Every finding on record at Regeis Care Center

Based on observation, record review, and interviews conducted during a survey, the facility failed to ensure that allegations of abuse were investigated thoroughly and that residents were protected from further abuse during the investigation. This was evident for one (1) out of six (6) residents (Resident #1) reviewed for abuse. Specifically, on 02/17/2026 at 5:30 PM, Resident #2's visitor reported to the Director of Nursing that they observed Certified Nursing Assistant #1 roughly handle and hit Resident #1 on the buttock. The Director of Nursing failed to thoroughly investigate the allegation of abuse and remove Certified Nurse Assistant #1 from direct care and access to residents after allegations were reported. This resulted in Immediate Jeopardy and Substandard Quality of Care with the likelihood of serious harm to 222 residents.The findings include:The facility's policy and procedure title Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property last revised on 09/11/2025, documented Residents of the facility will be protected from abuse, neglect, mistreatment, and misappropriation of property in accordance with State and Federal regulations. The policy also documented all alleged or suspected incidents of abuse, neglect, mistreatment or misappropriation of resident's property will be thoroughly investigated and findings documented and reported.Resident #1 was admitted to the facility with diagnoses that included non-Alzheimer's dementia, muscle weakness, and difficulty walking.The Minimum Data Set (a resident assessment tool) dated 01/02/2025 documented Resident #1 had severely impaired cognition.A review of the facility surveillance video footage from unit four (4) dated 02/17/2026 at 4:34 PM showed at 4:38 PM, Resident #1 got up from their wheelchair ambulating with unsteady gait up the hallway while holding onto the handrails in the hallway. Resident #1 walked over to the other side of the hallway, where a cart stocked with personal protective equipment was, then rolled the cart into two residents' rooms. Certified Nursing Assistant #1, who was wheeling a resident up the hallway as Resident #1 entered one of the rooms with the cart, stopped and went into the room behind Resident #1. Certified Nursing Assistant #1 rolled the cart into the hallway, and Certified Nursing Assistant #1 was seen standing in the doorway pulling Resident #1 by the arm. Certified Nursing Assistant #1 then pulled Resident #1 into the hallway. Certified Nursing Assistant #1 held Resident #1 under the left armpit and pulled Resident #1 up the hallway to their wheelchair as Resident #1 continued to resist. Certified Nursing Assistant #1 then put Resident #1 to sit on the edge of their wheelchair, as Resident #1 resisted sitting, Certified Nursing Assistant #1 held Resident #1 under the armpit and pants and dragged Resident #1 all the way back into the wheelchair. Certified Nursing Assistant #1 pushed Resident #1's upper body forward while their right hand moved back/forth at Resident #1's lower back (appeared to hit Resident #1 on the buttock) and Resident #1's body jerked forward. Resident #2's visitor (the complainant) observed standing in the doorway of Resident #2's room looking in the direction of Certified Nursing Assistant #1 and Resident #1. The family member and Certified Nursing Assistant #1 appeared to be exchanging words and hand gestures.A review of the undated facility Summary Investigation for Incident which occurred between Certified Nursing Assistant #1 and Resident #2's visitor on 02/17/2026 at 5:30 PM, revealed Resident #2's visitor went to the Director of Nursing office demanding Certified Nursing Assistant #1 receive a discipline as they engaged in a verbal altercation on the unit and were disrespectful to them. The visitor also said they heard a commotion on the unit and came out of Resident #2's room to observe what was happening and asked Certified Nursing Assistant #1, who was attending Resident 1, what they were doing. Immediately following the meeting, the camera was reviewed, and Resident #1 was observed sitting at the nursing station in their wheelchair. Resident #1 then got up and wandered into other residents' rooms and Certified Nursing Assistant #1 immediately assisted Resident #1 back into their wheelchair using compact pivot transfer to maintain safety. A review of Registered Nurse Supervisor #1's statement to the facility dated 02/17/2026 documented they were instructed (by Director of Nursing) to assess Resident #1. They entered Resident #1's room and observed Resident #1 sitting on their bed smiling and in good spirits. They assessed Resident #1 with no visible injury. Resident #1 reported no complaints of pain or discomfort. There was no documented evidence of a registered nurse assessment for Resident #1.The New York State Department of Health Surveyor went onsite on 02/25/2026 and the facility initiated the investigation into the abuse allegation on 02/27/2026. A review of Certified Nursing Assistant #1's Employee Attendance sheet dated 01/01/2026 - 02/27/2026 revealed Certified Nursing Assistant #1 last worked on 02/20/2026 and 02/21/2026 (on the evening shift).A review of the unit Staffing Sheet dated 02/20/2026 revealed Certified Nursing Assistant #1 worked on the second floor on the evening shift and worked on 02/21/2026 on the third floor on the evening shift. On 02/25/2026 at 10:02 AM, Resident #2's visitor (complainant) was interviewed and stated that on 02/17/2026 at approximately 5:30 PM, they observed Certified Nursing Assistant #1 roughly handle and hit Resident #1 on their buttocks. Resident #2's visitor stated they reported the incident to the Director of Nursing who promised to look at the issue.On 02/25/2026 at 1:23 PM, the Director of Nursing was interviewed and stated Resident #2's visitor did not report to them that they observed Certified Nurse Assistant #1 roughly handle and hit Resident #1 on their buttocks. The Director of Nursing stated that the visitor reported Certified Nursing Assistant #1 was rude to them. The Director of Nursing stated they reviewed the video footage to see the interaction between Certified Nursing Assistant #1 and the visitor. The Director of Nursing stated they did not identify the actions of Certified Nursing Assistant #1 to be abusive or excessively rough with Resident #1. The Director of Nursing stated Certified Nursing Assistant #1 denied the abuse allegations. Therefore, they did not further investigate the matter but suspended Certified Nursing Assistant #1 for one (1) day (02/18/2026) due to poor customer service. The Director of Nursing stated when Certified Nursing Assistant #1 returned from suspension, they were assigned to another unit to prevent interaction with Resident #2's visitor. On 02/25/2026 at 3:37 PM, Registered Nurse Supervisor #1 was interviewed and stated on 02/17/2026 at approximately 5:30 PM, the Director of Nursing came into the nursing office and reported that a family member reported Certified Nursing Assistant #1 on the fourth floor was cursing at them because they asked Certified Nursing Assistant #1 what they were doing with Resident #1. Registered Nurse Supervisor #1 stated that the Director of Nursing reported to them that they reviewed the surveillance video footage and observed Certified Nursing Assistant #1 attempting to put Resident #1 into their wheelchair. Registered Nurse Supervisor #1 stated that the Director of Nursing instructed them to conduct a body assessment on Resident #1. Registered Nurse Supervisor #1 stated they and the Director of Nursing went to the unit and performed a body assessment on Resident #1. Registered Nurse Supervisor #1 stated the assessment revealed no redness, discoloration or visible injury. Registered Nurse Supervisor #1 stated they did not document their assessment in Resident #1's chart and did not notify the medical doctor.On 02/25/2026 at 4:00 PM, the Assistant Administrator was interviewed and stated they reviewed the surveillance video footage and there was no harm to Resident #1. The Assistant Administrator stated they decided to suspend Certified Nursing Assistant #1 for poor customer service and removed them from the unit (Resident #1's unit). The Assistant Administrator stated there were no allegations of rough handling or hitting.On 02/27/2026 at 12:30 PM, Medical Doctor #1 was interviewed and stated they were not aware of any allegation of rough handling or abuse involving Resident #1 on 02/17/2026. Medical Doctor #1 stated they were not in the facility when they were informed of the alleged allegation on 02/26/2026.Immediate Jeopardy was identified, and the Administrator and the Director of Nursing were notified on 03/02/2026 at 2:15 PM. An acceptable immediate corrective action plan from the facility was received on 03/03/2026 at 10:25 AM.Immediate Jeopardy was removed prior to the survey exit of 03/04/2026 based on the following corrective actions taken by the facility:1. Certified Nursing Assistant #1 was removed on 02/25/2026.2. Resident #1 was assessed on 02/25/2026.3. Facility wide in-service conducted on 02/25/2026.4. Administration rounding on all units conducted 02/25/2026.5. Resident #1's care plan was reviewed and updated 02/25/2026.6. Audit log dated 02/25/2026 for Accident/Incidents reviewed for past 30 days.7. Facility reviewed and assessed 52 residents for abuse and mistreatment.8. Nurse Practitioner assessed Resident #1 on 02/26/2026.9. The Director of Nursing and Assistant Director of Nursing received in-service on 03/02/2026. Lesson Plan F610 - ensuring a thorough investigation of all allegations.10. Interdisciplinary Meeting held on 02/27/202611. Facility investigation dated 02/27/2026 reviewed12. Facility reviewed Policy and Procedure on Abuse Prevention on 03/02/2026 10 New York Codes, Rules, and Regulations 415.4(b)(3)

