveys (#2583366) the facility did not ensure sufficient staff to provide services to maintain the highest practicable physical, mental and psychosocial well-being as per individualized care plan for one (1) of one (1) resident (Resident #20) reviewed for behavior and emotional care. Specifically, ongoing monitoring/supervision and thirty-minute checks were not consistently implemented for Resident #20 with a history of wandering and defecating/urinating in inappropriate places. The findings include:Resident #20 had diagnoses that included but were not limited to dementia, schizophrenia, and depression. A 07//09/2025 Grievance documented a family member observed Resident #20 stabilizing themself by putting their hand on top of Resident #126's head and they were fumbling with the drawstrings on their pants. Resident #20's private area was close to Resident #126's face. No staff were supervising Resident #20 as they were tending to other residents. The family member had to call for staff assistance. The 07/18/2025 Annual Minimum Data Set documented severely impaired cognition, supervision for ambulation and maximal staff assistance for toileting.The care plan titled Behavior Management Program last revised 08/04/2025 documented requires ongoing redirection, monitoring, and structured activities to alter behavior, lock installed on closet to divert resident from taking others' clothing; examples of behaviors taking other resident clothing, urinating and defecating in inappropriate places. The care plan titled Behavior-Wandering last revised 08/04/2025 documented exhibits wandering as evidenced by entering peer rooms, wanders aimlessly. Staff redirection, provide pleasant diversions including activities, food, conversation, television, and books. 30-minute safety checks were initiated 07/07/2025.The care plan titled Socially Inappropriate Behaviors-Urinating and Defecating last revised 08/04/2025 documented monitor every half hour by staff, monitor for pacing behavior, and offer toileting. The 08/22/2025-09/23/2025 Thirty Minute Checks revealed no documentation for entire shifts on 27 of 30 dates and no documentation for all shifts on three (3) of 30 dates.During an observation on 09/23/2025 at 10:32 AM, Resident #20 was observed walking down the unit hallway and wandered into the room of a resident on contact precautions for clostridium difficile. Resident #20 proceeded to wander around the room, opening doors, touching furniture, windows and other items. During observation on 09/23/2025 at 2:10 PM while unsupervised Resident #20 leaned against the post/column outside the Apple unit dining room. Resident #20 had their hands on the waistband of their pants. Resident #20 pulled down their pants, squatted slightly and began to expel feces. During an interview on 09/24/2025 at 11:11 AM, Resident #44's spouse stated they have observed Resident #20 urinating and defecating in inappropriate places like the floor, in resident rooms, and in their closet. During an interview on 09/25/2025 at 10:04AM with the complainant they stated Resident #20 continues to roam the hallways unsupervised. They wander in and out of rooms all the time. On 07/09/2025 they observed Resident #126 sitting in a wheelchair in the common area, Resident #20 had their hand on Resident #126's head and was fumbling with their drawstring on their pants. They stated their private area was covered but in proximity to Resident #126's face. The complainant stated they did not believe Resident #20 was being sexually inappropriate, they just needed to go to the bathroom. They stated there were no staff monitoring and they had to call for assistance. They stated the facility should have been monitoring Resident #20. During an observation on 09/25/2025 at 11:18AM, Resident #20 ambulated down the unit hallway, attempted to open a door in the hallway but was unable, and continued to the window at the end of the hallway. Resident #20 then wandered into room [ROOM NUMBER], walked around in the room, came out, and headed back up the hallway independently. No staff supervision or redirection was observed. During an observation on 09/26/2025 starting at 08:30AM, Resident #20 was observed in their room eating breakfast independently. Their tray was collected at 08:50AM. Resident #20 wandered in their room and then left the room and was in the hallway, heading toward room [ROOM NUMBER]. Resident #20's pants were visibly soiled, their brief was bulging and appeared low, and their sweatshirt was on backwards. At 9:29 AM Certified Nurse Aide # was coming out of another room and directed Resident #20 back to their room and left. Resident #20 came out of their room again and was entering room [ROOM NUMBER]. Certified Nurse Aide # in the hallway saw Resident #20 and escorted them out of room [ROOM NUMBER] and back to their room for cares at 9:34 AM. During an interview on 09/26/2025 at 10:32 AM, Certified Nurse Aide #12 stated that Resident #20 does exhibit behaviors including going to the bathroom everywhere in inappropriate places and wandering into other residents' rooms. Thirty-minute checks are ordered, and the log is at the nurse's station. They stated they are supposed to sign at each check, but they have not completed it for the last few days. During an interview on 09/26/2025 at 10:45 AM, Registered Nurse Unit Manager #11 stated Resident #20 likes to wander and does enter other residents' rooms. They stated Resident #20 is easily redirected. They stated thirty-minute checks are ordered to monitor where Resident #20 is and redirect as needed. The checks should be completed, signed for, and omissions should not be there. They stated the Licensed Practical Nurse should be checking that thirty-minute checks are completed and signed for. During an interview on 09/26/2025 at 11:03 AM, the Assistant Director of Nursing stated Resident #20 does wanders and has an order for thirty-minute checks. They stated the checks are expected to be completed and signed for. During an interview on 09/29/2025 at 10:54 AM the Director of Social Work stated the incident involving Resident #20 on 07/09/2025 was investigated and no findings of ill intent or harm were identified. Resident #20 does exhibit behaviors and can be distracted with music and activities. They stated there was a regular sitter in the day room that was very helpful with redirection, activities, and monitoring, but they have not been here for some time. They stated they try to have unit assistants in the day room on the Apple Unit in addition to the scheduled nursing staff for safety, engagement, and activity but they are not sure of their schedules. During an interview on 09/29/2025 at 11:23 AM, the Assistant Director of Nursing stated unit assistants help with Resident #20 and monitor their behaviors in addition to nursing staff. They stated there was a time when their behaviors were worse. They stated unit assistants are scheduled on the Apple Unit but only for a few hours daily. During an interview on 09/29/2025 at 12:21 PM, Registered Nurse Unit Manager #11 stated the unit has unit assistants when they are available. They stated the unit assistants usually come in around 11AM and occasionally they have an assistant on evenings. They stated Resident #20 wanders and redirects easily, but staff are not always available to monitor all behaviors and wandering. They stated most residents on the unit are up and out of bed, so this minimizes possible resident to resident altercations when Resident #20 wanders into rooms. They stated they are trying to get more staff and may have more assistants in the future, but right now they do not have them on staff every day.10NYCRR

Based on record review and interviews conducted during an abbreviated survey (NY00384916), the facility did not ensure that comfortable and safe temperature levels were maintained in all areas during a heat emergency, when the air conditioning unit on one unit (Dogwood), located on the first floor of the building, was not functional on 06/23/2025. Specifically, the facility could not provide documentation that temperatures in resident rooms were adequate or comfortable during the breakdown of the air-conditioning system from 06/23/2025 to 06/24/2025. The air-conditioning was restored to residents' rooms on 06/24/2025 at 3:00 PM. The Administrator stated that they did not check resident room temperatures, as this was not part of the facility's policy. Since the hallway temperatures on Dogwood were within regulation, the air-conditioning issue was not reported as a heat emergency. The findings include: The facility policy titled Heat Emergency states that, during all seasons, a comfortable temperature must be maintained throughout the occupied areas of the facility, consistent with Department of Health regulatory requirements. It is the responsibility of the Maintenance Department to monitor and maintain temperatures within a desired range of 71°F to 81°F. The Director of Building Services is responsible for monitoring ambient air temperatures during periods of high heat and humidity and for documenting temperature readings on a Temperature Log Sheet. The Administrator must review the temperature log daily during periods of high heat. The Maintenance Department is supported in these efforts by all other departments, who are responsible for reporting any changes in the air-conditioning system that could place residents in jeopardy. Resident rooms are to be routinely checked to ensure proper air-conditioning function. The Administrator or designee must notify the local New York State Department of Health in the event of an actual or anticipated heat-related emergency. On 06/23/2025, hallway temperatures of the four (Apple, Birch, Cedar, and Dogwood) facility units ranged from 71°F to 78.3°F - within regulation. On 06/24/2025, hallway temperatures ranged from 71°F to 78.6°F - within regulation. On 06/25/2025, hallway temperatures ranged from 71°F to 74.5°F - within regulation. On 06/26/2025, resident room temperatures ranged from 71°F to 78.3°F - within regulation. There was no documented evidence that resident room temperatures were checked during the breakdown of the air-conditioning system from 06/23/2025 to 06/24/2025 on the Dogwood Unit. On 06/26/2025 at 1:20 PM, during a telephone interview with the Director of Nursing, they stated they were not aware of any air-conditioning issues and had not received complaints from residents or families regarding uncomfortable room temperatures. However, they stated they would follow up by checking resident room temperatures and calling back once the information was gathered. In a follow-up call on 06/26/2025 at 3:18 PM, the Director of Nursing stated that Resident #1's spouse did complain on 06/23/2025 about the unit (Dogwood) being too hot, but a grievance report was not completed because an air-conditioning unit was immediately installed in the dining area, and the issue was considered resolved. On 06/26/2025 at 2:38 PM, during a telephone interview with the Administrator, they stated that there were no issues with air-conditioning in the facility and that no complaints had been received from residents or families. On 06/30/2025 at 9:30 AM, a message was left for the complainant requesting a return call. On 06/30/2025 at 9:31 AM, during a telephone interview with the Director of Maintenance, they stated they did not check resident room temperatures but only monitored hallway temperatures for the four units on 06/23/2025, 06/24/2025, and 06/25/2025. On 06/30/2025 at 1:35 PM, during a telephone interview with the Administrator, they stated the air-conditioning failure was not reported to the New York State Department of Health because Dogwood hallway temperatures remained within regulation: 74.8-75°F at 9 AM, 74.7-76.1°F at 11 AM, 75.1-77.3°F at 1 PM, 76.3-77.5°F at 3 PM, and 77.9-78.3°F at 4:30 PM. The Administrator stated that they had only recently joined the facility (three months prior), and they intended to revise the Heat Emergency policy to include checking every resident room temperature. On 06/30/2025 at 2:50 PM, during a telephone interview with the Director of Nursing they stated that Resident #1's spouse expressed discomfort with the room temperature on 06/23/2025, although the resident was reportedly fine. The Director stated they visited Dogwood twice that day and did not personally feel the unit was hot. Nursing staff did not check resident room temperatures, and the Director was unaware that maintenance had also not checked them. Maintenance installed an air-conditioning unit in the Dogwood dining area and fans in the hallway but not in resident rooms. Full air-conditioning service in the Dogwood Unit was restored around 3 PM on 06/24/2025. The Director stated that no residents experienced heat-related symptoms between 06/23/2025 to 06/30/2025. 415.5(h)(2)

Based on record review and interviews during an abbreviated survey (NY00357873, NY00372738, NY00373759, NY00339079), the facility did not ensure sufficient nursing staffing to attain or maintain the well-being of each resident. Specifically, 1) upon review of the staffing schedule for multiple days and on all three shifts of staffing for each floor for February 2025, March 2025 and April 2025, the facility did not provide adequate staffing to meet the needs of the residents and were staffed below their minimum staffing levels on many occasions. 2) The findings are: The facility Staffing Plan dated 7/13/20 documented the nursing department will maintain sufficient nursing staff to meet the care needs of all residents. Nursing services are provided 24 hours a day, seven days a week. The Facility Assessment provided by the facility was last revised on 4/18/25. The last review by the Quality Assurance and Improvement Committee was on 1/30/25. The staffing plan documented a table describing the number of staff available to meet residents' needs, which listed the position of staff by title, as well as the number of full-time employees that hold those positions. The facility Staffing Plan- Minimum Staffing Guidelines documented on all units for the day shift there will be a minimum three Certified Nurse Aides, evening shift will be a minimum two- and one-half Certified Nurse Aides on all units and night shift will be a minimum one- and one-half Certified Nurse Aides. A review of the staffing schedules for February 2025 documented there were four occasions of staffing below three Certified Nurse Aides on the day shift (2/15,2/16,2/18,2/20), one occasion of staffing below two- and one-half Certified Nurse Aides on the evening shift (2/14, )and one occasion of staffing below one- and one-half Certified Nurse Aides below on the night shift (2/17). A review of the staffing schedules for March 2025 documented there were four occasions of staffing below three Certified Nurse Aides working on the day shift (March 8,9,25 and 27) one occasion of staffing below two and one half Certified Nurse Aides on the evening shift ( 3/8) and two occasions of staffing below one and one half Certified Nurse Aides on the night shift (3/28, 3/30). A review of the staffing schedules for April 1-23, 2025, documented there were five occasions staffing was below three Certified Nurse Aides on the day shift (4/12,4/13,4/14,4/20,4/21) and two occasions below 2.5 Certified Nurse Aides on the evening shift (4/5,4/8). During an interview on 4/21/25 at 12:03 PM, Certified Nurse Aide # 20 stated it was almost time for lunch and had one more resident to get out of bed with a Hoyer Lift. They stated they knew it would be done while meal trays were being delivered but must get more residents out of bed. Certified Nurse Aide #20 stated it is like this all the time, especially when there is only two Certified Nurse Aides on the unit. Two showers had been given already but more are on the schedule and will not be able to get it all done. They stated they had six heavy residents on their assignment, two requiring Hoyer lift for transferring to a chair. During an interview on 4/21/25 at 4:36 PM Certified Nurse Aide #18 stated it was very hard to get work done when the staffing is less than three Certified Nurse Aides on evenings. The meal trays arrive at 4:37 PM because it takes a long time to feed everyone. They stated there are so many residents to feed and no one from Administration helps with the problem. They stated they had two showers to do and a total of six are scheduled to be done on the evening shift. During an interview on 4/21/25 at 4:47 PM Registered Nurse Unit Manager#1 stated when there are two Certified Nurse Aides on the day shift, they are not able to complete all showers as scheduled. They have spoken to the Director of Nursing and was told they are working on getting staff. They stated lunch is served in the hallway for fall risk residents otherwise they will be in their rooms. They stated it is better to see the residents in hallway. During an interview on 4/22/25 at 2:44 PM The Staffing Coordinator stated having four Certified Nurse Aides on the day shift is goal, most of the time they will find three Certified Nurse Aides. If there are extra staff on the schedule will staff the Dementia unit first and then the Rehab unit because of the higher acuity. They stated they receive the minimum staffing numbers from the Administrator and strives to get the numbers at four. They use agencies and incentives for staff to cover the holes in the schedule. During an interview on 4/22/25 at 2:44 PM, Certified Nurse Aide # 12 stated staffing needs improvement. When somebody calls out there will only be one certified nurse aide on each side and you will have up to 15-20 residents each with only 2 aides when there should be 3. Certified Nurse Aide #12 stated the Birch unit would run smoothly on the evening shift when there are 3 certified nurse aides on the unit. When there are only 2 certified nurse aides it makes it less manageable. When they are dealing with rehab unit, the residents are waiting for 45 minutes to be toileted because they are more alert and will ask for more help. The residents were still taken care of, but they will wait longer periods of time. Certified Nurse Aide # 12 stated the resident's family complained often about staffing and waiting long periods of time for resident to be cared for. During an interview on 4/22/25 3:22 PM with Certified Nurse Aide #8 and Certified Nurse Aide # 11 stated the staffing was bad. The facility used to give them $150 every time they picked up weekend a shift and stopped providing it. Certified Nurse Aide #8 and Certified Nurse Aide # 11 stated when they were short staffed, they did not get provided care timely. They stated they saw more urinary tract infections because residents were not being changed as much, and wounds would break down more as a result of not providing timely incontinence care. Certified Nurse Aide #11 and Certified Nurse Aide # 8 stated staff were getting physically sick because they were working too much and they were often asked to stay on for an extra shift. Certified Nurse Aide #8 and Certified Nurse Aide # 11 stated when they were short staffed with only 2 certified nurse aides per unit, they would end up with 20 residents each. They stated when they had 2.5 scheduled for 3 PM to 11 PM, the third aide came in at 7 PM and they were not always sure that person would show up. During an interview on 4/22/25 at 3:49 PM, Certified Nurse Aide #13 stated that staffing was terrible. Certified Nurse Aide #13 stated they felt short staffed all the time. Certified Nurse Aide #13 stated for the day shift, it was a good day when they had 4 certified nurse aides, which would be 2 certified nurse aides per side of the unit. They had to deal with residents' behaviors so there was a lot to do when they had less than 4 certified nurse aides per unit on day shift. They stated they felt they could not always get things done when they were short staffed unless they had the right team meaning regular staff not agency staff. Certified Nurse Aide #13 stated if they were short staffed, they may ask the resident to postpone a shower to the next shift or the next day. During an interview on 4/22/25 at 3:24 PM the Director of Nursing stated they have tried incentive programs and bonuses for staff to improve staffing but there is a need for more staff to feed residents. They stated this has been discussed at their Quality and Performance Improvement meetings. During an interview on 4/23/25 at 3:39 PM the Administer stated they have been at the facility for a few weeks and is working on improving staff numbers and looking for new staff. 10NYCRR 415.13(a)(1)(i-iii)

Based on observation and interviews conducted during the abbreviated survey (NY00339079, NY00357873, NY00372568, NY00373759, NY00337630, NY00354632, NY00364043, NY00372738) from 4/21/25 to 4/23/25, the facility did not ensure that resident's dignity was maintained. 1) Specifically, residents on Apple unit were observed eating lunch and dinner meals on the unit hallways and residents waited a long time for assistance with eating; and 2) Certified Nurse Aide #20 referred to Resident #13 who required assistance with eating as a feeder and Activities Leader #4 referred to Resident #17 as a feeder in the presence of other residents. The findings are: The undated facility policy titled Resident Rights documented the purpose was to ensure the preservation of every resident's right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 1) During multiple observations of meal services on 4/21/25 and 4/22/25, residents were observed eating lunch and dinner in the hallways of Apple unit. Residents were observed waiting extended time to be assisted with eating by staff due to a shortage of tray tables and shortage of staff available to assist residents with eating. On 4/21/25 at 11:55 AM, the lunch food truck was delivered to Apple unit/low side. During an interview of 4/21/25 at 12:00 PM Licensed Practical Nurse #3 stated residents were being served lunch and dinner meals in hallways due to two residents on Apple unit who tested positive for respiratory syncytial virus, resulting in closure of dining room. During an interview on 4/21/25 at 12:25 PM, Dietary Aide #19 stated the Apple unit dining room had been closed since 4/3/25, due to an outbreak on the unit. Residents had been served meals in the hallways since that time. They stated that lunch and dinner were served in hallways so staff could observe residents who could choke, and they could assist residents with eating. During an observation and brief interview at 4/21/25 at 12:33 and 12:35 PM, Activities Leader #4 stated three residents in hallway were waiting for lunch trays to be served. They stated lunch trays were in food truck and could not be served due to lack of tray tables. The food truck was observed with door remaining open throughout lunch service. At 12:35 PM Activities Leader #4 provided a tray table for Resident #11, they placed the lunch tray on table, and then moved the lunch tray table approximately three feet away from resident. They stated lunch tray/table was placed away from Resident #11 because they required assistance with eating and had to wait until staff available to assist. Resident #11 was assisted with eating by certified nurse assistant #20 at 12:55 PM. The annual Minimum Data Set (a resident assessment too) dated 3/19/25 documented Resident #11 was dependent for eating. During an observation and brief interview on 4/21/25 at 12:36 PM, Licensed Practical Nurse #3 stated Resident #17 was waiting for a replacement tray due to initial tray spilling in food truck. Resident #17 was observed sitting at a table with another resident who had been served at 12:00 PM. Resident #17 was served replacement tray in hallway at 12:49 PM. During an observation and brief