Based on observation, record reviews, and interviews, conducted during a survey, the facility failed to ensure that a resident was free from physical abuse. This was evident for one (1) out of six (6) residents (Resident #1) sampled for abuse. Specifically, on 02/17/2026 at 5:30 PM, Resident #2's visitor reported to the Director of Nursing that they observed Certified Nursing Assistant #1 rough handed and hit Resident #1 on their buttock. A review of the facility surveillance video footage dated 02/17/2026 at 4:34 PM corroborated what the visitor reported to the Director of Nursing and later reported to the New York State Department of Health. The findings are:The facility's Policy titled Abuse Prohibition Policy and Protocol dated 09/11/2025 documented Residents of facility will be protected from abuse, neglect, mistreatment, and misappropriation of property in accordance with state and federal regulations. The policy also states the facility has zero tolerance for any kind of patient abuse, neglect, or mistreatment. Resident #1 was admitted to the facility with diagnoses that included non-Alzheimer's Dementia, muscle weakness, and difficulty walking.The quarterly Minimum Data Set (a resident assessment tool) dated 01/02/2026 documented Resident #1 had severely impaired cognition. Section GG - Functional Abilities documented Resident #1 required partial/moderate assistance - helper does less than half the effort. Helper lifts, holds, or support the trunk or limbs, but provides less than half the effort.A care plan for wandering/elopement dated 01/09/2026 documented Resident #1 walking into other residents' room uninvited which put resident at risk for potential abuse. The interventions are documented to monitor Resident #1's whereabouts and redirect as needed.There was no documented evidence for frequency of monitoring.A Care plan for behavior symptoms resistive to care dated 12/15/2025 documented interventions to provide positive reinforcement for appropriate behavior, redirect resident as appropriate, maintain calm, safe environment, and address resident in a calm and gentle manner.A review of the facility surveillance video footage dated 02/17/2026 at 4:34 PM showed at 4:38 PM Resident #1 got up from their wheelchair ambulating with unsteady gait up the hallway while holding onto the handrails in the hallway. Resident #1 walked over to the other side of the hallway, where a cart stocked with personal protective equipment was, then rolled the cart into two residents' rooms. Certified Nursing Assistant #1 who was wheeling a resident up the hallway as Resident #1 entered one of the rooms with the cart, stopped and went into the room behind Resident #1. Certified Nursing Assistant rolled the cart into the hallway, and Certified Nursing Assistant #1 was seen standing in the doorway pulling Resident #1 by the arm, Certified Nursing Assistant #1 then pulled Resident #1 into the hallway. Then, Certified Nursing Assistant #1 held Resident #1 under the left armpit and pull Resident #1 up the hallway to their wheelchair as Resident #1 continued to resist. Certified Nursing Assistant #1 then put Resident #1 to sit on the edge of their wheelchair, as Resident #1 resisted sitting, Certified Nursing Assistant #1 held Resident #1 under the left armpit, putting their right hand behind Resident #1 holding them by the pants and dragged Resident #1 all the way back into the wheelchair then push and held Resident #1's upper body forward with their left hand, while their right hand moved back/forth at Resident #1's lower back, and Resident #1's body jerked forward. Resident #2's visitor observed standing in the doorway of Resident #2's room looking in the direction of Certified Nursing Assistant #1 and Resident #1. The family member and Certified Nursing Assistant #1 appeared to be exchanging words and hand gestures.A review of the facility Summary Investigation for Incident which occurred between Certified Nursing Assistant #1 and Resident #2's visitor on 02/17/2026 at 5:30 PM, revealed Resident #2's visitor went to the Director of Nursing office demanding Certified Nursing Assistant receive a discipline as they engaged in a verbal altercation on the unit and was disrespectful to them. The visitor also said they heard a commotion on the unit and came out of Resident #2's room to observe what was happening and asked Certified Nursing Assistant, who was attending Resident 1, what they were doing. Immediately following the meeting, the camera was reviewed, and Resident #1 was observed sitting at the nursing station in their wheelchair. Then got up and wandered into other residents' rooms and Certified Nursing Assistant #1 immediately assisted Resident #1 back into their wheelchair using compact pivot transfer to maintain safety. A review of Registered Nurse Supervisor #1 statement to the facility dated 02/17/2026 documented they were instructed (by Director of Nursing) to assessed Resident #1. They entered Resident #1's room and observed Resident #1 sitting on their bed smiling and in good spirits. They assessed Resident #1 with no visible injury. Resident #1 reported no complaints of pain or discomfort. There was no documented evidence that the alleged abuse allegation was investigated or reported to the New York State Department of Health.On 02/25/2026 at 10:02 AM, Resident #2's visitor (complainant) was interviewed and stated that on 02/17/2026 at approximately 5:30 PM, they observed Certified Nursing Assistant #1 rough handed and hit Resident #1 on their buttocks. Resident #2's visitor stated they reported the incident to the Director of Nursing who promised to look at the issue.On 02/25/2026 at 2:00 PM Certified Nursing Assistant #1 was interviewed and stated they worked on the 3:00 PM - 11:00 PM shift on 02/17/2026. Certified Nursing Assistant #1 stated they were not assigned to Resident #1, but observed Resident #1 entered another resident's room with the Personal Protective Cart on 02/17/2026 at approximately 4:39PM. Certified Nursing Assistant #1 stated they put the cart into the hallway then held Resident #1 under the armpit and escorted Resident #1 out of the other resident's room. Certified Nursing Assistant #1 stated while they were walking with Resident #1, they were resisting and making noise. Certified Nursing Assistant #1 stated they took Resident #1 to their wheelchair and sat them in the chair. Certified Nursing Assistant #1 stated while they were putting Resident #1 to sit in the wheelchair a family member (Resident #2's visitor) asked them what they were doing with Resident #1. Certified Nursing Assistant #1 stated they did not answer Resident #2's visitor and the visitor started arguing with them. Certified Nursing Assistant #1 stated they walked away and informed Licensed Practical Nurse #1. Certified Nursing Assistant #1 stated they did not roughly handle or hit Resident #1 on their buttock.On 02/26/2026 at 11:28 AM, Licensed Practical Nurse #1 was interviewed and stated on 02/17/2026 at approximately 4:40 PM Certified Nursing Assistant #1 approached them and reported that Resident #2's visitor asked them what they were doing with Resident #1 and that they did not answer because Resident #1 was not their (Resident #2 visitor) loved one. Licensed Practical Nurse #1 stated Certified Nursing Assistant #1 informed them that Resident #2's visitor was arguing with them but did not elaborate on what the argument was about. On 02/25/2026 at 3:37 PM, Registered Nurse Supervisor #1 was interviewed and stated on 02/17/2026 Fat approximately 5:30 PM the Director of Nursing came into the nursing office and reported that a family member reported Certified Nursing Assistant #1 on the 4th floor was cursing at them because they asked Certified Nursing Assistant #1 what they were doing with Resident #1. Registered Nurse Supervisor #1 stated that the Director of Nursing reported to them that they reviewed the surveillance video footage and observed Certified Nursing Assistant #1 attempting to put Resident #1 into their wheelchair. Registered Nurse Supervisor #1 stated that the Director of Nursing instructed them to conduct a body assessment on Resident #1 and they both went to the unit and performed a body assessment on Resident #1. Registered Nurse Supervisor #1 stated the assessment revealed no redness, discoloration or visible injury. Registered Nurse Supervisor #1 stated they did not document their assessment in Resident #1's chart and did not notify the medical doctor.On 02/25/2026 at 1:23 PM, the Director of Nursing was interviewed and stated Resident #2's visitor did not report to them that they observed Certified Nursing Assistant #1 rough handled and hit Resident #1 on their buttocks. The Director of Nursing stated that Resident #2's visitor reported Certified Nursing Assistant #1 was rude to them. The Director of Nursing stated they reviewed the video footage to see the interaction between Certified Nursing Assistant #1 and the visitor. They did not identify the actions of Certified Nursing Assistant #1 as being abusive or excessively rough with Resident #1. Therefore, they did not further investigate the matter but suspended Certified Nursing Assistant #1 for one (1) day (02/18/2026) due to poor customer service. The Director of Nursing stated them and Registered Nurse Supervisor #1 performed a body assessment and there were no redness, discoloration or visible injuries. The Director of Nursing stated upon Certified Nursing Assistant #1's return to work, they were assigned to another unit to prevent interaction with Resident #2's visitor. On 02/25/2026 at 4:00 PM, the Assistant Administrator was interviewed and stated they reviewed the surveillance video footage and there was no harm to Resident #1. The Assistant Administrator stated they decided to suspend Certified Nursing Assistant #1 (one day) for poor customer service and removed them from the unit (Resident #1's unit). The Assistant Administrator stated there were no allegations of rough handling or hitting. Therefore, the allegation of abuse was not investigated or reported to the Department of Health.On 02/27/2026 at 12:30 PM, Medical Doctor #1 was interviewed and stated they were not aware of any allegation of rough handling or abuse involving Resident #1 on 02/17/2026. Medical Doctor #1 stated they were not in the facility when they were informed of the alleged allegation on 02/26/2026.10 New York Codes, Rules, and Regulations 415.4(b)(1)(i)

Based on observation, record review, and interviews conducted during a survey, the facility failed to ensure that all alleged violations involving abuse, exploitation, or mistreatment, including injuries of unknown source are reported immediately but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This was evident for one (1) out of six (6) residents (Resident #1) reviewed for abuse. Specifically, on 02/17/2026 at 5:30 PM, Resident #2's visitor reported to the Director of Nursing that they observed Certified Nursing Assistant #1 rough handed and hit Resident #1 on their buttock. The facility did not report the alleged allegation of abuse to New York State Department of Health.The findings include:The facility's Policy titled 'Abuse Prohibition' last revised on 09/11/2025 documented Residents of facility will be protected from abuse, neglect, mistreatment, and misappropriation of property in accordance with state and federal regulations. It was also documented that the facility would report all alleged violations and all substantiated incidents to the New York State Department of Health and to all other agencies as required and take all necessary corrective action depending on the results of the investigation. The policy also documented that all alleged violations involving abuse neglect, exploitation, or resident's property, are reported immediately, but not later than 2hours after the allegation is made.Resident #1 was admitted to the facility with diagnoses that included non-Alzheimer's Dementia, muscle weakness, and difficulty walking.The Minimum Data Set (a resident assessment tool) dated 01/02/2025 documented Resident #1 had severely impaired cognition.A review of the facility surveillance video footage dated 02/17/2026 at 4:34 PM showed at 4:38 PM Resident #1 got up from their wheelchair ambulating with unsteady gait up the hallway while holding onto the handrails in the hallway. Resident #1 walked over to the other side of the hallway, where a cart stocked with personal protective equipment was, then rolled the cart into two residents' rooms. Certified Nursing Assistant #1 who was wheeling a resident up the hallway as Resident #1 entered one of the rooms with the cart, stopped and went into the room behind Resident #1. Certified Nursing Assistant rolled the cart into the hallway, and Certified Nursing Assistant #1 was seen standing in the doorway pulling Resident #1 by the arm, Certified Nursing Assistant #1 then pulled Resident #1 into the hallway. Then, Certified Nursing Assistant #1 held Resident #1 under the left armpit and pull Resident #1 up the hallway to their wheelchair as Resident #1 continued to resist. Certified Nursing Assistant #1 then put Resident #1 to sit on the edge of their wheelchair, as Resident #1 resisted sitting, Certified Nursing Assistant #1 held Resident #1 under the left armpit, putting their right hand behind Resident #1 holding them by the pants and dragged Resident #1 all the way back into the wheelchair then push and held Resident #1's upper body forward with their left hand, while their right hand moved back/forth at Resident #1's lower back, and Resident #1's body jerked forward. Resident #2's visitor observed standing in the doorway of Resident #2's room looking in the direction of Certified Nursing Assistant #1 and Resident #1. The family member and Certified Nursing Assistant #1 appeared to be exchanging words and hand gestures.A review of the facility Summary Investigation for Incident which occurred between Certified Nursing Assistant #1 and Resident #2's visitor on 02/17/2026 at 5:30 PM, revealed Resident #2's visitor went to the Director of Nursing office demanding Certified Nursing Assistant #1 receive a discipline as they engaged in a verbal altercation on the unit and was disrespectful to them. The visitor also said they heard a commotion on the unit and came out of Resident #2's room to observe what was happening and asked Certified Nursing Assistant #1, who was attending Resident 1, what they were doing. Immediately following the meeting, the camera was reviewed, and Resident #1 was observed sitting at the nursing station in their wheelchair. Resident #1 then got up and wandered into other residents' rooms and Certified Nursing Assistant #1 immediately assisted Resident #1 back into their wheelchair using compact pivot transfer to maintain safety. A review of Registered Nurse Supervisor #1 statement to the facility dated 02/17/2026 documented they were instructed (by Director of Nursing) to assessed Resident #1. They entered Resident #1's room and observed Resident #1 sitting on their bed smiling and in good spirits. They assessed Resident #1 with no visible injury. Resident #1 reported no complaints of pain or discomfort. There was no documented evidence that the alleged abuse was reported to New York State Department of Health.On 02/25/2026 at 4:00 PM, the Assistant Administrator was interviewed and stated they reviewed the surveillance video footage and there was no harm to Resident #1. The Assistant Administrator stated they decided to suspend Certified Nursing Assistant #1 (one day) for poor customer service and removed them from the unit (Resident #1's unit). The Assistant Administrator stated there were no allegations of rough handling or hitting. Therefore, the allegation of abuse was not investigated or reported to the Department of Health. On 02/27/2026 at 12:30 PM, Medical Doctor #1 was interviewed and stated they were not aware of any allegation of rough handling or abuse involving Resident #1 on 02/17/2026. 10 New York Codes, Rules, and Regulations 415.4(b)(2)