interview on 4/21/25 at 12:37 Certified Nurse Aide #20 stated they were not available to assist Resident #13 with eating due to assisting other residents with eating. Resident #13 had been served a tray at 12:00 PM and was not observed eating independently. The annual Minimum Data Set (a resident assessment tool) documented Resident #13 had severe cognitive impairment and required supervision or touching assistance during meals with helper providing verbal cues and/or touching/steadying and/or contact guard assistance as resident as completes activity and assistance provided throughout the activity or intermittently. During an observation on 4/21/25 at 1:00 PM, Resident #13 was again observed with an open uneaten tray on table. At 1:05 PM, Certified Nurse Aide #20 handed Resident #13 the ginger ale from tray. They did not assist or encourage resident to eat. Certified Nurse Aide #20 stated Resident #13 needs encouragement and assistance with eating and were aware Resident #13 had not eaten. They stated they had to complete assisting another resident and would then assist and provide encouragement for Resident #13 to complete lunch service. During observation on 4/21/25 at 12:11 PM and 1:07 PM Resident #14's lunch tray was observed unopened or set up at resident bedside. Lunch tray was observed delivered at 12:11 PM by activities leader #4. Resident lying in bed awake. At 1:07 PM, Resident #14 was assisted to sit up at bed side and tray set up completed by Certified Nurse Aide #21. The quarterly Minimum Data Set (a resident assessment tool) documented Resident #14 required setup or clean-up assistance requiring helper set up or clean up. During an interview on 4/21/25 at 4:51 PM Unit Manager Registered Nurse #1 stated Apple unit has been on quarantine for a couple of weeks. They stated quarantine means residents do not eat in unit dining room, do not participate in group activities or therapies and do not leave the unit. They stated that residents currently eat meals in the unit hallways due to residents having higher fall risk and that having residents in hallways allows staff to watch residents. They stated that the infection preventionist has requested that residents do not eat in the dining room during outbreak. They stated residents are in the hallway at mealtime for supervision reasons, not infection control reasons. Activities and rehabilitation department staff assist during meals due to unit having many residents who require assistance with eating. After a review of 4/21/25 staffing schedule 7 AM-3 PM shift with Unit Manager Registered Nurse #1, they stated there were two Certified Nurse Aides present on day shift (7:00 AM-3:00 PM) instead of the minimum of three. They stated that residents can wait a long time to receive assistance with eating when short-staffed. They stated the Director of Nursing and Administration were aware of heavy assistance required for residents on unit and need of more staff. 2) During an interview on 4/21/25 at 12:09 PM on the low side hallway, Activities Leader #4 referred to Resident #17 as a feeder while explaining that the resident was waiting for a nurse to assist with eating. This was in the presence of other residents and one family member. Activities Leader #4 stated they were not aware that the term feeder should not be used for residents who required assistance with eating. During an observation and interview on 4/21/25 at 12:37 PM on the low side hallway with other residents present, Certified Nurse Aide #20 referred to Resident #13 as a feeder during the lunch service when stating that they did not have time to assist Resident #13 at that time. They stated they were not aware they should not use the term feeder when addressing residents. 10 NYCRR 415.5 (d) (1)(i)

Based on observations, record review, and interviews conducted during an abbreviated (NY00372738, NY00373759) surveys, for 2 of 8 residents (#5 and #4) reviewed for activities of daily living, it was determined the facility did not ensure residents who were unable to carry out ADLs received the necessary services to maintain good nutrition and personal hygiene. Specifically: 1.) There was no documented evidence in the February 2025 Certified Nurse Aide Accountability Record that Resident #5 was toileted on the day or evening shift for 2/14/25 2.) Resident #4 was observed waiting over an hour for assistance with eating, after the meal was delivered. Findings include: 1) Resident # 5 had diagnoses including Non-Alzheimer's Dementia, Arthritis and Depression. The 2/9/25 Minimum Data Set, an assessment tool, documented the resident's cognition was intact and they required substantial to maximal assistance for toileting. The 2/1/25 Activities of Daily Living Care Plan documented Resident #5 required substantial to maximal assistance for bed mobility and was dependent for transfers with a two person assist. Interventions included to assist with toileting as necessary to promote continence; provide assistance with bed mobility and provide one to two person assist for turning and positioning. The February 2025 Certified Nurse Aide documentation had no documented evidence Resident #5 was toileted on the day and evening shift on 2/14/25. The Certified Nurse Aide documentation history detail for 2/14/25 documented resident was toileted on the night shift. During an interview on 4/22/25 at 2:44 PM, Certified Nurse Aide # 12 stated when they were dealing with rehab unit, the residents waited for up to 45 minutes to be toileted and was alert and would ask for more help. Certified Nurse Aide #12 stated the Birch unit ran smoothly on the evening shift when there were three certified nurse aides on the unit. When there were only two certified nurse aides it was less manageable. The residents were still taken care of, but they would wait longer periods of time. Certified Nurse Aide #12 stated the resident's family complained often about staffing and waiting long periods of time for the resident to be cared for. During an interview on 4/22/25 at 3:39 PM, Licensed Practical Nurse # 7 stated Resident #5 would be reminded often that while they were in rehab they required a mechanical lift for transfers and adult brief would be changed. They further stated when the resident progressed in rehab, they were able to put them on the toilet. Licensed Practical Nurse #7 stated the resident would ring the bell and wanted to go back to bed and they would need a second person for transfer, so they would have to wait until a second person would be available. This could take more than 15 minutes when a certified nurse aid was providing care to another resident. During an interview on 4/23/25 at 10:18 AM, the Director of Rehab stated the 2/6/25 physical therapy note documented the resident required moderate assist of 2 to do a stand pivot transfer from bed to wheelchair. The Director of Rehab stated Resident #5 was able to transfer to toilet on 2/14/25 with a 2 person assist. 2) Resident #4 had diagnoses including seizures, diabetes and dysphagia The annual Minimum Data Set (an assessment tool) dated 2/21/25 documented the resident was rarely understood and was dependent on staff for all activities of daily living. The resident was always incontinent of bladder and bowel and was seen by the wound care team for deep tissue injury of the right medial heel. The resident was fully dependent on staff for feeding. The care plan for activities of daily living dated 3/20/24 documented interventions included tray set up and staff to feed and assist with completion of meal. The Certified Nurse Aide care record for the month of April 2025 documented for 23 days, only nine days had documentation of meal amounts for breakfast, eight days for lunch and 16 days for dinner. All other days were left blank. During an observation on 4/21/25 at 11:55 AM trays were delivered on the Apple unit low side. At 12:34 PM Resident #4's lunch tray was put in their room. At 12:57 PM Resident #4's lunch tray was at the bedside and the resident had not been fed by staff. At 1:15 PM Resident #4 was fed by Certified Nurse Aide #20. During an interview on 4/23/25 at 12:43 PM, Certified Nurse Aide #20 stated when there were only two Certified Nurse Aides the showers could run into lunch time. As soon as showers were finished, the priority was feeding the residents. They stated there were a lot of residents who needed to be fed and other departments sometimes came to help but not always. The Certified Nurse Aide stated they did document meals, but when there was not enough staff, sometimes it was not done. During an interview on 4/21/25 at 5:15 PM, Registered Nurse Unit Manager #1 stated the Certified Nurse Aides could not complete all showers as scheduled but did at least three to four today. They stated there are a lot of residents who need to be feed and they had spoken to Director of Nursing and was told they were working on getting staff in here. 10NYCRR 415.12(a)(3)

F684 Based on record review and interview during an abbreviated survey (NY 00372568) the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 out of 3 residents (Resident # 8) reviewed for medications. Specifically, Resident #8 had a seizure disorder, the immediate-use seizure medication was not transcribed from the Hospital Discharge Summary and not available when the resident had a seizure, resulting in the resident being transferred to the hospital for treatment. The findings are: The Policy and Procedure titled Medication Administration last revised 12/24, documented all medication entries in electronic medical record will require two nurses to review each order. Nurse reviewing the order must ensure the order is routed to the proper place. Resident #8 was admitted to the facility on [DATE] with diagnoses of seizure disorder, Lennox-Gastaut syndrome, unspecified intellectual disabilities. The Minimum Data Set (MDS) dated [DATE] documented the resident had moderately impaired cognition and was dependent on staff with toileting hygiene, toilet transfer, supervision with personal hygiene. The resident was always incontinent of bowel and bladder. The Hospital Discharge summary dated [DATE] documented the resident had known history of refractory symptomatic epilepsy and was prescribed anti-seizure medications including Diazepam, (a medication used for relief of an active seizure) 10mg/dose nasal spray 1 spray nasal once, may repeat once after at least 4 hours if needed. The Comprehensive Care Plan Seizure Disorder dated on 2/6/25, documented monitor for seizure activity, administer anticonvulsant medications as ordered by medical doctor, neurology consult as per medical doctor order. Physician admission orders dated 2/4/25 included: - Clonazepam 0.25 mg disintegrating tablet. Place 1 tablet (0.25 mg) by oral route every 12 hours for 14 days. - Valproic acid (as sodium salt) 250 mg/5 mL oral solution. Give 20 milliliters (1000 mg) by oral route 2 times per day. - Briviact 100 mg tablet. Give 1 tablet (100 mg) by oral route 2 times per day. - Epidiolex 100 mg/mL oral solution SIG: give 7.2 milliliters by oral route every 12 hours provided privately. - Onfi 20 mg tablet. Give 1 tablet (20 mg) by oral route 2 times per day. Physician admission orders dated 2/5/25 included: - Aptiom 400 mg, Give 3 tablets once daily for 5 days - Aptiom 600 mg tablet. Give 2 tablets (1,200 mg) by oral route once daily. Review of the physician's admission orders did not include Diazepam nasal spray, as on the Hospital Discharge Summary, or any other as needed (PRN) medication for breakthrough seizures. A Nurses Progress Notes dated 2/12/25 documented Resident #8 experienced a seizure in the morning that continued from the first initial report 10 AM, until Emergency Medical Technicians and paramedics arrived approximately 30-40 minutes later. Unable to give any oral, scheduled medications due to seizure, nurse practitioner made aware. Diazepam nasal spray ordered to be given immediately. Physician's Notes dated 2/12/25 documented Resident #8 had focal seizures for over an hour, the resident's mother at bedside, the resident was unable to take oral medications and intramuscular, and nasal medication was not available. During an interview on 4/23/25 at 2:38 PM Registered Nurse #23 stated they did the medication reconciliation upon resident's admission with Nurse Practitioner #1 over the phone. The nurse stated they reviewed hospital discharge papers with nurse practitioner and every medication before entering them as an order in the computer. The nurse stated if some medication was not entered that meant nurse practitioner did not approve it. The nurse stated they did not remember exactly what happened and why Diazepam nasal spray was not ordered. During over the phone interview on 4/23/25 at 2:02PM Nurse Practitioner #1 stated that they reviewed Resident #8 medications with admission nurse, and they did not remember what medications, and if Diazepam nasal spray was reviewed. 10 NYCRR 415.12

2). Resident #12 had diagnoses Alzheimer's disease, dementia and depression. An Annual Minimum Data Set (MDS) dated [DATE] documented the resident had severely impaired cognition and was dependent on staff with all activities of daily living. A physician order dated 11/26/24 documented to administer Baclofen 5 milligrams give 0.5 tablet (2.5 milligrams) 2 times per day, every day at 10 AM and 6 PM. Nurse's Progress Notes dated 12/4/24 documented the resident's family member was concerned that Baclofen might be making the resident lethargic. Registered Nurse Unit Manager #1 spoke with Nurse Practitioner #1 and Baclofen 2.5 milligrams was changed to once daily from twice daily. A physician order dated 12/4/24 documented to administer Baclofen 5 milligrams, give 0.5 tablet (2.5 milligrams) once daily. A physician order dated 12/5/24 documented to administer Baclofen 5 milligrams, give 0.5 tablet (2.5 milligrams) once daily. The December 2024 Medication Administration Record documented the physician's orders dated 12/4/24 and 12/5/24 to administer Baclofen 5 milligrams tablet, 0.5 tablet (2.5 milligrams) by oral route once daily. Licensed Practical Nurse #22 documented the medication was given 12/6/24, 12/7/24 and 12/8/24 at 10 AM for both physician's orders dated 12/4/24 and 12/5/24 for a total of 5 milligrams daily instead of 2.5 milligrams daily. During an interview on 4/22/25 at 1:27 PM, Registered Nurse Unit Manager #1 stated the physician order for Baclofen was put in twice and it was a duplicate order. Registered Nurse Unit Manager #1 stated that on 12/4/25 they entered the order for Baclofen 2.5 milligrams once daily every day at 10 AM. They stated that the same order was entered on 12/5/24 by another nurse. Registered Nurse Unit Manager #1 stated when the nurse noticed this situation they should have discontinue the duplicate order, contact the physician and documented the conversation. Registered Nurse Unit Manager #1 stated they could not comment as to if the medication was actually given twice. During over the phone interview on 4/22/25 at 1:57 PM Licensed Practical Nurse # 22 stated they remembered the situation with Baclofen medication in December. Licensed Practical Nurse # 22 stated on 12/8/24 they met with the resident's family and the family asked the nurse why the resident still received Baclofen 5 milligrams instead of Baclofen 2.5 milligrams once a day. Licensed Practical Nurse # 22 stated that they replied to the resident's family stating they saw two orders of Baclofen 2.5 milligrams in Medication Administration Record on 12/4/24 and 12/5/24 to give and assumed the medication dosage was increased. The nurse stated that they followed the orders, and unfortunately, they did not question these orders or asked anybody. Licensed Practical Nurse #22 stated that they gave a double dose of Baclofen 2.5 milligrams at 10 AM for three days and signed as they administered this medication. During an interview on 4/22/25 at 2:51 PM, Director of Nursing stated the nurse had to question any duplicate order, needed to clarify the order with the health care provider or any superior before administering the medication. They stated the administration of double dose was a medication error. 10 NYCRR 415.12 (m)(2) Based on observations, record review and interviews during the abbreviated surveys (NY00337630, NY00373759, NY00364043) conducted 4/21/25-4/23/25, the facility did not ensure residents were free from significant medication errors for two (2) of four (4) residents (Residents #15 and #12) reviewed for Drugs and Medications. Specifically, 1) during a medication administration observation, staff crushed, without a physician order and administered extended-release (Nifedipine ER 30 milligrams) medication to Resident #15 and signed for guaifenesin cough medicine but did not give the resident the medication. 2) Resident #12 had a duplicate order for Baclofen (muscle relaxant) and received twice the planned dosage for three days. The findings include: The facility policy Medication Administration revised 12/2024 documented it is the policy that all medications be administered in a safe and systematic way. Proper technique for crushed medications must be used; a physician order obtained, and crushable medication to be given per MD and Pharmacy. 1) Resident #15 had diagnoses including Alzheimer's disease, ataxia and hypertension. The Quarterly Minimum Data Set (assessment tool) dated 2/13/25 documented Resident #15 had severe cognitive impairment and needed supervision for meals. The physician orders dated 2/23/25 documented low sodium, cut up dental soft, thin liquids diet with Aspiration Precautions. Nifedipine ER 30 milligram tablet, extended release 24 hr; give one tablet by oral route once daily at 10 AM. The physician orders dated 4/20/25 documented Guaifenesin 100 milligrams/5 cc oral liquid; give five milliliters(100 milligrams) by oral route three times a day for ten days, ordered for 10 AM. During a medication observation on 4/22/25 at 10:32 AM on the Apple Unit with Licensed Practical Nurse #24 removed Nifedipine ER (Extended Release) 30 milligram tablet from the blister pack to a cup with other pills, crushed it and administered it to Resident #15 with applesauce on a teaspoon. A red and yellow sticker on the blister pack documented Do not crush. During the medication reconciliation with the physician orders, it was noted Guaifenesin cough syrup was not administered during the observation. The Medication Administration Record was reviewed and the time slot for ten am had Licensed Practical Nurse#24 initial indicating it was given at ten am. There was no documented evidence of a physician order to crush medications. During an interview on 4/22/25 at 11:50 AM, Licensed Practical Nurse #24 stated Resident #15 was supposed to get guaifenesin cough syrup but did not get it during the med pass because they overlooked it. They stated they did sign for it and should not have. During an interview with Licensed Practical Nurse #24 on 4/22/25 at 11:55 AM, the blister pack for the nifedipine 30 milligrams was observed with the Do Not Crush sticker. Licensed Practical Nurse #24 stated the medications had to be crushed as the resident could not swallow pills whole. They were not aware if there was an order to crush medications and stated they now see the warning sticker on the blister pack. They stated nifedipine extended release should not have been crushed. During an interview on 4/22/25 at 12:00 PM Registered Nurse Unit Manager #1 stated all meds that were crushed needed to have a physician order. Nifedipine Extended Release should not have been crushed, as it would cause the resident to get a bigger dose all at once. The nurse should have called the physician to get the form change to something the resident could swallow or a form that was not extended release. Registered Nurse Unit Manager #1 stated nurses should not be signing for medication they did not give and signatures were to be done after the medications were given.

Based on observation, interview and record review conducted during the Recertification Survey and Abbreviated Surveys (NY00354632, NY00357873, NY00337630, NY00372738, NY00372568, NY00373759, NY00364043, NY00339079) 4/21/25 to 4/23/25, the facility did not ensure one of five residents (Resident #11) were fed by staff members who completed a State-approved training course to assist residents in eating or drinking as required by regulations. Specifically, the facility was not able to provide documentation that Unit Assistants successfully completed a State approved training course for one Resident Assistants (Unit Assistant #26) observed feeding Resident #11 during a lunch meal. The findings are: Resident #11 diagnoses included Alzheimer's disease, Dementia and abnormal weight loss. The 4/21/25 Physician Order documented regular diet, blenderized texture, thin liquids consistency, aspiration precautions. The 3/19/25 Minimum Data Set documented Resident # 11 had severe cognitive impairment, was dependent on staff for all activities of daily living including eating and on a mechanically altered diet (requiring change in texture of food/liquids). The 12/27/21 revised Activities Daily Living Care Plan documented interventions to include tray set up, staff feeds and assists to completion of meals. The facility job description for Unit Assistant dated 4/2021 documented the Unit Assistant assists on the nursing unit with functions that do not require certification. Listed under task #18 is feeding During an observation on 4/23/25 at 12:57 PM Unit Assistant #26 was observed sitting next to Resident #11 and feeding them puree food. During an interview on 4/23/25 at 12:57pm on Apple Unit Assistant #26 stated they had been doing the job for three years and one of the tasks was to feed the residents. They stated they had training in feeding by someone in the therapy department and were not aware of a New York State training for feeding residents. During an interview on 4/22/25 at 3:15 PM the Director of Human Resources stated the Unit Assistants do not provide direct care. The Unit Assistants will go on outside appointments with residents, provide water pitchers, make beds and feed residents. They feed residents because they have been trained at the facility on feeding as far as they know the Unit Assistants have not taken a state test for feeding residents. During an interview on 4/23/25 at 2:44 PM the Director of Nursing stated there was no eight hour course provided or completed by any of the paid feeding assistants. They stated they did not know there was a change and had been doing it this way for a few years now. They stated they will look into getting the program because the Unit Assistants do a great job and need them until they can improve regular staffing numbers. 10 NY CRR415.14