Based on observation, record review, and interviews conducted during a survey, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents. Specifically, Resident #1 who has unsteady gait and was at risk for fall, was seen on the facility's surveillance video footage on 02/17/2026 ambulating in the hallway without assistance. Resident #1 walked over to the other side of the hallway, where a cart stocked with personal protective equipment was, then rolled the cart into two residents' rooms. The findings are:The facility's Policy titled Incident/Accident Prevention Program dated 02/09/2026 states it is the policy of the facility to monitor and evaluate any adverse occurrence which is not consistent with the routine operation of the facility or care of a resident(s). All accidents/incidents where there are mistreatment, neglect, abuse, or injuries of unknown origin will be reported to the Director of Nursing/Designee and Administrator/Designee immediately for further review and reporting based on State and Federal regulations.Resident #1 was admitted to the facility with diagnoses that included non-Alzheimer's Dementia, muscle weakness, and difficulty walking.The quarterly Minimum Data Set (a resident assessment tool) dated 01/02/2026 documented Resident #1 had severely impaired cognition. Section GG - Functional Abilities (walk 50 feet) documented Resident #1 required partial/moderate assistance - helper does less than half the effort. Helper lifts, holds, or support the trunk or limbs, but provides less than half the effort. Section GG also documented Resident #1 required partial/moderate assistance from a sitting in a chair to a standing position. Resident #1 uses a wheelchair for locomotion.A review of the Fall Care Plan last reviewed on 01/05/2026 documented interventions to keep room and hallways well-lit, clean, and clutter free, call bell within easy reach, encourage and remind residents to call for assistance, properly fitted footwear, gripper socks at night and to provide assistance with activities of daily living care as needed. Floors are dry and clean.A review of the facility surveillance video footage from unit four (4) dated 02/17/2026 at 4:34 PM showed at 4:38 PM Resident #1 got up from their wheelchair ambulating with unsteady gait up the hallway while holding onto the handrails in the hallway. Resident #1 walked over to the other side of the hallway, where a cart stocked with personal protective equipment was, then rolled the cart into two residents' rooms. Certified Nursing Assistant #1 who was wheeling a resident up the hallway as Resident #1 entered one of the rooms with the cart, stopped and went into the room behind Resident #1. Certified Nursing Assistant #1 rolled the cart into the hallway, and Certified Nursing Assistant #1 was seen standing in the doorway pulling Resident #1 by the arm. Certified Nursing Assistant #1 then pulled Resident #1 into the hallway. Certified Nursing Assistant #1 held Resident #1 under the left armpit and pulled Resident #1 up the hallway to their wheelchair as Resident #1 continued to resist. Certified Nursing Assistant #1 then put Resident #1 to sit on the edge of their wheelchair, as Resident #1 resisted sitting, Certified Nursing Assistant #1 held Resident #1 under the armpit and pants and dragged Resident #1 all the way back into the wheelchair. Certified Nursing Assistant #1 pushed Resident #1's upper body forward while their right hand moved back/forth at Resident #1's lower back (appeared to hit Resident #1 on the buttock) and Resident #1's body jerked forward.On 02/25/2026 at 2:00 PM, Certified Nursing Assistant #1 was interviewed and stated they worked on Resident #1's unit on the 3:00 PM - 11:00 PM shift on 02/17/2026. Certified Nursing Assistant #1 stated there were three (3) Certified Nursing Assistants and one (1) Licensed Practical Nurse on the Southeast (Resident #1's side of the unit) side of the unit. Certified Nursing Assistant #1 stated that one (1) Certified Nursing Assistant was monitoring residents in the dining room while another Certified Nursing Assistant took residents to their room and provided incontinent care before taking them to the dining room for dinner. Certified Nursing Assistant #1 stated while they were going in and out of residents' rooms, they were also keeping an eye on the other residents sitting in the hallway. Certified Nursing Assistant #1 stated that Licensed Practical Nurse #1 was also keeping an eye on the residents while they were administering medications. Certified Nursing Assistant #1 further stated they Resident #1 was not assigned to them, but they were aware Resident #1 was at risk for fall so when they saw Resident #1 ambulating in the hallway, they immediately stopped and escorted the resident back to their wheelchair.On 02/26/2026 at 1:30 PM, Certified Nursing Assistant #2 was interviewed and stated they were assigned to Resident #1 on 02/17/2026 on the 3:00 PM to 11:00 PM shift. Certified Nursing Assistant #2 started at approximately 4:45 PM after completing care for another resident, Certified Nursing Assistant #1 came into the room and informed them Resident #1 was misbehaving at the nursing station (standing up and walking into rooms) and that Resident #1 needed to change. Certified Nursing Assistant #2 stated they took Resident #1 into their room and performed incontinent care then transported Resident 1 to the dining room for dinner. Certified Nursing Assistant #2 stated all staff on the unit are supposed to monitor the residents and that Resident #1 was on hourly visual monitoring.On 02/26/2026 at 11:28 AM, Licensed Practical Nurse #1 was interviewed and started on 02/17/2026 at approximately 4:34 PM they were on Resident #1's unit administering medications and were going in and out of residents' rooms as they monitored the residents who were sitting in the hallway. Licensed Practical Nurse #1 also stated that the Certified Nursing Assistants were transporting residents to their room to provide incontinent care before dining (dinner time between 5:00 PM and 5:30 PM). On 02/25/2026 at 3:37 PM, Registered Nurse Supervisor #1 was interviewed and stated that Licensed Practical Nurse #1 is responsible for ensuring the Certified Nursing Assistants are monitoring all the residents on the unit. Registered Nurse Supervisor #1 stated they performed rounds on the unit at 4:15 PM on 02/17/2026 and the residents were in the dining room being monitored by a Certified Nursing Assistant.On 02/25/2026 at 1:23 PM, the Director of Nursing was interviewed and stated on 02/17/2026 they reviewed the surveillance video record which showed Resident#1 got up out of their wheelchair and was walking in the hallway and staff members were going in and out of residents' rooms. The Director of Nursing stated that the staff were also monitoring the three (3) residents who were sitting in the hallway. 10 New York Codes, Rules, and Regulations 415.12(h)(2)

Based on observation, record review, and interviews conducted during a survey, the facility failed to ensure the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was evident in one (1) out of six (6) residents sampled (Resident #1). Specifically, on 02/17/2026 at 5:30 PM, Resident #2's visitor reported to the Director of Nursing that they observed Certified Nursing Assistant #1 abused Resident #1. The facility surveillance video footage dated 02/17/2026 at 4:34 PM corroborated what the visitor reported to the Director of Nursing and later reported to the New York State Department of Health. Facility administration did not immediately investigate the alleged abuse and protect residents from further potential abuse. Additionally, the facility did not report the alleged allegation of abuse to the New York State Department of Health within 2 hours after the allegation was made.The findings are:The facility's Policy and Procedure entitled, Administration-Management with revision date 10/14/2024 documented the facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.Resident #1 was admitted to the facility with diagnoses that included non-Alzheimer's Dementia, muscle weakness, and difficulty walking.The Minimum Data Set (a resident assessment tool) dated 01/02/2025 documented Resident #1 had severely impaired cognition.A review of the facility surveillance video footage from unit 4 dated 02/17/2026 at 4:34 PM showed at 4:38 PM Resident #1 got up from their wheelchair ambulating with unsteady gait up the hallway while holding onto the handrails in the hallway. Resident #1 walked over to the other side of the hallway, where a cart stocked with personal protective equipment was, then rolled the cart into two residents' rooms. Certified Nursing Assistant #1 who was wheeling a resident up the hallway as Resident #1 entered one of the rooms with the cart, stopped and went into the room behind Resident #1. Certified Nursing Assistant rolled the cart into the hallway, and Certified Nursing Assistant #1 was seen standing in the doorway pulling Resident #1 by the arm, Certified Nursing Assistant #1 then pulled Resident #1 into the hallway. Then, Certified Nursing Assistant #1 held Resident #1 under the left armpit and pull Resident #1 up the hallway to their wheelchair as Resident #1 continued to resist. Certified Nursing Assistant #1 then put Resident #1 to sit on the edge of their wheelchair, as Resident #1 resisted sitting, Certified Nursing Assistant #1 held Resident #1 under the left armpit, putting their right hand behind Resident #1 holding them by the pants and dragged Resident #1 all the way back into the wheelchair then push and held Resident #1's upper body forward with their left hand, while their right hand moved back/forth at Resident #1's lower back, and Resident #1's body jerked forward. Resident #2's visitor observed standing in the doorway of Resident #2's room looking in the direction of Certified Nursing Assistant #1 and Resident #1. The family member and Certified Nursing Assistant #1 appeared to be exchanging words and hand gestures.A review of the facility Summary Investigation for Incident which occurred between Certified Nursing Assistant #1 and Resident #2's visitor on 02/17/2026 at 5:30 PM, revealed Resident #2's visitor went to the Director of Nursing office demanding Certified Nursing Assistant #1 receive a discipline as they engaged in a verbal altercation on the unit and was disrespectful to them. The visitor also said they heard a commotion on the unit and came out of Resident #2's room to observe what was happening and asked Certified Nursing Assistant #1, who was attending Resident 1, what they were doing. Immediately following the meeting, the camera was reviewed, and Resident #1 was observed sitting at the nursing station in their wheelchair. Resident #1 then got up and wandered into other residents' rooms and Certified Nursing Assistant #1 immediately assisted Resident #1 back into their wheelchair using compact pivot transfer to maintain safety. A review of Registered Nurse Supervisor #1 statement to the facility dated 02/17/2026 documented they were instructed (by Director of Nursing) to assess Resident #1. They entered Resident #1's room and observed Resident #1 sitting on their bed smiling and in good spirits. They assessed Resident #1 with no visible injury. Resident #1 reported no complaints of pain or discomfort. The New York State Department of Health Surveyor went onsite on 02/25/2026 and the facility initiated the investigation into the abuse allegation on 02/27/2026. A review of Certified Nursing Assistant #1's Employee Attendance sheet dated 01/01/2026 - 02/27/2026 showed Certified Nursing Assistant #1 lasted worked on 02/20/2026 and 02/21/2026.A review of the facility Staffing Sheet for the 3:00 PM - 11:00 PM shift revealed Certified Nursing Assistant #1 worked on 02/20/2026 and 02/21/2026 on the second and third floor. On 02/25/2026 at 1:23 PM, the Director of Nursing was interviewed and stated Resident #2's visitor did not report to them that they observed Certified Nurse Assistant #1 rough handled and hit Resident #1 on their buttocks. The Director of Nursing stated that the visitor reported Certified Nursing Assistant #1 was rude to them. The Director of Nursing stated they reviewed the video footage to see the interaction between Certified Nursing Assistant #1 and the visitor. The Director of Nursing stated they did not identify the actions of Certified Nursing Assistant #1 to be abusive or excessively rough with Resident #1. The Director of Nursing stated Certified Nursing Assistant #1 denied the abuse allegations. Therefore, they did not further investigate the matter but suspended Certified Nursing Assistant #1 for one (1) day (02/18/2026) due to poor customer service. The Director of Nursing stated when Certified Nursing Assistant #1 returned from suspension, they were assigned to another unit to prevent interaction with Resident #2's visitor. On 02/25/2026 at 4:00 PM, the Assistant Administrator was interviewed and stated they reviewed the surveillance video footage and there was no harm to Resident #1. The Assistant Administrator stated they decided to suspend Certified Nursing Assistant #1 (one day) for poor customer service and removed them from the unit (Resident #1's unit). The Assistant Administrator stated there were no allegations of rough handling or hitting. Therefore, the allegation of abuse was not investigated or reported to the Department of Health. 10 New York Codes, Rules, and Regulations 415.26

Based on observation, record review, and interviews during the Recertification Survey conducted from 01/13/2025 to 01/21/2025, the facility did not ensure that a comprehensive person-centered care plan was developed and implemented to address each residents' medical, physical, mental, and psychosocial needs. This was evident in 1 (Resident #146) of 1 resident reviewed for Antibiotic Use, out of 37 total sampled residents. Specifically, a care plan was not developed for Resident #146's diagnosis of Sinusitis and antibiotic use. The findings are: The facility's policy titled Comprehensive Care Plan with a revised date of 12/27/2024 documented that the residents of the facility will have an individualized Comprehensive Care Plan completed in accordance with Federal and State requirements. The Comprehensive Care Plan will include measurable objectives and timetables in order to meet the resident's medical, nursing, mental, and psychosocial needs which are identified from the comprehensive assessment (MDS 3.0) and application of the Care Area Assessment. Additional problems, strengths, or needs identified by members of the Comprehensive Care Plan Team will be included in the Comprehensive Care Plan as appropriate. On 01/13/2025 at 11:44 AM, Resident #146 was observed in bed and was interviewed. Resident #146 stated they had Pneumonia for the past week and had been taking antibiotic. Resident stated they had been in bed because of the flu. Resident #146 was observed with occasional non-productive cough during the interview. Resident #146 had diagnoses that included Anemia, Hypertension, Asthma/Chronic Obstructive Pulmonary Disease. The Quarterly Minimum Data Set, dated dated dated [DATE] documented Resident #146 had intact cognitive status and required substantial/maximal assistance for bed mobility, and dependent on staff for most activities of daily living. A Nurse Practitioner progress note dated 01/07/2025 documented Resident #146 was seen for chief complaint of cough and chest congestion. Resident was previously seen on 01/03/2025 for complaints of chest congestion, cough, and tested positive for Influenza A. A previous chest x-ray indicated no active disease. No treatment at this time, symptoms are more than 48 hours, will monitor for elevated temperature and changes in respiratory status; will offer increased fluids if tolerated. The Primary Medical Doctor was made aware. A medical progress note dated 01/08/2025 documented Influenza A positive, symptoms were greater than 48 hours, observe off antiviral, agreed to antibiotics for yellowish phlegm and malodor phlegm. On contact/droplet isolation, antibiotics for Sinusitis. A physician's order dated 01/08/2025 documented Amoxicillin and Clavulanate Potassium 875 mg - 125 mg tablet, 1 tablet by oral route every 12 hours for 10 days for Acute Sinusitis. A review of the electronic Medication Administration Record showed that Amoxicillin and Clavulanate Potassium 875 mg - 125 mg tablet (brand name: Augmentin) was administered to Resident #146 from 01/08/2025 - 01/14/2025. An entry dated 01/14/2025 at 6:00 AM documented that Amoxicillin and Clavulanate Potassium was not administered due to hospitalization . A review of Resident #146's Comprehensive Care Plan showed no documented evidence that a care plan with interventions to address the Resident's diagnosis of Acute Sinusitis and use of antibiotic was developed. On 01/21/2025 at 11:03 AM, Registered Nurse #1, who was Unit Manager, was interviewed and stated that Resident #146 tested positive of Flu on 01/07/2025 was started on Augmentin for Acute Sinusitis. Registered Nurse #1 stated they do not know why a care plan for Sinusitis and antibiotic use was not initiated for Resident #146. On 01/21/2025 at 11:45 AM, the Infection Control Prevention Registered Nurse was interviewed and stated that the Unit Mangers, Supervisors, or the Infection Control Registered Nurse are responsible for initiating a care plan for resident's use of antibiotic. They stated that Resident #146 tested positive for influenza and was ordered Augmentin for Sinusitis. The Infection Control Prevention Registered Nurse stated they must have forgotten to put in the care plan for Resident #146. On 01/21/2025 at 12:16 PM, the Director of Nursing was interviewed and stated that the nursing supervisor on duty is primarily responsible for initiating the episodic care plan. If the nursing supervisor missed it, the Unit Manager and the Infection Control Registered Nurse are supposed to check and capture it. The Director of Nursing stated the care plan is the blueprint of how to care for the resident and should have been in place. 10 NYCRR 415.11(c)(1)

Based on observation, record review, and interviews during the Recertification Survey conducted from 1/13/2025 to 1/21/2025, the facility did not ensure residents receive treatment and care in accordance with professional standards of practice, and comprehensive person-centered care plan. This was evident for 1 of 1 resident reviewed for Insulin (Resident #149), out of a sample of 37 residents investigated. Specifically, Resident #149 had a physician's order to notify the physician when Resident's finger stick blood sugar (method of drawing drops of blood from the finger for testing the blood glucose level) result is less than 200 milligrams per deciliter or more than 350 milligrams per deciliter. The licensed nurse failed to notify the physician when Resident #149's finger stick blood sugar was lower than 200 milligrams per deciliter on 7 occasions from 1/02/2025 through 1/13/2025 and higher than 350 milligrams per deciliter on 3 occasions from 12/02/2024 through 12/31/2024. In addition, Resident #149 was administered 6 units of Novolog insulin (a short acting insulin that lowers blood sugar) on 12/02/2024 and 12/10/24, and 8 units on 12/31/2024, when Resident #149's finger stick blood sugar results were above 350 milligrams per deciliter, without a physician's order. The findings are: The facility's policy titled Diabetes Management with a revised date of 6/18/2024 documented blood sugar level and frequency measured, per physician orders and facility protocol in place for physician notification with specific parameters. Resident #149 had diagnoses of Diabetes Mellitus, Peripheral Vascular Disease, and Cancer. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #149 had intact cognition. A Comprehensive Care Plan for Diabetes was initiated on 7/20/2022. The facility interventions include to monitor blood glucose level and administer oral hypoglycemic/insulin injection as per physician's orders. A physician's order dated 9/26/2024 documented check finger stick at bedtime. Notify the physician if blood sugar results are below 200 milligrams per deciliter. A physician's order dated 11/29/2024 documented Novolog FlexPen 100 units per milliliter (3 milliliters) subcutaneous, inject subcutaneously two times per day when finger stick blood sugar readings are as follows: Between 120 and 200 give 2 units, between 200 and 279 give 4 units, between 271 and 350 give 6 units. Above 350, call the physician. A physician's order dated 12/21/2024 documented Novolog FlexPen 100 units per milliliter (3 milliliters) subcutaneous, inject subcutaneously two times per day when finger stick blood sugar readings are as follows: Between 120 and 200 give 2 units, between 200 and 279 give 4 units, between 271 and 350 give 8 units. Above 350, call the physician. The electronic Medication Administration Records for 12/2024 and 1/2025 documented the following finger stick blood sugar results: On 12/02/2024 at 4:30 PM, 530 milligrams per deciliter. On 12/10/2024 at 12:00 PM, 370 milligrams per deciliter. On 12/31/2024 at 4:30 PM, 355 milligrams per deciliter. On 1/02/2025 at 9:00 PM, 192 milligrams per deciliter. On 1/04/2025 at 9:00 PM, 179 milligrams per deciliter. On 1/06/2025 at 9:00 PM, 174 milligrams per deciliter. On 1/07/2025 at 9:00 PM, 116 milligrams per deciliter. On 1/09/2025 at 9:00 PM, 187 milligrams per deciliter. On 1/10/2025 at 9:00 PM, 153 milligrams per deciliter. On 1/13/2025 at 9:00 PM, 176 milligrams per deciliter. A further review of Resident #149's electronic Medication Administration Record showed that 6 units of Novolog insulin was administered at 4:30 PM on 12/02/2024 and 12:00 PM on 12/10/24, and 8 units were administered at 4:30 PM on 12/31/2024, when Resident #149's finger stick blood sugar results were above 350 milligrams per deciliter, without a physician's order. A review of the nurses' and medical progress notes from 12/02/2024 through 1/13/2025 showed no documentation that the physician was notified when Resident #149's finger stick blood sugar results were below 200 milligrams per deciliter and above 350 milligrams per deciliter. On 1/16/2025 at 3:20 PM, Licensed Practical Nurse #1 was interviewed and stated the range for Resident #149's high blood sugar is not specified on the physician orders. Licensed Practical Nurse #1 stated they call the doctor when the blood sugar is alarming and then document in the resident's medical record. Licensed Practical Nurse #1 further stated they should have called the physician when Resident #149's blood sugar was 530 milligrams per deciliter because it was out of range. On 1/16/2025 at 11:16 AM, the Medical Doctor was interviewed and stated the licensed nurse should have followed the physician's orders to notify them of finger stick blood sugar results below 200 and above 350 so further instructions can be given. The Medical Doctor further stated they would give orders for insulin for high blood sugar results and request nurse to check blood sugar again and call if blood sugar is still high. On 1/16/25 at 3:32 PM, the Director of Nursing was interviewed and stated Licensed Practical Nurse #1 should have followed the physician's orders to notify the physician when Resident #149's blood sugar was below 200 or above 350 milligrams per deciliter. 10 NYCRR 415.12