Based on observation and interviews conducted during the abbreviated survey (NY00339079, NY00357873, NY00372568, NY00373759, NY00337630, NY00354632, NY00364043, NY00372738) conducted 4/21/25 to 4/23/25, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infection and did not ensure there was a system for preventing, identifying, reporting, investigating, and controlling infection and communicable disease for all residents. Specifically, 1) facility staff were observed entering and exiting a contact and droplet isolation room (Resident #14) without donning and doffing personal protective equipment or performing hand hygiene. 2) Licensed Practical Nurse #3 was observed with their thumb entering the milk carton for Resident # 9 and Activities Leader #4 was observed with their thumb entering the top of milk carton for Resident #17. 3) Resident #18 was positive for respiratory syncytial virus and was observed walking up and down hallways of Apple unit without a mask during lunch and throughout the afternoon on 4/21/25 and 4/22/25 while residents were eating in the hallways. Resident #18 also was observed sitting in close proximity of other residents during dinner service on 4/21/25. The findings are: The policy titled Infection Prevention and Control, reviewed 10/24 documented the facility will provide appropriate types, sizes and supplies of personal protective equipment. Facility shall train staff and establish protocols for selecting, donning and doffing appropriate personal protective equipment and demonstrate competency during resident care. 1) Resident #14's diagnoses included respiratory syncytial virus, unspecified dementia and chronic pulmonary obstructive disease. The Quarterly Minimum Data Set (a resident assessment tool) dated 4/11/25 documented that Resident #14 had moderate cognitive impairment, required set up/clean up assistance with eating and partial to moderate assistance from staff with showering/bathing and toileting. A physician order dated 4/21/2025 documented contact/standard isolation precautions for respiratory syncytial virus. Resident #14's care plan updated 2/11/25 titled at risk for alteration in respiratory status due to atelectasis /scarring documented a goal of resident's respiratory status will not impact on resident's activities of daily living. Interventions included notify physician of any respiratory changes for interventions and keep head of bed elevated at all times. During an observation and interview on 4/21/25 at 12:11 PM Activities Leader #4 was observed delivering lunch tray to Resident #14. Contact and droplet precaution signs were posted outside door. Activities Leader #4 did not don/doff personal protective equipment, perform hand hygiene, change mask, wear face shield/ eye covering or close door when entering / exiting room. At 12:21 PM, Activities Leader #4 was again observed re-entering the room, placed trash into garbage container and entered bathroom without donning/doffing personal protective equipment, changing mask, wearing face shield/goggles, performing hand hygiene or closing door to room upon exit. During an interview at 12:22 PM, they stated they did not follow the contact and droplet precaution guidelines posted outside the door to room. During an observation and interview on 4/21/25 at 12:25 PM and 12:47 PM, Dietary Aide #19 was observed entering Resident #3 and #14's room, delivering juices during lunch service. Dietary Aide #19 did not don or doff gown, gloves, wear face shield/goggles or perform hand hygiene prior to entering and exiting the room. They did not replace facemask they wore prior to entering room. During an interview with Dietary Aide #19, they stated they did not don/doff personal protective equipment or perform hand hygiene when entering and exiting room of Residents #3 and #14. They stated they did not observe the signs at room entrance indicating contact and droplet precautions and were not aware which resident was on precautions or if it was both residents. During an observation and interview on 4/21/25 at 1:07 PM Certified Nurse Aide #21 was observed entering the room of Resident #14, assisted the resident to sit up at side of bed and performed lunch tray set up without donning/doffing personal protective equipment or performing hand hygiene prior to entering/exiting room. During a brief interview with Certified Nurse Aide #21 upon exiting room, they stated they did not don/doff personal protective equipment or perform hand hygiene prior to leaving the room or change mask. They stated that did not notice the signs or personal protective equipment outside the room. They stated they had utilized hand sanitizer at the end of hallway upon entering unit and did not perform hand hygiene prior to leaving room. During an observation and interview on 4/22/25 at 10:20 AM and 10:35 AM, Nurse Practitioner #1 was observed entering the room of Residents #3 and #14. Nurse Practitioner #1 was wearing a face mask which was not changed prior to entering / exiting room, and they did not don or doff personal protective equipment or perform hand hygiene prior to entering room, exiting room or between residents. They were observed using their stethoscope and physically touching Residents #3 and 14 without donning gloves or performing hand hygiene. Nurse Practitioner #1 stated they were aware that Resident #14 tested positive for respiratory syncytial virus prior to entering the room. They were unable to explain why they did not don/doff personal protective equipment required for contact and droplet precautions or perform hand hygiene before, after and in between physical contact with the two residents present in the room. They stated they were not specifically aware of personal protective equipment requirements for residents on contact and/or droplet precautions. They stated they usually follow precautions and could not explain why they did not on this occasion. During an interview on 4/22/25 at 11:04 AM, Infection Preventionist Registered Nurse stated contact and droplet precautions required personal protective equipment use by all staff members entering a room where a resident was positive for respiratory syncytial virus, including interactions with a non-infected resident in the same room. They stated the residents positive for respiratory syncytial virus were placed on contact and droplet precautions to reinforce to staff the importance of masking and personal protective equipment use. 2) During an observation and interview on 4/21/25 at 12:09 PM, Activities Leader #4 was observed setting up lunch for Resident #16. Activities leader #4 placed their thumb into the top of the milk container. They stated they should not have placed thumb deep inside the opening of milk carton. During an observation and brief interview on 4/21/25 at 12:44 PM, Licensed Practical Nurse #3 was observed opening milk carton without gloves or performing hand hygiene before assisting with tray set up for Resident #9. Licensed Practical Nurse #3's right thumb was observed entering the top of milk carton when opening. During a brief interview Licensed Practical Nurse #3 stated their right thumb did not enter top of milk carton and stated hand hygiene was performed before observation. 3) On 4/21/25 Resident #18, who was positive for respiratory syncytial virus, was observed walking up and down the hallway without a mask on during lunch and dinner services and also sitting in close proximity of other residents during dinner meal service in hallway. Staff did not provide encouragement for Resident #18 to wear a mask and did not attempt to redirect. During an interview on 4/21/25 at 4:51 PM, Unit Manager Registered Nurse #1 stated that Resident #18 was positive for Respiratory Syncytial Virus. They stated that Resident #18 walked up and down the unit hallway continuously and they tried unsuccessfully to have Resident #18 wear a mask. The resident was routinely reoriented not to walk into other residents rooms. 10 NYCRR415.19

Based on record review and interviews during an abbreviated survey (NY00345900, NY00332503), the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for 12 out of 39 residents reviewed for identification bands. Specifically, during an observation on 11/12/2024 there were 12 residents on the Apple unit observed without identification bands in place. The findings are: The facility Medication Administration policy dated 12/2016 and last revised 10/2023 documented that prior to administration of medication, the nurse must verify the resident's identification by checking the resident's identification band with the patient's name and medical record number. During observation conducted on 11/12/2024 at 3 PM on the Apple unit, there were 12 out of 39 residents noted without identification bands in place. During an interview on 11/12/2024 at 11:10 AM, Licensed Practical Nurse #1 stated most of the residents they administered medications to today on the apple unit did not have an identification band in place. Licensed Practical Nurse #1 stated to identify the residents with no identification they had to ask other staff members or look at the picture in the electronic medical record system to identify the residents during the medication pass. During interview on 11/14/2024 at 2:16 PM, Registered Nurse #1 who works on the Apple unit stated whenever they find residents on their unit with no identification bands, they inform the unit secretary, and they provide a new identification band for the residents. Registered Nurse #1 stated they will conduct their own audit on the unit for identification bands and have the secretary print out new ones for the residents that need them. Registered Nurse #1 stated they try to check the identification bands for the residents on their unit at least once a week and replaces the bands for the residents who need it. The residents on the Apple unit often remove their identification bands. During an interview on 11/14/2024 at 5:16 PM, the Director of Nursing stated all residents should have an identification band in place. They stated they do have an issue on the Dementia (Apple) unit because the residents remove their identification bands. The Director of Nursing stated the residents on the Apple unit should be checked every shift to ensure they have their identification bands in place. The Director of Nursing sated they will follow up with Registered Nurse #1 about checking the resident's identification bands frequently to ensure they are in place. 10 NYCRR 415.12

Based on record review and interviews during an abbreviated survey (NY00345900, NY00332503), the facility did not ensure sufficient nursing staffing to attain or maintain the well-being of each resident for 39 residents on Unit A as determined by the facility nursing coverage plan as necessary to meet the needs of the residents. The findings are: The Facility Nursing Coverage Plan policy dated 8/3/2021 documented the purpose was to outline a staffing plan that shall be used to determine the personnel recommended for each shift as defined for each unit's core coverage and as necessary to provide the scope of services required to meet resident care. The Facility Assessment provided by the facility was last revised on 8/16/2024. The last review by the Quality Assurance and Improvement Committee was on 9/18/2023. The staffing plan documented a table describing the number of staff available to meet residents' needs, which listed the position of staff by title, as well as the number of full-time employees that hold those positions. The Facility Assessment on 11/12/2024 revealed the assessment did not include the staffing plan, the number of staff required/allotted for each unit or per shift. Review of an undated facility document titled [NAME] Ridge Staffing Guidelines documented 5 Certified Nursing Assistants for the Day shift for Unit A, 4 Certified Nurse Nursing Assistants for the Evening shift on unit A, and 2 Certified Nurse Nursing Assistants for the night shift on unit A 7 days/week. The document also noted that these are guidelines for ideal staffing at maximum PAR (Provider Average Ratio) levels. Review of the staffing schedules for the A unit for May 2024 revealed that staffing was below 4 Certified Nursing Assistants on the day shift and 2 Certified Nursing Assistants on the night shift: 3 Certified Nursing Assistants worked on the day shift on 5/7/2024, 5/11/2024, 5/12/2024, 5/15/2024, 5/20/2024, 5/21/2024, 5/28/2024, 5/30/2024 and 5/31/2024 and 1 Certified Nursing Assistants was scheduled for the night shift on 5/20/2024. Review of the staffing schedule for the A unit for June 2024 revealed that staffing was below 4 on the day shift and below 3 on the evening shift: 3 Certified Nursing Assistants worked on the day shift on 6/2/2024, 6/15/2024, 6/16/2024, 6/18/2024, 6/22/2024, 6/23/2024 and 6/30/2024, 2 Certified Nursing Assistants worked on the evening shift on 6/2/2024, 