Based on observation, record review, and interview during the Recertification Survey conducted from 1/13/2025 to 1/21/2025, the facility did not ensure that food served were at an appetizing temperature. This was evident in 1 (Resident #134) of 4 residents reviewed for Dining Observation out of 37 total sampled residents. Specifically, food served during lunch meal service was not maintained at palatable and appetizing temperatures. The findings are: The facility's policy titled Meal Service with a reviewed date of 10/2023 documented that the facility will assure adequate and appropriate meal service to all residents. The facility's policy titled Food Preparation and Appropriate Temperature with a revised date of 9/26/2024 documented that hot foods will be held at 135 degree Fahrenheit or higher. Resident #134 was admitted to the facility with diagnoses of Diabetes Mellitus, Hyperlipidemia and Hypertension. The Minimum Data Set assessment dated [DATE] documented that Resident #134 had intact cognition and required substantial assistance with eating. On 1/13/2025 at 12:25 PM, Resident #134 stated their food was cold by the time their tray reach their room. On 1/16/2025 at 12:40 PM, the food carts arrived in the dining room. From 12:45 PM to 1:11 PM, the nursing staff prepared and distributed the trays to residents in the dining room and delivered trays to residents in their room. On 1/16/2025 at 1:11 PM, test trays were conducted on Unit 5. The food temperatures were as follows: baked potato 138.2 degrees Fahrenheit, [NAME] chicken 106.6 degrees Fahrenheit, broccoli 105 degrees Fahrenheit, summer squash soup 134 degrees Fahrenheit, mashed potato 131 degrees Fahrenheit, pureed broccoli 133 degrees Fahrenheit, pureed chicken 132 degrees Fahrenheit, pureed soup 134 degrees Fahrenheit, and coffee 155 degrees Fahrenheit. On 1/21/2025 11:29 AM, Registered Nurse #1, who was the Unit Manager stated early trays are delivered to the unit around 12:30 PM and followed by rest of the trays in the food truck. The nursing staff will distribute trays to the residents in the dining room first and then to the rooms. Meal distribution is completed within 15 minutes after the truck arrives to the unit. On 1/17/2025 at 11:22 AM, the Food Service Director was interviewed and stated that hot foods are held above 140 degrees Fahrenheit or higher on the steam table and should be served above 135 degrees Fahrenheit for hot foods to be palatable. The Food Service Director stated food temperature issue had been brought up in the past and the team initiated a plan to change the meal service process. This change was only implemented in the Rehab Unit and is currently on pause due to some equipment/staffing issues. On 1/21/2025 at 11:50 AM, the Director of Nursing stated the food temperature issue was already identified some time last year and they initiated a plan to improve the dining experience including food temperature. They stated the plan was only implemented on Unit 6 because there were some challenges during implementation process. 10 NYCRR 415.14

Based on observations , record review, and interviews during the Recertification Survey conducted from 1/13/2025 to 1/21/2025, the facility did not ensure that the survey results were posted in a place readily accessible to residents, and family members and legal representatives of residents. This was evident for 11 (#10, #22, #31, #43, #44, #91, #97, #147, #148, #149, and #173) out of 16 residents attending the Resident Council meeting. Specifically, the survey results were kept in unlabeled plastic sleeve and was located across the Finance Department's office down the hall from the main entrance and not in plain view. Additionally, the survey results did not include complaint investigations made during the 3 preceding years. The findings are: During multiple observations conducted between 1/13/2025 at 1:00 PM and 1/16/2025 at 1:15 PM, the survey results were observed in a plastic sleeve hanging from a bulletin board, which was not in plain view, on the first floor across the Finance Department's office down the hall from the main facility entrance. The reports include survey results from a Complaint Survey dated 06/08/2022 and Recertification Survey dated 12/05/2022. The survey reports inside the plastic sleeve did not include all complaint investigations made during the 3 preceding years. The notices on the availability of the survey results were posted high near the ceilings, in bulletin boards across the elevators in resident units. A review of the minutes of the Resident Council Meetings dated 10/30/2024, 11/3020/24 and 12/12/2024 showed no documented evidence that the location or the postings of the survey results were discussed at the Resident Council Meetings. During the Resident Council Meeting on 1/14/2025 at 11:00 AM, Resident #s 10, 22, 31, 43, 44, 91, 97, 147, 148, 149, and 173 stated they were not aware of the location of the facility's posted survey results. On 1/16/2025 at 3:49 PM, the Director of Nursing was interviewed and stated the survey results were temporarily placed across the Finance Department office because of construction. The results were previously kept at the main entrance. The Director of Nursing stated the survey results did not include complaint survey results because they do not think the facility had complaint surveys in the last 3 years. On 1/16/2025 at 4:08 PM, the Administrator was interviewed and stated the survey results are hanging in a temporary place because they are redoing the wallpaper. The Administrator stated the postings on where to find the survey results must be at eye level on the bulletin boards in residents' units. The Administrator stated there were no complaint surveys to include in the survey results. 10 NYCRR 415.3 (d)(1)(v)

Based on record review and interviews during the Recertification Survey conducted from 01/13/2025 to 01/21/2025, the facility did not ensure Minimum Data Set assessments were electronically transmitted to the Centers for Medicare and Medicaid Services Data System within 14 days after assessments were completed. This was evident in 3 (Residents #164, #152, and #64) of 18 residents reviewed for Resident Assessment. Specifically, Residents #164, #152, and #64's Minimum Data Set assessments were not transmitted within 14 days after the assessments were completed. The findings include but are not limited to: The facility's policy titled Minimum Data Set 3.0 Completion and Submission dated 09/12/2024 documented that the facility will complete and submit an accurate Minimum Data Set 3.0 assessment for each resident on the current Federal and State guidelines. The Quarterly Minimum Data Set Assessment for Resident #164 was completed on 11/16/2024 and was transmitted to the Centers for Medicare and Medicaid Services Data System on 01/15/2025. The Quarterly Minimum Data Set Assessment for Resident #152 was completed on 12/19/2024 and was transmitted to the Centers for Medicare and Medicaid Services Data System on 01/09/2025. The Quarterly Minimum Data Set Assessment for Resident #64 was completed on 12/19/2024 and was transmitted to the Centers for Medicare and Medicaid Services Data System on 01/09/2025. The Facility Minimum Data Set submission report printed 01/15/2025 documented that 17 resident assessments were submitted late, which was more than 14 days after the assessment. On 01/15/2025 at 01:01 PM, Minimum Data Set Assessors #1 and #2 were interviewed and stated that the Minimum Data Set Coordinator was not available when the Residents' Assessments were due for submission. They were unable to submit the completed assessment because they have no access to Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System. On 01/16/2025 at 01:01 PM, the Minimum Data Set Coordinator was interviewed and stated they had been away from the facility for the past 2 weeks and could not effectively monitor the completion and transmittal of the Minimum Data Set assessments. The Coordinator stated that the Assessors were trained on how to submit the completed assessment, but they cannot explain why the assessments were submitted late. On 01/21/2025 at 12:24 PM. the Director of Nursing was interviewed and stated that the Minimum Data Set Coordinator is responsible to ensure that residents assessments are completed and submitted timely. The Director of Nursing stated they are not aware that residents' assessments were not submitted on time. 10 NYCRR 415.11

Based on observations, record review, and interviews conducted during the Recertification Survey from 11/28/22 to 12/05/22, the facility did not ensure a resident with an indwelling catheter, receives the appropriate care and services to prevent urinary tract infections to the extent possible. This was evident for 3 of 4 residents reviewed for Urinary Catheter out of 39 total sampled residents (Residents #34, #62, #149). Specifically, 1) there were multiple observations of Resident #34's Foley Catheter (FC) drainage bag touching the floor and there was no physician order (PO) for FC, 2) there were multiple observations of Resident #62's FC drainage bag touching the floor, and 3) there were multiple observations of Resident #149's FC drainage bag touching the floor. The findings are: The facility's policy titled Urinary Catheter Care last revised 07/20/2021 documented goal with urinary catheter is to maintain patency and minimize the risk of urinary tract infection. 1) Resident # 34 had diagnoses of obstructive and reflux uropathy and urinary tract infection. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #34 was severely cognitively impaired, required total assistance from staff to perform activities of daily living, and had an indwelling catheter. On 11/28/22 at 12:17 PM, 11/29/22 at 12:58 PM, and 11/30/22 at 10:03 AM, Resident #34 was observed in bed. The FC drainage bag attached to the resident was touching the floor upon each observation. On 12/01/22 at 11:15 AM, Resident #34 was observed with their FC drainage bag touching the floor. Registered Nurse (RN) #2 was present in the room during the observation and stated the resident's drainage bag should not be touching the floor. The Comprehensive Care Plan related to Urinary Incontinence initiated 12/8/2021 and last revised 10/20/2022 documented check Resident #34 every 2-4 hours and assess FC. Physician Notes dated 10/1/2022 documented resident has cloudy urine, labs, antibiotics were ordered. Nursing notes dated 10/20/2022 documented Resident #34 had an indwelling catheter, and it was draining an adequate amount of yellow urine. FC as per protocol. There was no documented evidence of a PO for FC care upon Resident #34's readmission to the facility on [DATE]. On 12/02/22 at 10:12 AM, an interview was conducted with Certified Nursing Assistant (CNA) #6 who stated they were given in service that FC drainage bag should not touch the floor as part of proper infection prevention protocols. On 12/02/2022 at 10:59 AM, an interview was conducted with RN # 2 who stated the PO for Resident #34's FC was missed. A PO is important because it is part of the facility's protocol when a resident has an FC in place. RN #2 stated staff received an inservice to ensure they are aware that FC drainage bags should not touch the floor. On 12/02/2022 at 02:22 PM, the Director of Nursing was interviewed and stated the order for FC was missed and the RN obtained an order for FC from the physician today. Staff were in-serviced regarding facility policy to promptly and accurately obtain a FC order. 2) Resident #62 had diagnoses of diabetes mellitus and dementia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #62 was severely cognitively impaired and had an indwelling catheter. On 11/28/22 at 12:03 PM, 11/29/22 at 1:03 PM, 11/30/22 at 10:45 AM, and 12/01/22 at 11:05 AM, Resident #62 was observed lying in bed. The FC drainage bag attached to the resident was observed touching the floor upon each observation. The Comprehensive Care Plan related to Urinary Incontinence initiated 5/6/2014 and last revised 6/28/2022 documented check Resident #62 every 2-4 hours and assess FC. Physician order dated 11/21/2022 documented FC due to stage 4 pressure ulcer. Care for FC daily with soap and water. On 12/02/22 at 10:12 AM, Certified Nursing Assistant (CNA) # 5 was interviewed stated they were not assigned to work with Resident #62 prior to today. CNA #5 noticed the FC drainage bag was touching the floor when they were assigned to Resident #62 today and repositioned the FC drainage bag, so it was no longer touching the floor. On 12/02/22 at 10:20 AM, Licensed Practical Nurse (LPN) # 1 was interviewed and stated FC drainage bags should not be touching the floor and the staff were inserviced regarding this. 3) Resident # 149 had diagnoses of chronic kidney disease and type 2 diabetes. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #149 was moderately cognitively impaired, was totally dependent on staff to perform activities of daily living and had an indwelling catheter. On 11/28/2022 at 10:52 AM, 11/29/22 at 1:04 PM, 11/30/22 at 11:05 AM, and 12/01/22 at 11:20 AM, Resident # 149 was observed lying in bed. The FC drainage bag attached to the resident was touching the floor. Physician order dated 11/13/2022 documented FC care daily with soap and water and record FC output every shift. On 12/02/22 at 10:30 AM, Certified Nursing Assistant (CNA) # 4 was interviewed and stated they are a floater, and this was the first day they were assigned to Resident #149. CNA #4 stated they observed Resident #149's FC drainage bag touching the floor this morning but received inservice that the FC drainage bag should not be touching the floor and attached the FC drainage bag to the bed frame to prevent it from touching the floor. On 12/05/22 at 12:30 PM, the Infection Control Preventionist (ICP) was interviewed and stated FC drainage bags must not touch the floor as part of infection control and facility protocol. On 12/02/22 at 02:25 PM, an interview was conducted with the Director of Nursing (DON) who stated observations of FC drainage bags touching the floor numerous times is a concern and staff will be inserviced regarding proper infection prevention and care of FC drainage bag. 415.12(d)(1)