6/29/2024 and 6/30/2024 and 1 Certified Nursing Assistants worked on the night shift on 6/7/2024, 6/11/2024, 6/22/2024, 6/23/2024, 6/28/2024 and 6/29/2024. Review of the staffing schedules for the A unit for July 2024 revealed staffing was below 4 Certified Nursing Assistants on the day shift and 3 Certified Nursing Assistants on the evening shift and 2 Certified Nursing Assistants on the night shift: 3 Certified Nursing Assistants worked on the day shift on 7/1/2024, 7/11/2024, 7/14/2024, 7/17/2024, 7/20/2024, 7/21/2024, 7/24/2024, 7/25/2024 and 2 Certified Nursing Assistants worked on the day shift on 7/28/2024, 2 Certified Nursing Assistants worked on the evening shift on 7/5/2024 and 1 Certified Nursing Assistants worked on the night shift on 7/28/2024 During an Interview conducted on 11/12/2024 at 1:05 PM, the Director of Nursing stated that the staffing requirements for the Certified Nursing Assistants on the A unit are 4 to 5 during the day shift, 3 to 4 during the evening shift, and 2 during the night shift. During an interview on 11/12/2024 at 11:20 AM, Certified Nursing Assistant #3 stated they have been working in the facility for 1 year and they do not have adequate staffing all the time. Certified Nursing Assistant #3 stated instead of 4 Certified Nursing Assistants, most days they have 3 Certified Nursing Assistants because when they have 4 scheduled, one is usually pulled to cover another unit. Certified Nursing Assistant #3 stated they have discussed this issue with the administration that they need more staff, and nothing has been done about it. Certified Nursing Assistant #3 stated sometimes staff is moved from a unit mid-way through an assignment or shift to complete an entire new assignment on a different unit. Certified Nursing Assistant #3 stated administration does not call the agency for staff and that there have been many times when agency staff report to the facility and are told they were not needed when they were short staffed. During an interview on 11/12/2024 at 11:36 AM, Certified Nursing Assistant #5 stated that staffing could be better on most days. They stated they have 9 residents who require total care assigned to them today. Certified Nursing Assistant #5 stated on the weekends the staffing is rough on the day shift where there can be only 3 Certified Nursing Assistants scheduled. Certified Nursing Assistant #5 stated there have been times when there were only 2 Certified Nursing Assistants scheduled to the unit on the day shift on the weekend and the staffing in the facility is not good. Certified Nursing Assistant #5 stated they speak with Administration about staffing all the time and nothing ever changes, they are told that new hires are coming, and no one ever comes. Certified Nursing Assistant #5 stated the facility was using agency staff, but they got rid of a lot of them. During an interview on 11/12/2024 at 11:50 AM, Certified Nursing Assistant #6 stated there are usually 4 Certified Nursing Assistants on the unit, 2 on each side. Certified Nursing Assistant#6 stated there are 41 residents on the unit and with 4 Certified Nursing Assistants each person has 10 assigned residents and all the residents on the unit need total care. Certified Nursing Assistant #6 stated they have a unit assistant to help with making the residents beds. Certified Nursing Assistant #6 stated if they are short staffed with only 3 Certified Nursing Assistants, they have to provide cares to 13 residents who need total care and that is tough. Certified Nursing Assistant #6 stated that if 4 Certified Nursing Assistants are assigned to the unit on the day shift, they will each have 10 residents and they can give good care to the residents. Certified Nursing Assistant #6 stated sometimes on the weekend there are only 2 Certified Nursing Assistants, and it is tough. Certified Nursing Assistant #6 stated they have told Administration about short staffing, and administration do try to call staff, but they cannot find anyone to cover the shifts. During an interview on 11/12/2024 at 1:05 PM, the Director of Nursing, they stated staffing for the Certified Nursing Assistants in the facility is as follows: Day shift: on all units- 4-5 Certified Nursing Assistants, 5 is the goal, usually they have 4, but they are working to get to the 5 Certified Nursing Assistants at all times; Evening shift: on all units 3-4 Certified Nursing Assistants; Night shift: on the B unit there are 3 Certified Nursing Assistants and 2 Certified Nursing Assistants on the other 3 units (A, C and D). The Director of Nursing stated they do use agency staff to a minimum and they are trying to hire more staff for the facility. The Director of Nursing stated they will use any measure to make the staffing better. Staffing is a big problem, but they are working very hard to address it. During an interview on 11/14/2024 at 5:16 PM, the Director of Nursing stated they are now hiring more staff and the staffing levels are getting to where they need to be. The progress can be seen in the scheduling within the last month compared to 6 months ago. The Director of Nursing stated when they came to the facility 2 years ago, they were using mostly agency staff, but they have hired on more facility staff, and they do not use agency staff as much anymore. During an interview on 11/14/2024 at 5:45 PM, the Administrator stated the staffing has greatly improved since they started in the facility, which has helped a lot with the issues they face. During a telephone interview on 12/16/2024 at 2:05 PM, the Staffing Coordinator/Nursing recruiter stated they have been working in the facility since March of 2024. The Staffing Coordinator/Nursing Recruiter stated there is a PAR (Provider Average Ratio) level sheet that they use for staffing the units. The Staffing Coordinator/Nursing Recruiter stated the PAR (Provider Average Ratio) level sheet is similar to the minimal staffing plan but reflects the ideal staffing for the units. The Staffing Coordinator/Nursing Recruiter stated they are expected to use the ideal staffing for the units instead of the minimal staffing plan. The Staffing Coordinator/Nurse Recruiter stated if they are short staffed then they will call in per diem staff, or ask regular staff to stay late, and If no one is available then they call the agency for staff replacement. The Staffing Coordinator/Nursing Recruiter stated the ideal staffing PAR (Provider Average Ratio) level for the units are as follows: 2- Licensed Practical Nurses and 4 (can schedule up to 5 now) Certified Nursing Assistants on all units for the 7 AM to 3 PM shift and the 3 PM to 11 PM shift. 1 Nurse on each unit and 2 Certified Nursing Assistants for each unit on the 11 PM to 7 AM shift. 10NYCRR 415.13 (A)(1)

Based on record review and interviews during an abbreviated survey (NY00345900, NY00332503) the facility did not ensure medications were administered in accordance with the prescriber's order or in accordance with professional standards for 3 out of 3 residents (Resident #1, Resident #2, Resident #3) reviewed for medication administration. Specifically, (1) Resident #1 had an order for the medication Depakote sprinkles, for their seizure disorder, and was administered their medication outside of the regulated time of an hour before or an hour after the scheduled time on 10/30/2024, 11/7/2024, 11/11/2024 and 11/12/2024. There was no documented evidence that the physician was made aware of the medication being administered late. (2) Resident #2 had an order for the medication Carbidopa-Levodopa, for their Parkinson's disease, and was administered their medication outside of the regulated time of an hour before or an hour after the scheduled time on 8/30/2024, 9/4/2024, 9/6/2024 and 9/17/2024. There was no documented evidence that the physician was made aware of the medication being administered late. (3) Resident #3 had an order for the medications Trazodone and Melatonin, for their insomnia. Review of the medication administration record for January 2024 revealed the resident refused their Trazodone on the following dates: 1/11/2024 and 1/12/2024. The medication administration record revealed the resident also refused their Melatonin on the following dates: 1/11/2024, 1/12/2024, 1/13/2024, 1/14/2024, 1/15/2024, 1/16/2024, 1/19/2024, 1/20/2024, 1/21/2024 and 1/22/2024. Further review of the medication administration record revealed neither the Trazodone or the Melatonin was signed as administered on 1/7/2024. There was no documented evidence that the physician being made aware of Resident #3's refusals of the medications or not being administered the medications. The Findings are: The Facility Medication Administration policy dated 12/16 and last revised 10/23 documented it is the policy of the facility that all medications will be administered in a safe and systematic way. The nurse will document in the resident's electronic medical record after the medication is administered by signing the electronic medical record. The nurse should double check and ensure all medications were administered to the resident as per the physician order, with no missing signatures. Upon completion of the medication pass, the nurse should review the administration dashboard to ensure there is no missing documentation. 1)Resident #1 initially admitted to the facility on [DATE] and last readmitted on [DATE] with diagnoses including but not limited to Frontotemporal Neurocognitive Disorder, Seizures and Obstructive and Reflex Uropathy. A Quarterly Minimum Data Set (an assessment tool that measures health status) dated 9/10/2024 documented the resident had severe cognitive impairment. Review of a seizure disorder care plan initiated 5/6/2024 documented the resident had a history of seizure disorder and is at risk for injury related to seizure activity. Resident was on Depakote and the goal was the resident's seizures would be controlled by medication x 90 days. Interventions listed included administer anticonvulsant medications as ordered by physician and document and monitor all seizure activity. Review of the physician's order dated 10/30/2024 documented Depakote Sprinkles 125 mg capsule delayed release give 8 capsules (1,000 mg) by mouth 2 times daily-(total dose 2,000 mg daily) at 9 AM and 9 PM. Review of Resident #1's medication administration detail report revealed on 10/30/24 the Depakote Sprinkles 9 PM dose was administered at 11:24 PM. During an interview on 11/14/2024 at 4:08 PM Licensed Practical Nurse #3 stated they know what medication Resident #1 gets, but they do not remember what time they signed it out for on 10/30/2024. Stated they did not notify the physician that Resident #1 had received their Depakote medication late. Review of a physician's order dated 11/3/2024 documented Divalproex 125 mg capsule, delayed release sprinkle give 6 capsules (750 MG) by mouth 3 times daily- (total daily dose 2,250 mg) at 6 AM, 12 PM and 10 PM. Review of Resident#1's medication administration detailed report for November 2024 revealed, the resident's Depakote Sprinkles were not administered within the regulated timeframe as follows: -11/7/2024-6 AM dose was administered at 1:25 PM -11/7/2024-12 PM dose was administered at 1:25 PM -11/11/2024-6 am dose given at 8:01 AM -11/12/2024-12 PM dose administered at 2:16 PM During an interview on 11/14/2024 a 1:40 PM Licensed Practical Nurse #4 stated if a medication is given outside of the hour before or hour after the medication due time, then the physician should be made aware. Licensed Practical Nurse #4 stated they would also have to write progress note about the medication being given late. Licensed Practical Nurse #4 stated they made an error in the documentation on 11/7/2024 for Resident #1's 6 AM and 12 PM doses of Depakote and that they gave the Depakote to Resident #1 on time. During an interview on 11/14/2024 at 1:55 PM Licensed Practical Nurse #1 stated if a medication is given late then they have to inform the physician and also write a progress note. Licensed Practical Nurse #1 stated Resident #1's 6 AM dose of Depakote on 11/11/2024 was signed in error by them and the 12 PM dose is administered on their time. Stated they gave Resident #1 their Depakote on time at 12 PM on 11/12/2024, but they signed off on the medication record late. There was no documented evidence of the physician being made aware of Resident #1 receiving their Depakote sprinkles medication late on 11/7/2024, 11/11/2024 or 11/12/2024. 2)Resident #2 initially admitted to the facility on [DATE] and last readmitted on [DATE] with diagnoses including but not limited to Parkinson's disease, Hypotension and Repeated Falls. A Quarterly Minimum Data Set (an assessment tool that measures health status) dated 10/21/2024 documented the resident had moderate cognitive impairment. The resident required supervision for eating and bed mobility, dependent for toileting and required moderate assistance with transfers. Review of a Parkinson's care plan initiated 7/25/2024 and last reviewed 10/28/2024 documented the resident will maintain highest level of functional mobility. Interventions listed included administer medication as per physician's order, monitor for hypotension, hallucination and confusion, monitor mobility and activities of daily living ability and initiated rehabilitation screen as necessary. A physician's order dated 8/28/2024 documented Carbidopa 25 mg- Levodopa 100 mg tablet give 2 tablets by mouth 4 times daily. Review of Resident #2's medication administration record revealed the Carbidopa-Levodopa was scheduled for 4 times a day at the following times: 10:30 AM, 2:30 PM, 6:30 PM and 10:30 PM. Review of Resident #2's detailed medication administration report revealed on 8/30/2024 their 10:30 AM dose of Carbidopa-Levodopa was administered at 12:05 PM. Further review of the detailed administration report revealed Carbidopa-Levodopa was administered as follows: 10:30 AM dose on 9/4/2024 administered at 12:13 PM, 10:30 AM dose on 9/6/2024 administered at 1:25 PM, 6:30 PM dose on 9/6/2024 administered on 8:48 PM and 6:30 PM dose on 9/17/2024 at 9:15 PM. During an interview on 11/14/2024 at 4:30 PM Licensed Practical Nurse #6 stated they do not remember giving Resident #2 their 6:30 PM dose of Carbidopa-Levodopa late on 9/17/2024. Stated they would inform the physician if they gave the medication late and they try to sign off for their medication administration as they go, but if they are short staffed then they may sign off for the administration late, if helping the certified nurse assistants with cares. During an interview on 11/14/2024 at 4:48 PM Licensed Practical Nurse #4 stated they are administering medications at the designated time, but they are not able sign immediately at times because it can be very busy. Stated they did not notify the physician that they administered Resident #2's 10 :30 AM and 6:30 PM doses of Carbidopa-Levodopa late on 9/6 2024, because the medication was administered at the right times. During an interview on 11/14/2024 at 5:10 PM Licensed Practical Nurse #5 stated they miss signed for Resident #2's 10:30 AM doses of Carbidopa-Levodopa on 8/30/2024 and 9/4/2024, but they administered the medication on time. Licensed Practical Nurse #5 stated they just signed the medication administration documentation late. Licensed Practical Nurse #5 stated sometimes they click the signature box in the electronic medical record, and it does not go register, there is a glitch in the system, and they go back later and sign it again. 3)Resident #3 admitted to the facility 5/28/2023 with diagnoses including but not limited to Heart Failure, Chronic Obstructive Pulmonary Disease and Major Depressive Disorder. An Annual Minimum Data Set (an assessment tool that measures health status) dated 12/31/2023 documented the resident was cognitively intact. Review of an insomnia care plan initiated 6/5/2023 documented the resident had difficulty sleeping and was taking melatonin and trazadone. Interventions listed included administer medications as per physician's order and observe for adverse effects and notify the physician/Nurse Practitioner. Review of a physician's order dated 12/20/2023 documented Trazodone 50 mg tablet give 1/2 tablet (25 mg) by mouth daily at 9 PM for insomnia. Review of Resident #3's medication administration record for January 2024 revealed the resident refused the Trazodone medication on 1/11/2024 and 1/12/2024. Further review of the medication administration record revealed the medication was not administered on 1/7/2024. Review of Resident #3's medication administration record for January 2024 revealed the resident refused the melatonin on: 1/11/2024, 1/12/2024, 1/13/2024, 1/14/2024, 1/15/2024, 1/16/2024, 1/19/2024, 1/20/2024, 1/21/2024 and 1/22/2024. Further review of the medication administration record revealed the melatonin was not signed as administered on 1/7/2024. During an interview on 11/14/2024 at 5:16 PM The Director of Nursing stated if a medication is given late, then the nurse needs to follow up with the physician and inform them that the medication was given late. Stated a progress note needs to be written entailing that the physician was informed and what their response was, as to if the medication can be administered or needs to be held. The Director of Nursing stated if a not administered appears on the medication administration record, it could be a charting omission, or it was not given. The Director of Nursing stated education will be provided facility wide regarding late medication administration, physician notification and the documentation that needs to be completed as this is totally unacceptable with the medication administration and documentation. 10 NYCRR 415.12(m)(2)

Based on record review and interviews during an abbreviated survey (NY00345900, NY00332503), the facility did not ensure the residents environment remained free of accident hazards as is possible and that each resident received adequate supervision to prevent accidents for 2 out of 3 (Residents #2, #3) residents reviewed for accidents. Specifically, (1) Resident #2 who had history of falls and required moderate assistance for transfers had falls from their wheelchair on 8/3/2024, 8/8/2024, 8/30/2024, 9/14/2024, 9/29/2024 with no injuries; (2) Resident #3 had unwitnessed falls on 8/7/2023, 11/14/2023, 1/5/2024 and 1/10/2024 with minor injuries. There was no documented evidence that new interventions were implemented to prevent further falls and care plans were not updated on each occurrence for both Residents #2 and #3. The findings are: The Facility Fall Risk Assessment and Fall Prevention policy dated January 2003 and last revised November 30, 2017, documented all residents will be free of falls and free of injuries associated with falls. The facility will implement common sense interventions to aide in the prevention of falls, implement a plan of care based upon the resident risk category and assess all residents for falls at least on admission, re-admission, quarterly, when conditions deteriorate and upon fall. 1) Resident #2 initially admitted to the facility on [DATE] and last readmitted on [DATE] with diagnoses including but not limited to Parkinson's disease, Hypotension and Repeated Falls. A Quarterly Minimum Data Set, dated dated dated [DATE] documented the resident had moderate cognitive impairment. The resident required supervision for eating and bed mobility, dependent for toileting and required moderate assistance with transfers. Review of a falls care plan initiated 7/25/2024 and last reviewed 10/10/2024 documented the resident is at risk for falls due to a history of falls, poor safety awareness and impulsiveness. Interventions listed included: 8/31/2024- fall risk assessment quarterly, well it and clean/dry environment, provide assist with activities of daily living as needed, non-skid socks, keep in view of staff as much as practical, 9/29/2024-remind to stay in wheelchair and ask for assistance, 10/10/2024-keep in a supervised area with supervision in place, 10/13/2024-velcro release seat belt in wheelchair and 11/12/2024-wheelchair pad alarm. Review of an accident/incident report on 8/3/2024 at 2:30 PM revealed Resident #2 had an unwitnessed fall in the dayroom, wheelchair alarm sounded. The certified nurse assistant in the dayroom was assisting another resident when Resident #2 fell . Resident had x-rays done of the pelvis and bilateral hips to rule out fracture, results negative. There were no documented interventions implemented to prevent further falls. Review of an accident/incident report on 8/8/2024 at 7:30 AM revealed Resident #2 was found on their knees in the television room, attempted to climb out of the recliner chair, approximately 5 feet away from their wheelchair. There were no documented interventions implemented to prevent further falls. Review of an accident/incident report on 8/30/2024 at 4 PM revealed Resident #2 was found on the floor in the television room in front of their wheelchair. There were no documented interventions implemented to prevent further falls. Review of an accident/incident report on 9/14/2024 at 1:50 PM revealed Resident #2 was found sitting on the floor in front of their wheelchair. There were no documented interventions implemented to prevent further falls. Review of an accident/incident report on 9/29/2024 at 1:35 PM revealed Resident #2 stood up quickly from their wheelchair and lost their balance and fell , sustained an abrasion to the right knee. The resident then got up from the floor before they could be assessed by the Registered Nurse. Resident #2 was reminded to ask for assistance. There were no documented interventions implemented to prevent further falls. 2) Resident #3 admitted to the facility 5/28/2023 with diagnoses including but not limited to Heart Failure, Chronic Obstructive Pulmonary Disease and Major Depressive Disorder. A Quarterly Minimum Data Set (an assessment tool that measures health status) dated 10/1/2023 documented the resident was cognitively intact. The resident required a walker or a wheelchair for locomotion, set up assistance with meals and was independent with toileting, bed mobility and transfers. Review of a risk for falls care plan initiated on 5/28/2023 and last reviewed on 1/24/2024 documented interventions such as anti-skid socks, clean/dry environment, fall risk assessment quarterly, monitor for adverse effects of medication, if awake during the night offer: toileting, snacks, ambulation, maintain a well-lit environment, call bell within reach, provide assistance with activities of daily living as needed and safety re-education as needed. Review of an accident/incident report dated 8/7/2023 at 1:35 AM revealed Resident #3 stated they were trying to get up and transfer to their wheelchair to go to the bathroom and they missed the side of the bed and fell . The resident was found on their right side on the right side of the bed, no injuries were noted. There were no documented interventions implemented for fall prevention. Review of an accident/incident report dated 11/14/2023 at 4:45 PM revealed Resident #3 was found on the floor in their room next to the bed. Resident #3 stated they tried to get out of bed on their own and did not ask for help. Resident #3 sustained a minor injury, skin tear to their right forearm, which was treated and wrapped. Resident #3 did not complain of pain or discomfort at the time and bilateral hip x-rays were completed with negative results. There were no documented interventions implemented for fall prevention. Review of an accident/incident report dated 1/5/2024 at 2:15 PM revealed Resident #3 was ambulating in their room and appeared to slip and fall. The resident was found sitting upright on the floor near their wheelchair with their oxygen nasal