Based on observations, record review and interviews conducted during the Recertification Survey from 11/28/22 to 12/05/22, the facility did not ensure that a person-centered comprehensive care plan (CCP) was developed and implemented to address the residents' medical, physical, mental, and psychosocial needs. This was evident for 1 (Resident #73) of 1 resident(s) reviewed for Dialysis and 1 (Resident #544) of 1 resident(s) reviewed for hospitalization out of 39 total sampled residents. Specifically, 1) a CCP was not developed to address Resident #73 hemodialysis (HD) and Diabetes Mellitus (DM) treatment and, 2) a CCP was not developed to address Resident #544's oxygen therapy. The findings are: The facility policy titled CCP last revised 11/01/2017 documented the CCP will include measurable objectives and timetables in order to meet the resident's Medical, Nursing, Mental, and Psychosocial needs which are identified from the comprehensive assessment Minimum Data Assessment 3.0 (MDS). Additional problems, strengths, or needs identified by members of the CCP Team will be included in the CCP as appropriate. 1) Resident #73 had diagnoses of end-stage renal disease (ESRD) and DM. On 11/29/22 at 10:50 AM, Resident #73 was interviewed and stated they receive HD treatment and had a serious bleeding incident where they were transferred to the hospital for evaluation. Resident #73 has fingerstick blood sugar (FSBS) testing and insulin administration daily to address their diagnosis of DM. The MDS dated [DATE] documented Resident #73 was moderately cognitively impaired, received HD treatment as a resident, and received insulin injections daily. Physician's Order initiated 9/23/2022 and renewed 11/16/22 documented Resident #73 received HD three times weekly, had FSBS testing three times daily, and received Admelog SoloStar U-100 insulin 5 units 3 times daily after FSBS testing for diagnosis of DM, and received Januvia 100 mg once daily for a diagnosis of DM. Nursing Note dated 9/23/2022 documented Resident #73 was readmitted to the facility from the hospital with diagnosis of ESRD on HD and DM. There was no documented evidence the facility developed a CCP related to Resident #74 HD treatment and DM diagnosis with insulin use. On 12/01/22 at 10:25 AM, an interview was conducted with Registered Nurse (RN) #1 who stated Resident #73 has been receiving HD and insulin injections for DM since admission. The nurse who completed the admission assessment for Resident #73 was responsible for developing CCPs to address the resident's diagnoses and treatments. RN #1 could not provide a reason Resident #73 did not have CCPs with interventions to address HD and DM. The unit RNs and the MDS Department are responsible for checking and updating a resident's CCP as needed. On 12/01/22 at 11:28 AM, an interview was conducted with MDS Coordinator (MDSC) who stated they are responsible for checking a resident's record and initiating and/or updating CCPs upon admission and readmission. The RN on the unit is responsible for initiating episodic CCPs and updating the CCPs in the resident's chart. The CCPs related to HD and DM were available in Resident #73's CCP library in their medical record but they were not activated upon the resident's readmission to the facility. The MDS assessors may not be able capture care plan updates. The nursing staff on the resident's unit should be checking to ensure the resident's plan of care is updated. On 12/02/22 at 11:55 AM, an interview was conducted with the Director of Nursing (DNS) who stated Resident #73 receives HD treatment and DM management. The CCP Library contained the CCPs related to HD and DM upon admission, but they were not activated when the resident was admitted by RN Supervisor. MDS staff failed to activate the care plans when they are doing the assessments. 44842 2) Resident #544 had diagnoses of acute kidney disease and chronic obstructive pulmonary disease. The Admission MDS dated [DATE] documented Resident #544 was cognitively intact and received oxygen therapy. On 11/30/22 at 9:39 AM, 12/01/22 at 10:13 AM, and 12/2/22 at 10:17 AM, Resident #544 was observed receiving oxygen therapy via nasal canula. The Physician's Order dated 11/15/22 documented orders for continuous oxygen via nasal canula at 2 liters per minute. A Nursing Note dated 12/1/22 documented Resident #544 was receiving oxygen according to the physician order. The Treatment Administration Record (TAR) dated 11/15/22 to 12/04/2022 documented Resident #544 received Oxygen at 2 liters per minute continuously. On 12/02/22 at 2:24 PM, the MDS Coordinator (MDSC) was interviewed and stated Resident #544 should have had a CCP related to Oxygen as it was identified on the MDS but not documented on the Cardiac Decompensation CCP. There should have been a CCP developed for oxygen use since Resident has an order for oxygen. The MDS assessor (MDSA) was responsible for initiating and updating the CCPs upon admission and readmission and did not capture oxygen for Resident #544. The nurses on the unit should also be checking the residents' CCPs to ensure accuracy. On 12/05/22 at 11:08 AM, the Registered Nurse Educator (RNE) was interviewed and stated the Registered Nurse Supervisor (RNS) should have developed a CCP related to oxygen use within 48 hours on Resident #544. 415.11(c)(1)

Based on record review and interviews conducted during the Recertification survey from 11/28/2022 to 12/5/2022, the facility did not ensure residents were involved in developing the comprehensive care plan (CCP) and making decisions about their care. This was evident for 1 (Resident #81) of 3 residents reviewed for Participation in Care Planning out of 39 total sampled residents. Specifically, Resident #81 was not invited to participate in their quarterly CCP meeting with the interdisciplinary team (IDT). The findings are: The facility policy titled CCP dated 11/1/17 documented the IDT prepares the CCP which includes the resident and the resident's family or legal representatives. The resident and the resident's representative should be involved in the development of the CCP. Resident # 81 had diagnoses of vascular dementia without behavioral disturbance and schizophrenia. The Quarterly Minimum Date Set 3.0 (MDS) dated [DATE] documented Resident # 81 had moderate cognitive impairment and no designated representative participated in the assessment. On 11/29/22 at 10:59 AM, Resident #81 was interviewed and stated they are responsible for making their own decisions. The resident stated they were not invited to every care plan meeting to discuss and develop their care plan. The MDS Monthly Schedule for January 2022 documented Resident # 81 had a quarterly CCP meeting 1/11/2022. The CCP Attendance Record dated 1/11/2022 did not document a signature from Resident #81 and/or their designated representative. There was no documented evidence Resident #81 and/or their designated representative was invited to attend the quarterly CCP meeting held 1/11/22. On 12/01/22 at 02:56 PM, Director of Social Worker (DSW) was interviewed and stated they invited residents and/or their designated representatives to all care plan meetings. They received monthly schedule of CCP from the MDS department and invited residents and/or their designated representatives to the CCP about 1 week in advance of the meeting. DSW stated they invited residents by invitation letters and the designated representatives by calls. DSW also stated all the CCP invitations were documented in the Social Services notes. DSW checked Resident # 81's medical record and was not able to find any documented evidence that Resident # 81 and/or their designated representative were invited to the care plan meeting on 1/11/2022. DSW stated they were not able to explain the reason Resident # 81 and/or their designated representative were not invited to the care plan meeting on 1/11/2022. 415.11(c)(2)(i-iii)

Based on observations, record review, and staff interviews conducted during the Recertification survey from 11/28/22 to 12/05/22, the facility did not ensure food was stored in accordance with professional standards for food service safety. This was evident during review of the Kitchen. Specifically, 2 cold sandwiches placed on resident meal trays during tray line service were not maintained at a safe temperature of 41 degrees Fahrenheit (F) or below. The findings are: The facility policy titled Food Temperatures Prior to Meal Service revised 7/22 documented cold food should be kept under 41 F. Cold food is placed on ice for proper temperature holding; all cold foods are to be prepared in advance to allow foods to be under 41 F. The Manger/Supervisor monitors compliance by signing off on sheets daily, conducting test tray audits, training staff on appropriate food temperatures, calibrating thermometers, and maintaining copies of temperatures on file for 3 months. Kitchen tray line service was observed on 11/29/22 at 12:01 PM. The Director of Buildings (DOB) conducted random temperature checks on two sandwiches (turkey and cheese) placed on individual resident trays for service. The turkey sandwich temperature was 67.5 F, and the cheese sandwich temperature was 67.5 F. The DOB directed staff to remove and replace the 2 sandwiches on the resident trays. On 12/01/22 at 11:28 AM, Dietary Aide (DA) #1 was interviewed and stated the sandwiches go from the freezer onto the resident trays about 10 minutes before service starts. When the sandwiches come out of the freezer, the DA keeps them on a pan filled with ice. No one checks the temperatures of the sandwiches. On 12/01/22 at 12:05 PM, DA #2 was interviewed and stated sandwiches go into the refrigerator once they are made and must be kept at 41 F prior to serving the residents. On 12/01/22 at 11:58 AM, the DOB was interviewed and stated the kitchen staff who prepared the sandwiches did not have time to cool the sandwiches down. The sandwiches were prepared and placed on ice instead of in the refrigerator because it was close to tray line service time. The person who prepares the sandwiches is responsible for checking sandwich temperatures. 415.14(h)

Based on record review and interviews conducted during the Recertification and Abbreviated survey (NY00297954) the facility did not ensure an alleged violation involving abuse was reported to the New_York State Department of Health (NYSDOH) within 2 hours of occurrence. This was evident for 1 (Resident #543) of 2 residents reviewed for Abuse out of 39 total sampled residents. Specifically, the facility did not report an allegation of resident-to-resident abuse between Resident #90 and Resident #543 within 2 hours of the occurrence. The findings are: The facility's policy titled Abuse Prohibition dated 10/24/2022 documented alleged or suspected incidents of Abuse will be immediately investigated, and findings of such investigation will be provided to the Administrator within three working days of the occurrence of such incident and to the department of health within five working days. Resident # 90 had diagnoses of epilepsy and cerebral infarction. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident # 90 was severely cognitively impaired. Resident # 543 had diagnoses of heart failure and seizure disorder. The MDS assessment dated [DATE] documented Resident # 543 was cognitively intact. The NYSDOH Aspen Complaint Tracking System (ACTS) facility-reported incident (NY00297954) dated 6/23/22 at 1:38 PM documented staff responded to Resident #543's call bell on 6/22/22 at 1:37 AM. Resident #543 reported Resident #90 turned on the light and swung an extension cord that hit Resident #543 on the arm. The facility Summary of Case #NY00297954 dated 06/24/2022 documented that on 06/21/2022 at 11:37 PM, staff responded to the call bell in the resident's room. Resident # 543 reported that their roommate, Resident #90, turned on the light while they were sleeping and begun to swing a cord from a personal device brought in by family and hit Resident # 543 on the right forearm. The Registered Nurse supervisor with immediate response to the room and assessed both residents. Resident # 543 sustained a bruise on the right forearm. No prior issues were noted between the parties and statements obtained by Resident # 543 and the unit staff. There was no documented evidence the facility reported the allegation of resident-to-resident abuse within 2 hours of occurrence. On 12/02/22 at 9:22 AM, an interview was conducted with Registered Nurse Supervisor # 1(RNS #1) who stated they initiated the investigation into the incident between Resident #543 and Resident #90. RNS #1 then informed the Director of Nursing (DNS). The DNS is informed immediately anytime something happens. On 12/02/2022 at 2:17 PM, the DNS was interviewed and stated the unit manager informed them of the incident on 06/22/2022 at approximately 11:00 AM. The RNS placed the incident investigation in the DNS' mailbox. The DNS completed the investigation and wrote the investigation summary. The incident was reported to NYSDOH within 24 hours. When abuse is suspected and there is injury, it is reported to NYSDOH within two hours of the occurrence. All other incidents are reported in 24 hours. Resident-to-resident abuse occurred, and the victim had a minor bruise on the arm. The Administrator, the DNS, and the Assistant DNS are required to report allegations of abuse to the NYSDOH. 415.4(b)(2)