cannula in place and attached to wheelchair. The oxygen tubing was around the wheelchair. Resident #3 hit the top of their head and was noted to have a tender area with a 1.5 cm bump offered ice. The resident complained of pain to the right arm. Review of an accident/incident report dated 1/10/2024 documented at 5:45 AM revealed Resident #3 was found on the floor and was unable to state what occurred. The resident was confused at times. The resident was found sitting on the floor wearing their oxygen nasal cannula. Resident #3 sustained minor injury, a hematoma to the middle of their forehead an ice pack was applied, and they were sent to the emergency room for evaluation. During an interview on 11/14/2024 at 5:16 PM, the Director of Nursing stated they have an at risk meeting every Thursday with the interdisciplinary team, rehabilitation, and unit managers to discuss falls. The Director of Nursing stated in the meetings they talk about safety interventions in place and how effective and what the next steps should be. The Director of Nursing stated they have been having these risk meetings for almost a year. The Director of Nursing stated Resident #3 was alert, but they had poor safety awareness. The Director of Nursing stated they still tried with the resident to maintain their safety, but because of Resident #3's cognitive status, the resident is able to make their own decision and move about and go where they want. The Director of Nursing stated they feel Resident #3 has some confusion. The Director of Nursing stated Resident #2 is very impulsive, the resident has a safety belt in place on their wheelchair, which so far seems to be working. The Director of Nursing stated they want their residents in the facility to be safe. The Director of Nursing did not provide new interventions that were put in place for Resident #3. During an interview on 11/14/2024 at 5:45 PM, the Administrator stated they have been in the facility since mid-August of 2024. The Administrator stated they have quarterly quality assurance and performance improvement meetings in which they discuss where they can improve as a facility. The Administrator stated the areas discussed at these meetings are incidents, accidents, falls and any areas that can potentially be improved. The Administrator stated plan changes that have been instituted from the meetings are regarding toileting schedules and having residents sit in common areas so they can be monitored for safety. 10 NYCRR 415.12(h)(1)

Based on record review and interviews during an abbreviated survey (NY00345900), the facility did not ensure that a resident with urinary and bowel incontinence received appropriate treatment and services to prevent urinary tract infections. This was evident for 1 out of 3 residents (Resident #1) reviewed for incontinence. Specifically, Resident #1 who was always incontinent of bladder and bowel functions and dependent on direct care staff for cares was diagnosed with a urinary tract Infection on 5/7/2024 and 9/9/2024. Review of Resident #1's certified nurse accountability reports for May 2024, June 2024, July 2024, August 2024, and September 2024 revealed numerous occasions where there was no documented evidence of direct care staff providing bladder and bowel incontinence care. The Findings are: The undated Facility Incontinence policy documented residents who are incontinent of urine, feces, or both are kept dry, clean and comfortable while maintaining their dignity. Disposable diapers and pads are used throughout the long-term care facility for residents who are incontinent of urine, feces, or both. Residents are washed and changed when wet or soiled. Residents with incontinence problem are checked for toileting and changing at least every four hours. The plan for incontinence care is written in the resident's care plan. Resident #1 initially admitted to the facility on [DATE] and last readmitted on [DATE] had diagnoses including but not limited to Frontotemporal Neurocognitive Disorder, Seizures and Obstructive and Reflex Uropathy. A Quarterly Minimum Data Set (an assessment tool for health status) dated 9/10/2024 documented the resident had severe cognitive impairment. The resident had impairment to both upper and lower extremities on both sides. The resident was dependent for eating, toileting, bed mobility and transfers. The resident was always incontinent of bladder and bowel. Review of an incontinence care plan initiated 6/15/2024 and last updated 11/4/2024, documented Resident #1 had a catheter which was discontinued on 6/14/2024. Resident #1 is now incontinent of bladder and bowel. The goal was the resident would be free of urinary tract infection x 90 days. Interventions listed included apply barrier ointment after cares, clean peri-area from front to back, provided incontinence care every 2 to 4 hours and as needed, monitor for signs and symptoms of urinary tract infection, and observe skin for integrity changes with incontinence cares and notify the physician of changes. Review of Resident #1's urinalysis lab reports dated 5/7/2024 and 9/9/2024 revealed they were diagnosed with urinary tract infections. Review of Resident #1's certified nurse assistant accountability report for May 2024 revealed that direct care staff did not document that they provided bladder incontinence care on 9 occasions and bowel incontinence care on 5 occasions. Review of Resident #1's certified nurse accountability report for June 2024 revealed that direct care staff did not document that they provided bladder incontinence care on 19 occasions and bowel incontinence care on 21 occasions. Review of Resident #1's certified nurse accountability report for July 2024 revealed that direct care staff did not document that they provided bladder incontinence care on 67 occasions and bowel incontinence care on 35 occasions. Review of Resident #1's certified nurse accountability report for August 2024 revealed that direct care staff did not document that they provided bladder incontinence care on 94 occasions and bowel incontinence care on 46 occasions. Review of Resident #1's certified nurse accountability report for September 2024 revealed that direct care staff did not document that they provided bladder incontinence care on 43 occasions and bowel incontinence care on 15 occasions. During interview on 11/14/2024 at 2:16 PM, Registered Nurse #1 stated that with the certified nurse assistant accountability documentation they can see what was done and what is overdue. Registered Nurse #1 stated they have not seen any trends with missing signatures in the certified nurse assistant documentation. Registered Nurse #1 stated they remind their staff daily between 2 PM or 2:30 PM to complete their documentation before the shift is over. Registered Nurse #1 stated since they do not work the evening shift, they will speak to the nurses directly and they would inform the supervisor so they can address it the issue with the night shift staff. Registered Nurse #1 stated the residents are supposed to be checked and changed every 2 to 4 hours and that residents who are more frequently incontinent may be checked every 2-3 hours. During an interview on 11/14/2024 at 5:16 PM, the Director of Nursing stated if not documented symbol in indicated in the check box on a certified nurse accountability, it could be a charting omission, or it could indicate the task was not completed. The Director of Nursing stated it is the responsibility of the unit managers to monitor the certified nurse assistant documentation errors. The Director of Nursing stated the unit managers can monitor for documentation errors on their I-pad. The I-pad also helps them to check and see what is going on in the unit. The Director of Nursing stated the unit managers dashboard in the electronic medical record shows when residents tasks are due or if medications are due, so that they can follow up with their staff to ensure their staff is doing what they are supposed to do. 10 NYCRR 415.12(d)(1)

Based on observation, interview and record review conducted during a recertification and abbreviated survey (Complaint # NY 4371), the facility did not ensure safe and effective use of assistive devices and prevent serious injury to one of six residents reviewed for accidents (Resident #1). Specifically, on September 17, 2020, Resident #1 fell from the transfer lift due to the straps on the transfer pad tearing. In response to the incident, the facility reportedly completed a house wide audit of all transfer pads to ensure they were in safe working condition. Observation by survey staff revealed three (3) facility-inspected Hoyer transfer pads that were torn and/or frayed present on two of four resident units. In addition, there was one torn and/or frayed Hoyer transfer pad in the laundry room ready for use. This resulted in actual harm and the potential for serious harm to the health and safety of 34 residents in the facility that is Immediate Jeopardy and Substandard Quality of Care. The findings are: Facility Policy and Procedure titled Mechanical Lift revised August 2018 indicates all staff must assure that Hoyer slings are in good repair. If the sling is noted to be in disrepair, it must be taken out of service. Resident #1, MDS (Minimum Data Set, a resident assessment tool) dated 8/10/2020 indicated intact cognition. Functional Status indicated total support for transfers. The Physician Orders dated 6/5/2020 indicated transfer via Hoyer lift with 2-person assist at all times. Nursing Progress Note dated 9/17/2020 at 7:41PM documented Resident#1 had a fall related to equipment malfunction. Nurse Practitioner ordered transfer to Hospital emergency room immediately. Review of the Facility Accident/Incident Report indicated that the Director of Nursing (DON) completed the investigation on 09/17/2020 and removed the equipment from the unit. The investigation indicates Resident #1 was being assisted from the wheelchair to the bed via the Hoyer lift with assist of 2. When Resident # 1 was lifted, the wheelchair was wheeled back and that's when the straps snapped resulting in Resident #1 falling to the floor. An interview was conducted on 9/18/20 at 2:15pm and 3:45pm with the Director of Environmental Services who over sees the laundry department. He stated staff are expected to check the Hoyer pads before use but do not document. An Interview was conducted on 9/18/20 at 2:35PM with the facility Administrator. She stated after the incident with Resident #1 a facility wide audit was conducted, and no other Hoyer Pads were found to be unsafe. She also stated the Hoyer pads are checked regularly but staff do not document it anywhere. She stated staff just change them when needed. During an observation on 9/18/2020 at 3:45PM with the Director of Environmental Services, three Hoyer pads were noted to be frayed and or torn on two units with one in a laundry room ready for use. In room 305A a pad was found in a resident's wheelchair the straps were visibly torn. When the Director of Environmental Services tugged on the strap it separated from the pad. An interview was conducted on 9/22/20 at 3:05PM with the Nurse Educator. She stated the Hoyer lift in-service did not include directions for monitoring/inspecting/documenting the condition of facility Hoyer pads. 415.12(h)(1) On 9/18/20 the facility conducted audit of the pads and replaced all pads that were in disrepair. The facility developed policies and procedures to ensure that the pads were inspected regularly by housekeeping and prior to use by the nursing and therapy staff. The facility developed audit tools to monitor staff compliance. On 9/22/20 Immediate Jeopardy was lifted as the facility provided evidence that 94% of the staff including nursing, housekeeping and therapy staff were educated to the new policy and procedures. This was corroborated by staff interviews and observations prior to survey exit.