Based on observations, interviews and record review conducted during an abbreviated survey (NY 759), the facility failed to permit a resident to return to the facility after a transfer to the hospital. This was evident in 1 of 3 residents sampled (Resident #1). Specifically, on 04/06/2022, Resident #1 was transferred to the hospital for evaluation due to danger to self and others. The facility refused to readmit Resident #1 when the hospital notified them that Resident #1 was ready for discharge back to the facility on [DATE]. An Interim Order, from an Administrative Law Judge, dated 05/27/2022, directed the facility to readmit Resident #1 to the first available appropriate bed as expeditiously as possible. The facility did not adhere to the Interim Order and Resident #1 was not admitted timely. Resident #1 was admitted to the facility on [DATE] while surveyor was onsite. The findings include: Review of the facility's Policy and Procedure entitled Admissions to [NAME] Care Center revised 01/02/2021 documented: It is the policy of the facility to admit new residents who meet both medical and financial criteria. It will be determined, prior to admission that these new referrals will meet the facility's standards. Admissions department verifies that the patient is medically acceptable with the Director of Nursing or their designee. There was no information regarding readmitting residents after a hospital transfer. Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 02/15, indicating severely impaired cognition. Review of the hospital Screen form dated 08/03/2021 documented that Resident #1 did not have a serious Mental Illness. Review of the Hospital Discharge Summary dated 08/12/2021, revealed that Resident #1 was on 1:1 for the entire hospital course due to elopement risk. A review of the Potential Comprehensive Care Plan (CCP) entitled Return to Community Referral/Discharge Potential dated 08/19/2021, documented discharge potential poor due to cognitive status. The interventions included staff to provide care as per care plan and Medical Doctor's orders. Reassessed potential for discharge quarterly. The CCP was updated on 02/16/2022 to reflect that attempts for alternate placements were unsuccessful. A review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Nursing Progress Note dated 04/06/2022 at 12:24 PM documented that Resident #1 was displaying highly disruptive and dangerous behavior today. Resident #1 exited the floor and went down the stairwell alone. Resident #1 later picked up large canisters of hot water and coffee in a reckless manner refusing to let go and was also observed pulling buttons off his/her shirt and attempting to swallow them. Resident #1 was extremely difficult to redirect. Resident #1 was fully ambulatory and disregarded all safety directions from staff. Resident #1 was seen by two Physicians today, ordered transfer to Psychiatric emergency room (ER) for evaluation of ongoing dangerous/self- injurious behavior. A review of Resident #1's Discharge Notice dated 04/06/2022 documented the resident requested discharge or transfer as indicated by the information that was checked off. A review of an Administrative Law Judge document revealed that a hearing was held on 05/16/2022, 05/25/2022, and 05/26/2022 because the facility refused to accept Resident #1. An interim order was issued orally at the conclusion of the 05/26/2022 hearing, ordering the facility to accept Resident #1 back from the hospital. An Interim Order, from an Administrative Law Judge, dated 05/27/2022 documented that the facility was directed to readmit Resident #1 to the first available appropriate bed as expeditiously as possible. Review of the facility's Daily Census revealed the following available beds: 05/27/2022 = 49, 05/28/2022 = 47, 05/29/2022 = 49, 05/30/2022 = 50, 05/31/2022 =50, 06/01/2022 =50, 06/02/22 = 52, 06/03/2022 = 50, 06/04/2022 =51 and 06/05/2022 and 06/06/2022=50. During an interview on 06/13/2022 at 2:35 PM, the Assistant Director of Social Services (ADSS) stated that he/she was Resident #1's Social Worker. The ADSS stated that Resident #1's placement in the facility was long term, as per Resident #1's family request. The ADSS stated that after Resident #1's behavioral symptoms escalated, it was discussed with Resident #1's family. The ADSS stated that Resident #1's family agreed for Resident #1 to be transferred to a more appropriate facility. During an interview on 06/13/2022 at 2:45 PM, the Director of Social Services (DSS) stated that he/she could not recall if Resident #1 had any other behavior problems apart from wandering on initial admission. The DSS stated that there was no discharge planning for Resident #1 because Resident #1's family stated that they couldn't manage Resident #1 at home. The DSS stated that Resident #1 started pulling things out of place and Resident #1 was seen with a wire hanger around his/her neck. The DSS stated that referrals were sent to about four facilities with locked Dementia units, but the facilities did not accept Resident #1. The DSS said he/she mailed the Discharge Notice to Resident #1's family on the following day (04/07/2022). The DSS stated that he/she was not part of the team involved in the decision not to readmit Resident #1 back to the facility. During a follow up interview on 06/15/2022 at 1:07PM, the DSS stated that he/she made an error in checking off that Resident #1 requested discharge or transfer on the Discharge Notice Form dated 04/06/2022. The DSS stated that he/she meant to check the box for urgent medical need. During an interview on 06/13/2022 at 3:00 PM, the Director of Nursing (DON) stated that he/she was not aware that Resident #1 was on 1:1 for the entire hospital course due to elopement risk prior to Resident #1's initial admission to the facility. The DON stated that the facility refused to readmit Resident #1 because they felt that Resident #1 needed a more structured lock down unit. The DON stated that the facility did not have a lock down Dementia unit. The DON stated that Resident #1 was transferred to the Hospital on 04/06/2022 because the facility could no longer manage Resident #1's behaviors. Resident #1 suddenly grabbed a hot water cannister from a cart while staff were in the Day Room. The DON stated that Resident #1 was on close monitoring at that time. The DON stated that the facility had first received information from the hospital that Resident #1 was ready to return to the facility in April 2022 (was not sure of the exact date). The DON stated they had informed the hospital that they could not readmit Resident #1. The DON stated that the facility had to get their legal representative. The DON stated that the final ruling was sent to the facility's Attorney on Friday 06/10/2022 and he/she received the information that the facility was ordered to readmit Resident #1 late after 5:00 PM on 06/10/2022. The DON stated that Resident #1 was returning to the facility on [DATE]. The DON stated that the facility was waiting for Resident #1's updated Patient Review Instrument (PRI). During an interview on 06/15/2022 at 12:17 PM, the Director of Admissions stated that he/she was part of the team who reviews residents Patient Review Instruments (PRIs) and Hospital Discharge Summaries. The Director of Admissions stated that he/she reviewed and accepted Resident #1's initial Patient Review Instrument (PRI) and Hospital Discharge Summary. The Director of Admissions stated that the PRI documented that Resident #1 had no behaviors. The Director of Admissions stated that he/she could not recall seeing that the Hospital Discharge Summary stated that Resident #1 was on 1:1 for elopement risk. The Director of Admissions stated that on 04/14/2022, the facility received clinical information from the hospital, informing them that Resident #1 was ready to be discharged from the hospital back to the facility. The Director of Admissions stated that he/she was informed on 04/14/2022 by either the DON or the Administrator that the facility could not accept Resident #1 due to Resident #1's behaviors. During a follow up interview on 06/28/2022 at 1:35 PM, the DON stated that the facility had available beds after the facility received the Interim Order from the Administrative Law Judge. The DON stated that the available beds were not appropriate for Resident #1. The DON stated that there were over 20 beds available on the third floor but there were four COVID-19 Positive residents on the other side of the floor. The DON stated the COVID-19 Positive residents isolation precautions were discontinued between 05/31/2022 and 06/05/2022. The DON stated that the other vacant beds within the facility were not appropriate for Resident #1 due to Resident #1's behaviors. The DON stated that Resident #1's was admitted back to his/her former private room [ROOM NUMBER]/14/2022. During an interview on 06/28/2022 at 3:35PM, the facility's Administrator stated that they became aware of the court order to readmit Resident #1 as soon as the judgement was made. The Administrator stated that the facility's Attorney informed them of the court order, but he/she does not recall the date of notification. 415.3(h)(4)(iii)

Based on interviews and record review conducted during the recertification survey, the facility did not ensure that residents were provided with information on how to file grievances. Specifically, all resident council members at the Resident Council Meeting were unaware that they had the right to file a grievance in writing and to obtain a decision regarding his or her grievance in writing. This was evident for 12 out of 12 residents who attended the Resident Council Meeting. The findings are: The policy and procedure related to Grievances, revised on 3/20/13, documented that if a complaint/grievance is expressed by a resident/family/legal representative, a Grievance/Misappropriation Reporting and resolution Form is filled out and given to the Director of Social Work (DSW). If a resident needs assistance with filling out the form, any staff member can assist. A copy of the form will be distributed by the social worker to all disciplines required to resolve the complaint/grievance and must be returned to the DSW within 7 days. The social worker (SW) and staff from any other discipline involved with the complaint will meet with the resident to chare the investigative findings. On 02/05/20 at 11:03 AM, a Resident Council Meeting was held with the President of the Resident Council, Resident #16, and 11 additional members of the resident council who regularly attend meetings. When the members were asked if they were aware of how to file a grievance, 12 out of 12 of the attendees stated that they did not know how to file a written grievance and were unaware that they had the right to do so in writing. The council members stated that when they voice a concern, the social worker or other facility staff member that they report it to, do not follow-up with them regarding an outcome. The staff do not provide any investigative findings in writing. The attendees stated that these concerns were related to nursing staffing concerns, care issues, and attitudes of some of the staff. The Grievance Misappropriation Log documented that there were missing clothing, dentures, earrings, makeup, phones, and other items from July of 2018 through January 2020. There was no Grievance Misappropriation Log for 2017. There were no documented grievances concerning issues with facility staff or care received. Documentation regarding the last Resident Council Meeting where resident's rights were reviewed was requested, but it was provided. An interview was conducted with the DSW on 02/10/20 at 11:59 AM. The DSW stated that he had been working for the facility for approximately [AGE] years, and he attends Resident Council Meetings approximately twice per year to review grievance reporting rights and other areas related to resident's rights. He does not put every concern that a resident has in writing for a grievance. The DSW writes a SW note in the resident's medical record. A meeting is held with resident's family if they have concerns. The meeting allows the family to report their concerns. The Director of Nursing (DNS) is then informed of concerns involving the nursing staff, which are most of the concerns. The DNS does her own investigation and informs the DSW of the outcome of the investigation. He stated he does not always follow-up with the resident regarding the outcome because there are times when personnel decisions have been made, and the resident should not be aware of this information. Personnel decisions were defined as instances when a nursing staff member may be reprimanded, suspended, or fired as a result of a resident's complaint. The DSW does not inform the resident or family member in writing of the outcome of any investigations. Sometimes, the residents have an issue with the Certified Nursing Assistant (CNA) assigned to them and just request for this CNA to stop taking care of them. The DSW was unable to recall all of the incidents or complaints that have been reported to him because he does not document them on any tracking/log or grievance form. He stated there have not been any care grievances recorded in the last 3 years. An interview was conducted with the DNS on 02/10/20 at 02:11 PM. The DNS stated that the residents, including those from Resident Council, began coming to her individually about issues with nursing care and nursing staff. This began approximately 4 months ago. Resident #16 meets with her about personal issues with the nursing staff or dietary issues such as food temperatures. He also makes the DNS aware of concerns from the Resident Council. Resident #16 will also inform the DNS if there are other residents that may want to speak with her about general concerns, but Resident #16 has not brought any specific care concerns to her attention in these meetings. Any specific care concerns are communicated to the DSW who then reports those concerns to the DNS so that she can investigate them. The DNS then informs the DSW what the outcome of those investigations are. The DNS does not update the residents about the outcome of the investigations. The DNS stated that she believes it is the DSW's responsibility to inform the residents of the outcome of the investigation and provide them with something in writing that they must sign to acknowledge receipt. 415.3(c)(1)(i)

Based on observation, interviews, and record review conducted during the recertification survey, the facility did not ensure that appropriate care and services to prevent complications of tube feeding were provided. Specifically, the medication nurse did not use the correct amount of water to flush the feeding tube prior to initiating tube feeding. This was evident for 1 of 3 residents reviewed for Tube Feeding (Resident #203). The findings are: A facility policy and procedure related to Enteral (Tube) Feeding revised as of 4/30/14 documented that the nurses should check the Physician order [REDACTED]. The tube should be flushed with the amount of water prescribed by the Medical Doctor at the beginning and end of feeding. Resident #203 had a [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented that the resident was cognitively intact and had a peg tube. On [DATE] at 03:57 PM, the Licensed Practical Nurse (LPN #1) was observed starting the tube feeding for Resident #203. LPN #1 looked at the electronic medical record (EMR) then gathered a flush bottle, a bottle of Vital AF 1.2 formula, and a tray and entered the resident's room. She washed her hands and then brought the flush bottle into the resident's bathroom to fill it with water. After donning gloves, the LPN checked for placement of the peg tube by inserting a syringe into the tube and checking for residual. She then filled a flush bag and hung it along with the formula from the tube feeding pole. Once she started priming the pump, LPN #1 drew 30mls (milliliters) of water into a syringe to flush the peg tube prior to starting the feeding. The 30mls of water was observed being inserted into the peg tube. The LPN then connected the feeding tube to the pump and started the tube feeding. The physician's orders [REDACTED]. The orders documented that the resident should receive 30ml of water before and after med pass. The Medication Administration Record [REDACTED]. An interview was conducted with LPN #1 on [DATE] at 04:07 PM. The LPN stated that she provided the resident with a flush of 30mls of water prior to initiating the tube feeding. This is per the facility policy related to tube feeding, and this is the amount of water she has always given to the resident when starting the tube feeding. LPN #1 had initiated the resident's tube feeding on multiple occasions. After reviewing the physician's orders [REDACTED]. She stated since the feeding has already been started, she would be unable to provide additional water at this time to account for the missing 70mls. LPN #1 stated that she will need to add water to the resident's flush during medication administration or at the end of the resident's tube feeding. An interview was conducted with the Registered Nurse (RN) Manager for the unit, RN #1, on 02/07/20 at 11:03 AM. RN #1 stated that the resident should receive 100mls of water flush prior to tube feeding administration. She performs competencies with the staff on the unit to ensure that they are able to understand the physician's orders [REDACTED]. The medication nurse needs to check the physician's orders [REDACTED]. 415.12(g)(2)

Based on observations, record review, and staff interviews during the recertification survey, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, a resident's right hand splint was not applied as ordered and per the Comprehensive Care Plan (CCP). This was evident for 1 of 2 resident reviewed for limited range of motion (Resident #119). The findings are: The facility policy Contractures/Adaptive equipment dated 01/04/2019 documented: All residents with contractures will be identified upon admission and ongoing basis. Interventions will be provided as appropriate .Interventions will be provided. If needed, in-services will be provided to the caregivers with return demonstrations noted. Resident #119 was admitted to the facility with [DIAGNOSES REDACTED]. The Annual Minimum Data Set 3.0 (MDS), Assessment Reference Date (ARD) 1[DATE]19, documented that the resident had severe impairment in cognition with long and short-term memory problems. The MDS documented the resident required total dependence of 2 for bed mobility, transfer, toilet use, and total dependence of one person for Locomotion, dressing, eating, and personal hygiene. The resident had range of motion impairment on both sides of the upper and lower extremities. The CCP further documented the resident received no splint or brace assistance. On [DATE] at 11:24 AM, 02/05/20 at 11:05 AM, and 02/07/20 at 09:53 AM the resident was observed in bed with a right hand contracture and no splint device in place. On 02/05/20 at 10:04 AM and [DATE] at 10:48 AM and 12:31 PM, the resident was also observed in bed with no hand splint in place, and a hand splint was at the foot of the resident's bed. The Comprehensive Care Plan (CCP) for ADL (Activities of Daily Living): Rehabilitation, effective 8/10/13, documented that resident had a right hand contracture and foot drop. The CCP included the intervention of Right (Rt) grip orthosis to be worn in the morning and evening with removal during hours of sleep, hygiene care, and Passive Range of Motion (PROM). The intervention was added 4/9/15. The CCP was last reviewed on [DATE] at the quarterly care plan meeting. The physician's orders [REDACTED]. Remove during hours of sleep, hygiene care and PROM. The order was initiated 3/1/18. On [DATE] at 12:31 PM, and interview was conducted with the Certified Nursing Assistant (CNA#1). CNA #1 stated that she has been caring for the resident for about 5 years. CNA #1 stated that resident has a right-hand splint that is used when the resident is out of bed which is every other day or if the nurse instructs them to take the resident out of bed. The application of the splint is documented whenever the resident is taken out of bed. On 02/07/20 at 09:53 AM, an interview was conducted with the Certified Nursing Assistant (CNA#2). CNA #2 stated that she is assigned to the resident if the regular CNA is off. The resident has a device for the right hand that is only applied when the resident is out of bed. On 02/07/20 at 10:00 AM the Registered Nurse (RN#2) was interviewed. The RN stated that she has been on the unit since December 2019. Report is given to the CNAs by the nurses every shift regarding the care needs of the residents assigned to them. The CNA Accountability Record includes all care and interventions needed by the resident as per the plan of care. The RN stated that she believes the device is placed on the resident's hand after the CNA provides care. On 02/07/20 at 11:14 AM, an interview was conducted with the Occupational Therapist-OT, (Staff#3). The OT also stated that resident was recommended to have grip orthosis to be worn on right hand in the AM (Morning) and PM (Evening), to be removed during hours of sleep, hygiene care and passive range of motion. The OT stated that the nursing staff are educated on the placement of the device and they are expected to be placing the device every day except during care for hygiene/range of motion and during hours of sleep. 415.12

Based on observation, record review and staff interviews conducted during the Recertification survey, the facility did not ensure that services provided, as outlined per the comprehensive care plan, met professional standards of quality. Specifically, residents prescribed oxygen as needed did not have oxygen saturation levels monitored as ordered to assess the need for oxygen. This was evident for 2 of 3 residents reviewed for Respiratory Care (Resident #141 and #220). The findings are: The policy and procedure for Care of Residents on Humidified Oxygen dated 5/15/12 documented: It is the responsibility of the Registered Nurse (RN) or Licensed Practical Nurse (LPN) to check and review the physician's orders [REDACTED]. to MD (Physician). The policy does not specify how the resident's response to oxygen therapy should be assessed. It does contain specifics regarding how oxygen saturation monitoring should be done. 1.) Resident #141 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident had moderately impaired cognition. The MDS further documented the resident was completely dependent on the assist of staff for bed mobility, transfer, dressing, toileting, personal hygiene, and locomotion. On [DATE] at 15:05 PM and 2/10/20 at 11:00 AM, the resident was observed with oxygen not in use. The Comprehensive Care Plan (CCP) for Respiratory Distress dated 11/5/19 documented the resident had the potential for respiratory distress as evidenced by history a history of aspiration pneumonia. The CCP further documented the resident was on [MEDICATION NAME] [MED] inhaler every 6 hours as needed. The CCP interventions included: monitor of signs and symptoms (s/s) and/or c/o (complaints of) of respiratory distress and notify MD of abnormal findings; and administer treatments per MD order. The CCP was updated 2/10/20, after surveyor intervention, with the interventions of administer 2 liters oxygen as needed and monitor oxygen saturation every shift. Nursing Notes dated [DATE] documented that the resident was transferred to the hospital with a temperature of 102.1 and oxygen saturation of 81% on room air. The resident was readmitted to the facility on [DATE]. The readmission physician's orders [REDACTED].@ 2 liters per minute (L/m) as needed (PRN) and oxygen saturation monitoring every shift. These orders were renewed on [DATE]20. There was no documented evidence that oxygen saturation monitoring every shift was done from [DATE]20 to 02/07/2020. The Nursing Notes documented oxygen saturation for one shift only on 5 days (1/21, 1/25, 1/29, 1/30, and 1/31). 2) Resident #220 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] identified the resident had severely impaired cognition and was completely dependent on staff for activities of daily living. The Comprehensive Care Plan (CCP) for Respiratory Distress dated 8/27/15 documented the resident had the potential for respiratory distress related to a history of Pneumonia. The interventions included: monitor for s/s of respiratory distress and notify MD of abnormal findings; monitor for effectiveness; and administer oxygen 2 L/min (Liters per minute) via N/C (nasal cannula) PRN (as needed). The CCP intervention of monitor oxygen saturation eery shift was added on 2/10/20 after surveyor intervention. The physician's orders [REDACTED].<) 94%. There was no documented evidence that oxygen saturation monitoring every shift was done from 01/01/2020 to 02/07/2020. The oxygen saturation monitoring record documented oxygen saturation taken daily on four days (1/7, 1/22, 1/31, and 2/7). On 02/07/2020 at 1:20 PM, the Licensed Practical Nurse (LPN #4) was interviewed. The LPN stated that she takes the resident's oxygen saturation but does not always record it. The nurse who picked up the order for oxygen saturation monitoring did not register it in the EMR in the pulse oximeter level section. She stated there is no place to document the oxygen saturation monitoring. On 02/07/2020 at 1:20 PM, the Unit Registered Nurse Manager (RN #3) was interviewed and stated the nurses pick up up and transcribe any new physician's orders [REDACTED]. She stated she did not know what happened, but she will get back to the surveyor. On 02/07/2020 at 4:30 PM, the 3-11 shift LPN was interviewed and stated she spoke to her supervisor. She stated that she does not take the oxygen saturation level regularly, but she should have done so as ordered and documented it in the record. 4[AGE].21(b)(30(1)